Bolliger C T, Perruchoud A P
Division of Pneumology, University Clinic, Basel, Switzerland.
Eur Respir J. 1998 Jan;11(1):198-212. doi: 10.1183/09031936.98.11010198.
Advances in operative technique and perioperative care have considerably reduced surgical morbidity and mortality after pulmonary resections. Various single and combined parameters of functional operability have been proposed to assess the surgical risk. Pulmonary function tests adequately assess the pulmonary risk, and baseline or stress electrocardiography, echocardiography and nuclear cardiac studies assess the cardiac risk. Patients with normal or only slightly impaired pulmonary function (forced expiratory volume in one second (FEV1) and transfer factor of the lung for carbon monoxide (TL,CO) > or = 80% of predicted) and no cardiovascular risk factors can undergo pulmonary resections up to a pneumonectomy without further investigation. For others, exercise testing, pulmonary split-function studies, or a combination of these two methods are recommended. Exercise testing, most frequently performed as a symptom-limited test with the measurement of maximal oxygen uptake (V'O2,max), assesses both the pulmonary and cardiovascular reserves. A V'O2,max of <10 mL.kg(-1).min(-1) is generally considered prohibitive for any resection, a value of >20 mL.kg(-1).min(-1) or >75% of predicted normal, safe for major resections. Split-function studies are radionuclide-based estimations of the predicted postoperative (ppo) values of various parameters. The currently used ppo-parameters are FEV1-ppo, TL,CO-ppo and, most recently, V'O2,max-ppo. Suggested cut-off values for safe resection are: for FEV1-ppo and TL,CO-ppo > or = 40% pred; and for V'O2,max > or = 35% pred, combined with an absolute value of > or = 10 mL.kg(-1).min(-1). The lowest acceptable ppo-values will still have to be established by additional prospective studies. In the long-term, resections involving not more than one lobe usually lead to an early functional deficit followed by later recovery. The permanent functional loss in pulmonary function is small (< or = 10%) and exercise capacity is only slightly reduced or not at all. Pneumonectomy, on the other hand, leads to an early permanent loss of about 33% in pulmonary function and 20% in exercise capacity. Thus, pulmonary function tests alone overestimate the functional loss after lung resection.
手术技术和围手术期护理的进步已显著降低了肺切除术后的手术发病率和死亡率。人们提出了各种单一和综合的功能可操作性参数来评估手术风险。肺功能测试能充分评估肺部风险，而基线或负荷心电图、超声心动图和心脏核素检查则评估心脏风险。肺功能正常或仅轻度受损（一秒用力呼气量（FEV1）和肺一氧化碳转运因子（TL,CO）≥预测值的80%）且无心血管危险因素的患者，在无需进一步检查的情况下可接受直至全肺切除术的肺切除手术。对于其他患者，建议进行运动测试、肺分功能研究或这两种方法的联合应用。运动测试最常作为症状限制性测试进行，测量最大摄氧量（V'O2,max），可评估肺部和心血管储备。一般认为，V'O2,max<10 mL.kg(-1).min(-1)对任何切除术都具有禁忌性，>20 mL.kg(-1).min(-1)或>预测正常值的75%对大手术是安全的。分功能研究是基于放射性核素对各种参数术后预测值（ppo）的估计。目前使用的ppo参数是FEV1-ppo、TL,CO-ppo，以及最近的V'O2,max-ppo。安全切除的建议临界值为：FEV1-ppo和TL,CO-ppo≥预测值的40%；V'O2,max≥预测值的35%，且绝对值≥10 mL.kg(-1).min(-1)。最低可接受的ppo值仍需通过额外的前瞻性研究来确定。从长期来看，涉及不超过一个肺叶的切除术通常会导致早期功能缺陷，随后恢复。肺功能的永久性功能丧失较小（≤10%），运动能力仅略有降低或根本没有降低。另一方面，全肺切除术会导致肺功能早期永久性丧失约33%，运动能力丧失20%。因此，仅靠肺功能测试会高估肺切除术后的功能丧失。
