Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection.
BACKGROUND
Contemporary liver surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. This study evaluated preoperative cardiopulmonary exercise testing (CPET) in high-risk patients undergoing hepatic resection.


METHODS
In a prospective cohort referred for liver resection, patients aged over 65 years (or younger with co-morbidity) were evaluated by preoperative CPET. Data were collected prospectively on functional status, postoperative complications and survival.


RESULTS
Two hundred and four patients were assessed for hepatic resection, of whom 108 had preoperative CPET. An anaerobic threshold (AT) of 9·9 ml O(2) per kg per min predicted in-hospital death and subsequent survival. Below this value, AT was 100 per cent sensitive and 76 per cent specific for in-hospital mortality, with a positive predictive value (PPV) of 19 per cent and a negative predictive value (NPV) of 100 per cent: no deaths occurred above the threshold. Age and respiratory efficiency in the elimination of carbon dioxide (VE/VCO(2)) at AT were statistically significant predictors of postoperative complications. Receiver operating characteristic (ROC) curve analysis showed that a threshold of 34·5 for VE/VCO(2) at AT provided a specificity of 84 per cent and a sensitivity of 47 per cent, with a PPV of 76 (95 per cent confidence interval (c.i.) 58 to 88) per cent and a NPV of 60 (48 to 72) per cent for postoperative complications. Long-term survival of those with an AT of less than 9·9 ml O(2) per kg per min was significantly worse than that of patients with a higher AT (hazard ratio for mortality 1·81, 95 per cent c.i. 1·04 to 3·17; P = 0·036).


CONCLUSIONS
CPET provides a useful prognostic adjunct in the preoperative assessment of patients undergoing hepatic resection.
National Institute for Health Research Manchester Biomedical Research Centre and Regional Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK.
M A
MA
Junejo
J M
JM
Mason
A J
AJ
Sheen
J
J
Moore
P
P
Foster
D
D
Atkinson
M J
MJ
Parker
A K
AK
Siriwardena
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015308:Anaerobic Threshold / Q000502:physiology; D002318:Cardiovascular Diseases / Q000517:prevention & control; D005080:Exercise Test / Q000379:methods*; D005260:Female; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D011300:Preoperative Care; D011446:Prospective Studies; D012372:ROC Curve; D012120:Respiration Disorders / Q000517:prevention & control; D018570:Risk Assessment / Q000379:methods; D055815:Young Adult