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\nIntroduction: The relationship between preoperative peak oxygen uptake/weight (VO2/W) and postoperative pulmonary complications (PPC) in lobectomies, including video-assisted thoracoscopic surgery, remains unclear. Traditional pulmonary function tests are often unreliable in this group, necessitating alternative predictive methods. Therefore, this study aimed to clarify the predictive value of preoperative peak VO2/W for PPC and explore factors related to PPC in lung cancer patients with chronic obstructive pulmonary disease (COPD). Methods: This single-center retrospective cohort study included 40 patients with lung cancer complicated by COPD who underwent a preoperative cardiopulmonary exercise test between January 2017 and March 2024. Patients were divided into those with and without PPC (PPC and non-PPC groups, respectively). Clinical parameters such as surgical approach, pulmonary function, low attenuation area, and peak VO2/W were compared between the groups. The association between these parameters and PPC was analyzed using multivariate logistic regression. Results: The preoperative % diffusing capacity of the lung for carbon monoxide (%DLCO) and peak VO2/W were significantly lower in the PPC group than in the non-PPC group (p < 0.01 and p < 0.001, respectively), while the ventilatory equivalent/ventilatory carbon dioxide (VE/VCO2) slope was significantly higher in the PPC group than in the non-PPC group (p < 0.05). In the multivariate logistic analysis including the %DLCO, peak VO2/W, VE/VCO2 slope, and forced expiratory volume in 1 s, only peak VO2/W was identified as a significant independent factor for predicting PPC. The area under the receiver operating characteristic curve of peak VO2/W to predict PPC was 0.93, with a cutoff value of 14.6 mL/min/kg, sensitivity of 78%, and specificity of 95%. Conclusions: This study revealed that peak VO2/W was the most important parameter for predicting PPC in lung cancer patients with COPD. Incorporating cardiopulmonary exercise tests into preoperative assessments could improve risk stratification and perioperative management, potentially reducing the incidence of PPC in this high-risk population. Lung cancer surgery can be risky, especially for patients who also have chronic obstructive pulmonary disease (COPD). COPD makes it harder to breathe and can lead to serious lung problems after surgery. Doctors often use breathing tests before surgery to predict these complications, but these tests are not always accurate. In our study, we focused on a different kind of test called the cardiopulmonary exercise test (CPET). This test measures how much oxygen a patient can use during exercise, known as peak oxygen uptake (VO2/W). We wanted to see if this measurement could better predict lung problems after surgery for lung cancer patients with COPD. We looked at 40 patients who had lung cancer and COPD and who had undergone lung surgery at Kindai University Hospital. All these patients did a CPET before their surgery. We found that patients with lower VO2/W had more lung problems after surgery. In fact, VO2/W was a better predictor of these complications than the traditional breathing tests. Our results suggest that measuring VO2/W before surgery can help doctors identify patients who are at higher risk for lung problems. This could lead to better preparation and care for these patients, potentially improving their outcomes after surgery. In summary, using CPET to measure VO2/W can give doctors a more accurate tool to predict and prevent complications in lung cancer patients with COPD. This could make lung surgery safer for this high-risk group of patients. [ABSTRACT FROM AUTHOR]