American College of Chest Physicians algorithm for lung resective surgery: Real-life validation

The preoperative evaluation of candidates for resective surgery has been addressed in several guidelines, the most recent is the American College of Chest Physicians (ACCP) algorithm; however, validating information in routine clinical practice is scant.

This is a retrospective cohort study based on an ongoing registry of candidates for thoracic surgery that began in 2011; therefore, relevant data were prospectively collected. This study is based on patients who operated from January 2011 to 16 December 2023. The last survival update was done on 16 March 2024.

Overall, postoperative mortality increased from 3.1% at 30 days to 5.5% at 90 days. Factors associated with mortality included age, predicted-postoperative (PPO) FEV₁, PPO-DLco, intermediate ACCP risk and pneumonectomy. Video-assisted thoracic surgery (VATS) reduced risk. When adjusted for covariates, independent risk factors were age, ACCP intermediate risk and pneumonectomy. Thirty-day mortality: age >70 years OR = 7.5 (95% CI 2.1-26.6), ACCP intermediate risk = 5.6 (1.2-25.8) and pneumonectomy = 6.5 (1.7-24.8); 60-day mortality: age >70 = 10.5 (3.0-37.1), ACCP intermediate risk = 4.5 (1.22-16.33) and pneumonectomy = 8.2 (2.2-29.3); 90-day mortality, age >70 = 6.5 (1.1-24.8), ACCP intermediate risk = 8.2 (2.3-29.26), pneumonectomy = 8.1 (2.78-24.3).

The ACCP algorithm remains a valid tool for the assessment of fitness for anatomical lung resection. Our data support some reworking of the algorithm (i.e. considering age >70 years and pneumonectomy in the decision algorithm as intermediate-risk determinants). Mortality continues to increase from 30 to 90 days with higher risk, and this should be considered in the risk/benefit analysis of therapeutic alternatives.