Pneumonectomy

Chapter 67 Pneumonectomy



James E. Davies, MD, Mark S. Allen, MD



INTRODUCTION


The first successful pneumonectomy was performed by Rudolph Nissen in 1931 in Berlin, Germany. His patient was a 12-year-old girl with severe bronchiectasis of the entire left lung. This was a staged procedure with a cervical phrenic crush performed initially, followed by a left thoracotomy. The pneumonectomy was performed by placing a rubber tube ligature around the hilum of the left lung. The chest was packed, and 2 weeks later, the lung sloughed off. A small bronchial fistula developed but closed spontaneously 2 months later.1 On April 5, 1933, Everts Graham,2 Chair of Surgery at Washington School of Medicine, performed the first successful single-stage pneumonectomy. The patient was a 48-year-old gynecologist with a squamous cell carcinoma of the left lung that could be removed only with a pneumonectomy.


Since these early reports, the number of pneumonectomies has steadily increased and mortality rates have improved. These improvements are probably secondary to a combination of better surgical approaches, patient selection, anesthesia, and postoperative care. Wilkins and coworkers3 showed a decrease in operative mortality, from 56% to 11%, over a period of 4 decades (1931–1970) at the Massachusetts General Hospital. Numerous reports since 1980 have shown mortality rates from 3% to 12%.3–6 Certain risk factors associated with higher mortality rates have been identified. Right-sided pneumonectomies have a higher morbidity and mortality than left-sided pneumonectomies. Reports by Nagasaki and associates4 and Wahi and colleagues5 confirmed significantly higher mortality rates with right-versus left-sided pneumonectomies. Wahi and colleagues reported in 19895 that right-sided pneumonectomy had a 12% mortality versus only 1% with left pneumonectomy. In 2001, Martin and coworkers,7 from Memorial Sloan-Kettering Cancer Center, reported a 24% mortality for right-sided pneumonectomy versus 2.4% for left-sided pneumonectomy. Other risk factors shown to be associated with higher mortality include age greater than 70 years, neoadjuvant therapy, completion pneumonectomy, and resection for inflammatory or infectious disease.8–14



INDICATIONS



• Carcinoma of lung (centrally located)

• Inflammatory/infectious lung disease with destroyed lung

• Proximal bronchial stricture/obstruction with destroyed lung

• Completion pneumonectomy

• Extrapleural pneumonectomy for malignant mesothelioma

• Trauma


OPERATIVE STEPS



Step 1 Anesthesia (double-lumen endotracheal tube and epidural catheter)

Step 2 Posterolateral thoracotomy

Step 3 Exploration of pleural cavity

Step 4 Mediastinal lymphadenectomy

Step 5 Mobilization of pulmonary hilum

Step 6 Ligation of pulmonary veins

Step 7 Ligation of pulmonary artery

Step 8 Transection of bronchus

Step 9 Closure


Mediastinal Lymphadenectomy



Chylothorax


Chylothorax is a rare complication after pneumonectomy. In 1993, Vallieres and associates15 published a review of the literature that showed a total of only 27 cases. Since that time, other series have shown an incidence of 0.37% to 0.5% of pneumonectomies.16,17 Cerfolio and colleagues17 reviewed the Mayo Clinic experience from 1987 to 1995 (315 patients) and found an incidence of 0.37%.



• Consequence



Initially, chylothorax is difficult to diagnose in the pneumonectomy patient because normally all chest tubes are removed within 24 hours. This leads to a delay in the diagnosis and a potentially extended hospital stay. The diagnosis should be suspected when there is rapid accumulation of fluid within the pleural cavity. In the series by Sarsam and coworkers,16 nine patients had a rapid accumulation of fluid but only four were symptomatic. These symptoms are normally increased respiratory difficulty or compromise. Tension chylothorax requiring emergency drainage was described by Karwande and associates in 1986.18

Chylothorax can lead to serious metabolic defects secondary to the composition of chyle. The loss of protein, fat, and fat-soluble vitamins requires increased nutritional support, and the immunologic status of the patient can be affected by the loss of chyle.

Grade 2/3 complication


• Repair



The initial treatment for a chylothorax is conservative management with external drainage, nutritional support, and observation. The diagnosis is suggested by the presence of milky white drainage and confirmed by an elevated triglyceride level of the fluid (>110 mg/dl). The patient should be placed on total parental nutrition or a medium-chain triglyceride diet, and the volume of the fluid should be observed and recorded accurately. If it is greater than 500 ml/day, it is less likely to resolve with conservative therapy and surgical intervention should be performed. The leak can be isolated by giving 100 to 200 ml of olive oil or cream to the patient by nasogastric tube 2 to 3 hours prior to the surgical exploration.19 This will increase the output of the milky fluid from the duct and make it easier to identify intraoperatively. The chest should be reopened on the side of the pneumonectomy and the thoracic duct ligated. This can be done by direct closure on the leak, mass ligation of the ductal tissue, or supradiaphragmatic ligation of the duct on the right side. Other techniques that have been described include pleuroperitoneal shunting with double-valve Denver peritoneal shunts and the use of fibrin glue.20,21


• Prevention



The best way to prevent an injury to the thoracic duct during a pneumonectomy or any thoracic procedure is through knowledge of the anatomy of the duct (Fig. 67-1). It originates from the cisterna chyli at the level of the second lumbar vertebrae and ascends through the aortic hiatus into the chest. The duct continues superiorly on the anterior surface of the vertebral column behind the esophagus and between the aorta and the azygos vein. At the level of T4 or T5, it crosses the midline behind the aorta into the left side of the chest. The duct continues superiorly adjacent to the esophagus and drains into the left subclavian–jugular junction.22

image

Figure 67-1 Anatomy of the thoracic duct.



Recurrent Laryngeal Nerve Injuries


Recurrent laryngeal nerve injuries are not common with pneumonectomy or any pulmonary resection. They can be intentional (sacrificing the nerve for a complete oncologic resection) or unintentional (secondary to traction or direct injury). Mediastinal lymphadenectomy can lead to more injuries, especially on the left. Bollen and colleagues23 reported that 3 out of 62 patients undergoing complete mediastinal lymphadenectomy suffered unintentional injury. Conversely, in the American College of Surgical Oncology Group’s (ACOSOG) study24 of lymphadenectomy versus lymph node sampling, no increase was observed in the incidence of recurrent nerve injuries with mediastinal lymph node dissection.



• Consequence



Injury to recurrent laryngeal nerve leads to unilateral vocal cord paralysis. The degree of dysfunction is variable, but it may cause inadequate cough, inability to clear secretions, or aspiration in the postoperative setting. Patient age, recent weight loss, and overall pulmonary function prior to resection correlate with the patient’s ability to compensate postoperatively.

Grade 3 complication


• Repair



The treatment and timing for recurrent laryngeal nerve injuries depend on the status and condition of the patient. Definitive treatment is with medialization of the vocal cords, normally performed by an otolaryngologist. Three techniques described include vocal cord injection, neuromuscular transfer, and vocal cord implant.25


• Prevention



Injury to the recurrent laryngeal nerve is most common on the left during resection of stations 5 and 6 lymph nodes. Care must be taken during this portion of the procedure to avoid direct injury or excessive traction on the recurrent laryngeal nerve. If needed, sharp dissection rather than cautery should be used. A vessel loop can also be placed around the nerve for gentle traction. This decreases the crushing effect of picking up the nerve directly. Figure 67-2 shows the anatomy of the nerve in relation to levels V and VI lymph nodes.

image

Figure 67-2 Anatomy of the left aortopulmonary window with levels V and VI lymph nodes.



Mobilization of the Pulmonary Hilum



Esophagopleural Fistula


Esophagopleural fistula (EPF) occurs in 0.5% to 0.65% of patients undergoing pneumonectomy.26–28 EPFs are more common of the right side, and the incidence is increased in patients undergoing pneumonectomy for inflammatory or infectious diseases. This is most likely secondary to the difficulty in the dissection of the pulmonary hilum in these patients. Massard and Wihlm29 divided EPFs into two groups: early and late (>3 mo). The etiology in the early group was direct operative trauma or devascularization/necrosis versus recurrent cancer or chronic infectious/inflammatory disorder in the late group. The diagnosis can be difficult to make in either group because EPFs tend to present in the same way as a bronchopleural fistula (BPF). Therefore, the work-up tends to be directed at ruling out a BPF with a flexible bronchoscopy. If this is negative, a water-soluble swallow study should be performed immediately to rule out an EPF.



• Consequence



EPF presents with an associated empyema in both the early and the late groups. Early reports cited a mortality of 50% in these patients.28,30 More recent reports, including one from the Mayo Clinic by Deschamps and coworkers in 2001,31 showed a mortality of approximately 7.5% in patients with empyemas after pneumonectomy. The increased mortality depends on the etiology of the fistula; the late group has a higher incidence of recurrent malignancy.

Grade 3 complication


• Repair



The initial treatment of empyema with EPF is drainage of the empyema, appropriate antibiotics, and nutritional support with nasogastric tube or parenteral nutrition. Definitive treatment depends on the etiology of the fistula, but EPF is treated in the same way as a BPF, which is discussed in detail later in this section.


• Prevention



If a difficult dissection of the mediastinum is suspected or found during the operation, a large bougie may be inserted to aid in identifying the esophagus. This may help avoid but will not prevent direct injury to the esophagus. If an injury is suspected, methylene blue or air may be injected into the nasogastric tube to help identify the injury. Once the injury is located, it can be closed in two layers of fine nonabsorbable suture and buttressed with a pleural flap or other viable tissue.30


Cardiac Herniation


Cardiac herniation or torsion is a rare complication after pneumonectomy, but it is associated with a mortality rate of 40% to 50%.32,33 It is associated with opening the pericardial sac for intrapericardial pneumonectomy. On the left, herniation results in strangulation of the left ventricle with decreased filling and ejection. There is also decreased or no coronary blood flow, leading to myocardial ischemia. The right-sided herniation leads to a counterclockwise rotation of the heart and obstruction of the superior and inferior vena cava (Fig. 67-3). These normally present within 24 hours but have been reported up to 72 hours postoperatively.


image

Figure 67-3 Chest radiograph of right-sided cardiac herniation.



• Consequence



The patient will develop abrupt hypotension, tachycardia, increased venous pressure, and progressive cardiovascular collapse. If the diagnosis and treatment are not instituted immediately, fatality will result.32,33

Grade 3/5 complication


• Repair



After diagnosis, the patient should be placed immediately with the operative side up and taken back to the operating room. Upon reopening of the thoracotomy, the cardiac herniation should be reduced and the pericardium reconstructed, usually with a synthetic patch.


• Prevention



Closure of all but very small pericardial defects should be performed intraoperatively. If the pericardium cannot be closed without causing cardiac restriction, a synthetic patch should be used. This does not fully eliminate postoperative herniation, as reported by Veronesi and associates in 2001.34 Also, the pleural cavity should not be placed or kept on excessive suction. Figure 67-4 shows a large pericardial defect after a left extrapleural pneumonectomy.

image

Figure 67-4 Intraoperative large pericardial defect after intrapericardial pneumonectomy.



Ligation of the Pulmonary Veins



Peripheral Tumor Embolus



• Consequence



Peripheral tumor embolus during a pneumonectomy is a rare but potentially lethal complication.35 It was first described by Taber36 and Senderoff and Kirschner37 in the early 1960s. Whyte and colleagues38 reported that the distribution of the emboli were most commonly major arterial sites: the aortic bifurcation and femoral arteries (50%), the carotid and cerebral arteries (32%), and the visceral arteries (18%).

Grade 3/4 complication


• Repair



If a tumor embolus is suspected in the perioperative period, an angiogram should be performed. Once the diagnosis is confirmed, removal by an embolectomy is done if the patient is clinically stable enough to return to the operating room.


• Prevention



If a tumor is suspected pre- or intraoperatively within the pulmonary vein, a transesophageal echocardiogram is performed to assess intra-atrial involvement.35,39 At the time of surgery, the intrapericardial portion of the pulmonary hilum is explored and assessed for resectability. Another technique described by Taber36 is placement of a pursestring suture in the left atrium and transatrial digital palpation. If the tumor involves the left atrium or distal pulmonary vein, it may be removed with or without cardiopulmonary bypass.35,38,39 Figure 67-5 shows a management algorithm described by Whyte and colleagues in 1992.38

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Pneumonectomy

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