Patient selection and risk stratification for lung resection: a narrative review

Anatomical lung resection remains the cornerstone of curative treatment for early-stage non-small cell lung cancer, and patient selection is a major determinant of postoperative outcome. For more than a decade, preoperative assessment relied on three guidelines-American College of Chest Physicians (ACCP) (2013), European Respiratory Society/European Society of Thoracic Surgeons (ERS/ESTS) (2009) and British Thoracic Society/Society for Cardiothoracic Surgery (BTS/SCTS) (2010)-sharing a sequential approach of cardiac assessment, pulmonary function testing and, in selected patients, cardiopulmonary exercise testing (CPET). Since then, minimally invasive surgery became standard, randomised trials validated sublobar resection, and evidence accumulated for new predictors, particularly the minute ventilation-to-carbon dioxide output (VE/VCO₂) slope, frailty and sarcopenia. This review synthesises current preoperative risk stratification in light of the 2025 ERS/ESTS guideline and the 2021 American Association for Thoracic Surgery (AATS) expert consensus.

We searched PubMed/MEDLINE for English-language literature on preoperative risk stratification and patient selection for anatomical lung resection, supplemented by hand-searching of reference lists and prioritising guidelines, randomised trials, systematic reviews and multicentre cohort studies. All numerical data were verified against the original publications.

The 2025 ERS/ESTS guideline introduces formal assessment of frailty and nutritional status, endorses prehabilitation, and repositions risk-prediction models as tools for benchmarking rather than individual selection. Its exercise-testing algorithm considers peak oxygen consumption and the VE/VCO₂ slope together in three risk categories (peak VO₂ ≥15, 12-15 and <12 mL/kg/min; slope <35, 35-40 and >40). The graded recommendation itself is confined to the use of CPET and does not endorse any specific parameter or cut-off, identifying only a peak VO₂ below 12 mL/kg/min or a VE/VCO₂ slope above 40 as suggestive of high surgical risk. The AATS consensus independently ranks frailty and functional status above chronological age. Together, these developments support a shift from a binary judgement of operability to a structured process that also determines how to operate, adapting the extent of resection and the surgical approach to the patient's physiological reserve.

Contemporary risk stratification integrates cardiopulmonary physiology, ventilatory efficiency, frailty and nutrition with the configuration of the operation itself. Threshold calibration in the minimally invasive era, the optimal VE/VCO₂ slope threshold and standardised frailty measurement remain unresolved.