Key Points

• Most risk factors for complications after major lung resection and esophagectomy are well known.
• Age is a marker of potential increased risk due to comorbidity and frailty but should not be the only reason a patient is denied surgery.
• Comorbidity substantially increases the risk of major thoracic surgery.
• Assess risk factors before major thoracic surgery.
• Consider intervention for comorbid factors if it will reduce the risk of surgery.
• Consider expected long-term quality of life when making recommendations regarding thoracic surgery.
• The values, concerns, and goals that a patient has might not be similar to those of the surgeon.

Preoperative evaluation of patients who are candidates for thoracic surgery is a complex process that is essential in fulfilling a variety of objectives. The surgeon requires such assessment to plan the operative approach, anticipate potential operative and postoperative complications, decide on the necessary level of postoperative care, and determine what resources might be required to support the patient until full recovery takes place. The patient requires such assessment so that he or she can ask relevant questions about the recommended procedure, gain an understanding of the short- and long-term consequences of having surgery, and make an informed decision about whether to proceed.

The preoperative evaluation of candidates for thoracic surgery is an art as much as it is a science. Despite the plethora of noninvasive and invasive tests that is available for assessing operative risks and predicting outcomes, the final decision ultimately is based on the surgeon’s impression of the likelihood of success of the planned operation. Success can be identified in a number of ways, such as absence of complications, survival until hospital discharge, correction of an underlying disorder, cure of a cancer, or improved long-term quality of life (QOL). This chapter focuses on the physiologic evaluation of patients and on the associations among surgery and perioperative complications, operative mortality, long-term survival, and postoperative QOL.