Präoperative Funktionsdiagnostik vor lungenresezierenden Eingriffen

Zusammenfassung

Die präoperative Risikostratifikation vor lungenresezierenden Eingriffen erfordert die Messung von FEV₁ und TLCO. Der Bestimmung der relativen Werte und der prädiktiven postoperativen (ppo) Werte ist den Absolutwerten der Vorzug zu geben. Nationale und internationale Guidelines benutzen unterschiedliche Wege in der präoperativen Funktionsdiagnostik. Im Allgemeinen empfehlen sie die Durchführung der Spiroergometrie, wenn die FEV₁ und die TLCO < 80 %-Soll oder ppo-Werte < 40 %-Soll sind. Von Inoperabilität wird ausgegangen, wenn die ppo-Werte der V'O₂-max < 10 ml/kg/min oder < 35 %-Soll sind. Auf der Basis dieser Grenzwerte wird ein vereinfachter diagnostischer Algorithmus (Hemer-Algorithmus) für die präoperative Entscheidungsfindung der funktionellen Operabilität dargestellt. Dennoch bleiben offene Fragen. Diese betreffen zum einen die Bewertung des individuellen operativen Risikos von Patienten, die sich rechnerisch im oder knapp außerhalb des anerkannten Grenzbereichs der funktionellen Operabilität befinden; zum anderen den Umgang mit der Tatsache, dass Patienten trotz der (hoch-)risikobehafteten funktionellen Situation bereit sind, ein höheres Morbiditäts- und Mortalitätsrisiko in Kauf zu nehmen, insbesondere wenn ein kurativer Therapieansatz besteht.

Abstract

Preoperative risk stratification for lung surgery requires the determination of FEV₁ and TLCO. Calculation of relative values and predective postoperative values in dependence on the extent of resection is preferable in comparison to absolute values. National and international guidelines have different recommendations for preoperative functional assessment. In general they recommend cardiopulmonary exercise testing if preoperative FEV₁ and TLCO are < 80 %-pred. or if ppo values are < 40 %-pred. Inoperability is assumed if ppo values of V'O₂-max are < 10 ml/kg/min or < 35 %-pred. On this basis, a more simplified algorithm for the preoperative assessment of candidates for lung resection (Hemer algorithm) is presented. Nevertheless, there still remain some unresolved questions. These concern the assessment of the individual operative risk of patients who are at or just beyond the limits of functional operability. Furthermore, there is the fact that patients - in spite of a severe functional impairment - are willing to accept a higher risk of morbidity and mortality, especially if there is a curative option.

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