**2. Preoperative optimisation of specific risk factors**

The outcome of surgical procedures is not measured only by clinical end points but also shorter stays and lower costs [9]. Patients' discharge is delayed commonly due to inadequate pain relief, infection, arrhythmias, prolonged air leak and debility [9]. Many complications that occur from thoracic operations can be anticipated. An aggressive preoperative work up mitigates morbidity and shortens convalescence.

#### **2.1. Smoking**

Preoperative cessation of smoking prevents postoperative complications to a large extent.

Support groups, counselling and nicotine replacement therapy should be used [10]. Histori‐ cally, 6 weeks of smoking cessation before surgery is recommended to avoid the copious bronchorrhea that accompanies regeneration of the cilia that clear mucus between 2 and 4 weeks after smoking cessation [11].there are few studies which challenge this challenge this notion of timing of smoking cessation. Even 3-5 days of stopping could improve clearance and decrease of secretions. Vaporciyan el al showed that patients who quit smoking 4 weeks or more before surgery had a lower incidence of pulmonary complications than patients who continued to smoke or quit fewer than 4 weeks before pneumonectomy [12]. However, Barrera and co-workers found no difference in the incidence of pulmonary complications between patients who were still smoking at the time of surgery and those who had quit fewer than 2 months before thoracotomy for lung resection [13]. In many centres including ours the recommendation is to stop smoking at any time and provide support services to help out with the same.

#### **2.2. Preoperative education and physiotherapy**

Preoperative physiotherapy and education is done in many centres as part of work up for thoracotomy. Physiotherapists and thoracic ward medical and other staff perform a variety of care for patients undergoing surgery both pre and post operatively. All these are done to prevent postoperative complications like atelectasis, pneumonia, effusions and empyema. Various manoeuvres include education, deep breathing and coughing manoeuvres, chest physiotherapy and early mobilization education post sugery [14]. According to few studies this has led to an improvement in the prevention of atelectasis, collapse and consolidation. Many other interventions like incentive spirometry and respiratory muscle strengthening have been shown to reduce the incidence of these complications. During the work up assessment of the pulmonary functions are done and bronchodilators optimised.

In the education session instructions may be given for deep breathing and splinted coughing exercises, prophylaxis exercises for deep vein thrombosis, and shoulder exercises [15]. There studies which question the benefit of preoperative education and physiotherapy and few studies have shown them to be non-beneficial16 but we continue to follow preoperative education as well as physiotherapy prior to thoracic surgery.

Patients are also investigated for cardiac ailments if there are symptoms, signs or significant cardiac history prior to performing elective thoracic surgery. Investigations may include echocardiography, cardiac viability study or angiogram. Patients who are on antiplatelets should have their medications withheld 7 days prior to surgery is possible. If patients are on warfarin then it is stopped 3 days prior to surgery and are covered with heparin

Patients are given a single dose of antibiotics for elective cases and they are continued for infected cased or restarted postoperatively if needed. If surgical intervention is elective, we advocate a short period of preparation may be beneficial if directed at improving the patient's physical status and specifically at pulmonary preparation, conditioning exercises, and nutrition.
