Post-Pneumonectomy Complications Flashcards
Mortality for pneumonectomy
3-12%
Mortality increased for Right or Left pneumonectomy
Right sided pneumonectomy
- Primarily due to higher incidence:
- BPF
- empyema
- pulmonary edema
Risk factors for mortality after pneumonectomy
- Right sided pneumonectomy
- Completion pneumonectomy
- older age
- induction therapy
- resection for infectious or inflammatory diseaes
- extended procedures
- carinal pneumonectomy
- extrapleural pneumonectomy
Morbidity after pneumonectomy
15-75%
Most frequent complications after pneumonectomy
- Respiratory failure
- PNA
- BPF
- empyema
- arrhythmia (AF)
- MI
- PE
5 important complications associated with pneumonectomy
- Post-pneumonectomy syndrome
- Cardiac herniation
- Post-penumonectomy pulmonary edema
- BPF
- Empyema
Progressive mediastinal shift after pneumonectomy
Post-pneumonectomy sydrome
Etiology of post-pneumonectomy syndrome
Stretching or compression of trachea or remaining bronchus by PA, Ao, or vertebral column
- Theoretical etiologies:
- hyperinflation of remaining lung
- hyperplasia
- size of pneumonectomy space
- elasticity of mediastinal tissues
- chest wall or diaphragmatic changes
Post-pneumonectomy syndrome more common after pneumonectomy of right OR left side?
Right sided pneumonectomy
Long-term effects of post-pneumonectomy syndrome
- Severe respiratory compromise
- Tracheobronchial malacia
- Recurrent infections
- Bronchiectasis
- Parenchymal destruction
Age group at higher risk for post-pneumonectomy syndrome
Children (present early)
(Adults develop late sx: dyspnea, stridor, recurrent infections, orthopnea)
Dx test of choice for post-pneumonectomy syndrome
Bronchoscopy
CT chest
TOC for post-pneumonectomy syndrome
Thoractomy with placement of prosthetic device (silicone breast implant) in pneumonectomy space to restore mediastinal anatomic position and relieve airway obstruction
Most significant complication after intrapericardial pneumonectomy
Caridac herniation
- Rare
- Equal after right or left pneumonectomy
Surgical technique to decrease risk of cardiac herniation after left sided intrapericardial pneumonectomy
Open pericardium all the way inferiorly to the diaphragm
MOA of cardiac herniation (right side)
torsion of LV anteriorly and torsion to the right through the defect (occludes SVC and IVC inflow)
MOA of cardiac herniation (left side)
LV herniation trough defect with strangulation (impariment of diastolic, systoic and coronary perfusion)
Mortality rate associated with cardiac herniation after pnuemonectomy
~ 50%
- Occurs wtihin first 72 hours
- Triggered by change in patient position
Presentation of cardiac herniation
- Fist 72 hrs postop
- Recent change in patient position
- Cyanosis, elevated CVP, hypotension, tachycardia
- Displaced cardiac impulse
- Rapid clinical deterioration
TOC of cardiac herniation (right side)
- Place patient left side down (immediately)
- Emergent return to OR for redo thoracotomy and patch closure of pericardial defect
Clinical presentation of post-pneumonectomy pulmonary edema
Rapidly progressive dyspnea, hypoxemia, and CXR e/o pulmonary edema in patient with normal PFTs and unremarkable 12-24 hour postoperative course after right pneumonectomy
Incidence of post-pneumonectomy pulmonary edema
~ 2-5%
Mortality associated with post-pneumonectomy pulmonary edema
~60-90%
Risk factors for post-pneumonectomy pulmonary edema
- Right sided pneumonectomy
- Extensive resection (carinal pneumonectomy)
MOA of post-pneumonectomy pulmonary edema
Similar to ARDS (endothelial injury) with an increased gradient across the pulmonary microcirculation (i.e. hyperpermiability)
Factors thought to contribute to post-pneumonectomy syndrome
- Excessive fluid administration
- Disruption of lymphatics draining remaining lung
- Immunologic reaction to blood products (FFP)
- Extent and duration of opertaion
- Use of underwater seal drainage system vs. balanced system
- Mechanical factors (hyperinflation, air blocking)
Dx w/u for post-pneumonectomy pulmonary edema
Invasive right heart monitoring
CT
Pan-cultures
Bronchoscopy
Tx post-pneumonectomy pulmonary edema
- IVF restriction
- Early use of diurectics
- Pain control
- Pressors for hypotension
- Avoidance of barotrauma (PC ventilation)
- iNO
- Steroids (controversial)
Incidence of BPF afgter pneumonectomy
1-10%
Mortaliy associated with BPF after pneumonectomy
30-50%
RF for BPF after pneumonectomy
- Right sided pneumonectomy
- Completion pneumonectomy
- Resection for inflammation/infection (esp TB with positive sputum)
- Prior mediastinal/hilar XRT
- Prolonged mechanical ventilation
- DM
- Post-pneumonectomy empyema
- Residual tumor at bronchial stump
- Stump devascularization, incomplete closure, long bronchial stump
- Old age
- Steroid use, malnutrition, induction chemo and XRT
- *
BPF eary after surgery (1-2 days) usually due to
Technical factors
(devascularization, incomplete closure, long stump)
Presentation of early BPF
- Massive air leak
- Progressive SQ air
- Respiratory insufficiency
Presentation of BPF later in postoperative course
Due to inadequate healing of broncial stump
Fever and/or productive cough
Risk for flooding remaining lung (place patient with operative side down, head up, and immediate drainage of pleural space with tube thoracostomy or redo thoracotomy)
Presentation and diagnosis of occult BPF
Most common form
Asymptomatic or minimally symptomatic (fall in plural space fluid)
Dx: bronchoscopy (maybe methylene blue injection into pneumonectomy space)
(alternate: inhaled radionuceotide)
TOC of occult BPF
Close observation (if asymptomatic)
Prompt drainage of pleural space (signs or syptoms of infection)
TOC of clinically evident BPF
- Early presentation (within 2 weeks):
- Abx
- Reoperation, repair and coverage of stump (omentum, pericardial fat, muscle)
- Open drainage if severe empyema
- Late presentaiton (> 2 weeks):
- Abx
- Pleural space drainage (tube or open drainage)
- Cleansing of pleural space
- Closure of bronchial stump with coverage
- If unable to close, transpose muscle flap between divided ends to avoid re-fistulization
- Sterilization of pleural space (Clagett procedure)
- If fails, pleural space obliteration with muscle flaps
Incidence of empyema after pneumonectomy
2-16% (5-7% in most series)
Dx and TOC of post-pneumonectomy empyema
- Dx: sampling of pleural fluid
- TOC:
- Abx and drainage
- Early empyema without BPF:
- VATS drainage, irrigation, and Abx
- Large empyema without BPF:
- Open drainage
- Sterilizaiton of pleural space (Clagget procedure)
- Pleural space obliteration with flaps
- Thoracoplasty
