Rank the clinical scenarios in order of greatest likelihood of serious postoperative pulmonary complications

B. Right middle lobectomy for bronchogenic cancer in a 65-year-old smoker.

D. Right hemicolectomy in an obese 60-year-old smoker.

C. Vagotomy and pyloroplasty for chronic duodenal ulcer disease in a 50-year-old who had chest film findings of old, healed tuberculosis.

A. Transabdominal hysterectomy in an obese woman that requires 3 hours of anesthesia time.

E. Modified radical mastectomy in a 58-year-old woman who is obese.

DISCUSSION: If one considers the constellation of risk factors for pulmonary complications that is provided in tabular form in the accompanying chapter, one should readily recognize B, right middle lobectomy for bronchogenic cancer in a 65- year-old smoker, as the highest risk of a clinical situation for the likelihood of serious pulmonary complications. The next in rank may be properly debated between answer D and answer C. D, right hemicolectomy, is judged to have somewhat greater likelihood of complications since the patient is older, smokes, and is obese, although the procedure may be done through a transverse or lower abdominal incision. C, vagotomy and pyloroplasty, is viewed as being somewhat less serious since it is an upper abdominal operation on an elective basis in a 50-year-old whose only abnormalities include old, healed tuberculosis on a chest film. A very low risk of pulmonary complication should follow a transabdominal hysterectomy done through a lower abdominal incision in a woman whose only risk factors are obesity and a 3-hour anesthesia time. The lowest risk probably resides with the younger patient undergoing modified radical mastectomy, whose only risk factor is obesity. This is particularly true since this operation is conducted on the surface of the body, is associated with relatively little postoperative pain, and provides free and unrestricted respiratory function.