Preoperative chest x-rays: a teachable moment.

MrX,aman inhismid50swithahistoryofmild intermittent asthma and an increasingly painful umbilical hernia, presented to a general surgery clinic for a preoperative evaluation.Basic laboratorytest resultsandcardiopulmonary examination findings were normal, and a reducible hernia was noted. A chest radiograph (CXR) was obtainedfortheindicationofpreoperativeevaluationinapatient with asthma older than 55 years. The CXR revealed a 7-mm left perihilar lung nodule, with a radiologist recommending further evaluation of the lung with computedtomography(CT).Asaresult,herniasurgerywasdelayed andCT scan of the chestwas undertaken. Fourweeks later, Mr X followed up to review the resultsofhisCTscan,which revealednopulmonarynodule but revealed a right adrenal nodule. The radiologist recommended that dedicated adrenal CT imaging be orderedby themedical team, further delaying surgery. Adrenal CT revealed findings consistent with a benign adenoma.Hernia repairwas finally completedmore than 6months after his preoperative evaluation. Throughout this time,Mr X noted persistent pain fromhis hernia and anxiety over the positive test results. ThevalueofpreoperativeCXRhasneverbeenestablished. TheRoyal College of Radiology examined the utilityofpreoperativeCXR in8hospitals and 10 619patients in1979.Itconcluded,“Inviewoftheabsenceofclinicalusefulnessof routine[preoperativeCXR] in...nonemergency operations,”therewaswidespreadoveruse,and“thepolicy of abandoning routine [preoperative CXR]... should be discussed.”1Sincethattime, littleevidencehassurfacedto supportpreoperativeCXR,butthepracticecontinues.Recently, theChoosingWiselycampaignidentifiedpreoperativeCXRasapriorityareatoraiseawarenessofitsoveruse.2 Assessing the utility of this screening method requires estimating what fraction of CXRs have unexpected findings that proveuseful inmanagement.Most studies define a CXR-related change inmanagement as delay or cancellation of surgery or a change in anesthesia protocol, neither of which have been shown to lead to better patient outcomes. Existingstudiesonchangesinanesthesiamanagement donot include randomizedcontrolled trials; theyarepredominantly retrospectivetrials.Reviewsof thetopicconsistently cite the same nonblinded and nonrandomized studies. Silvestri et al3 conducted the largestmulticenter studytodate(6111patients).Patientsundergoingelective surgerywhohad submitted to a preoperative CXR at the surgeon’sdiscretionwereenrolled.Anesthesiologistswere interviewedafterthesurgicalprocedureandaskedwhether preoperativeCXRchangedmanagement.Resultsshowed thatpreoperativeCXRresulted ina revisionofanesthesia managementfrom0%to13.5%ofthetimedependingon theanesthesiologistquestioned.Giventhenonblinded,retrospectiveformatofthesurvey, theseresultsareproneto bias;thevariability inresponsesismoreconsistentwiththe variabilityofanesthesiologypreferencethanusefulpredictors of theutility of preoperativeCXR. In the absenceofbetter evidence, theAmericanSocietyofAnesthesiologists(ASA)statedin2001,“[theASA] does not believe that extremes of age, smoking, stable COPD[chronicobstructivepulmonarydisease],stablecardiac disease, or resolved recent upper respiratory infection should be considered unequivocal indications for chest radiography.”4 In2005,Jooetal5publishedasystematicreviewof14 articles evaluating the practice of preoperative CXR. Althoughthis reviewconsideredthesamenonrandomized, nonblinded, largely retrospective trials referencedearlier in this article, theauthors took intoaccount thequalityof theevidenceandconcludedthatroutinepreoperativeCXR shouldnotbeperformedinasymptomaticpatients.Bytheir assessment,mostabnormalitiesarechronic,areexpected, ordonotaffectmanagementorpostoperativeoutcome.5 DespitetheevidencethatpreoperativeCXRisunlikely tobebeneficial, itcontinuestobeusedindailypractice.Exposingapatienttomultipleadditionalstudiesprolongssurgical delay, increasesexposure to radiation, prolongsand exacerbatesunderlyinganxiety,andincreasesthelikelihood of additional incidentalomas. The existing studies would likelylabelMrX’scaseasuccess;preoperativeCXRhadidentified anunexpected abnormality that changedmanagementbydelayingsurgery.However, a closer lookatan individualcasesuchasMrX’smayactuallyillustratealessrosy view of the consequences of preoperative CXR. He had morethan100timestheradiationofasingleCXR,anxiety due to multiple incidental findings, and one objective patient-orientedoutcome—delayinthemanagementofhis painful hernia.