Complications and Post-operative Care of Pulmonary Resection

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Complications and Post-operative Care of
Pulmonary Resection

• Department of Surgery, Division of General
  Thoracic Surgery, Veterans General Hospital
  Kaohsiung.
• Chou Yi-Pin, MD.

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Surgical candidate of pulmonary resection

• Age.
• Pulmonary function
• PaO2 gt 50 mmHg.
• PaCO2 lt 50 mmHg
• FEV1 gt 0.8 L
• Vital capacity gt 15ml/kg
• DLCO gt 40
• Pulmonary artery lt 40 mmHg

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A. INTRAOPERATIVE COMPLICATIONS

• The 3 major intraoperative complications
• 1. Injury to the large vessel with massive
• bleeding
• 2. Arrhythmia and myocardial ischemia
• 3. Contralateral pneumothorax

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A. INTRAOPERATIVE COMPLICATIONS

• Other complications are not lethal immediately
  but cause morbidity
• injury of the intrathoracic nerve, thoracic
• duct, esophagus, spinal cord and dura.
• Tumor embolism is rare but lethal. It is not
  diagnosed immediately intraoperatively.

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A. INTRAOPERATIVE COMPLICATIONS

• Injury to a Major Pulmonary Vessel
• Prevention
• Proximal control
• Exposed intrapericardially

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A. INTRAOPERATIVE COMPLICATIONS

• Intraoperative Cardiac Complications
• Intraopeative arrhythmias and myocardial
  
• ischemia are often seen in patients
  with
• underlying heart diseases.
• Preoperative identifications are
  necessary.
• A Swan-Ganz catheter, preoperative and
• intraoperative medication may be
  indicated.

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A. INTRAOPERATIVE COMPLICATIONS

• Intraoperative Cardiac Complications
• Excessive manipulation of the heart can
• induce arrhythmia.
• Rietchie et al. noted that prophylactic
• digitalization has No effect to reduce
• inptraoperative arrhythmia.
• Amar et al. noted that the effect of
  Ca-channel
• blocker to prevent postoperative
  supraventricular
• arrhythmia is unknown.

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A. INTRAOPERATIVE COMPLICATIONS

• Contralateral Pneumothorax
• Its incidence is 0.8.
• It may occur during ultra-radical lymph
• node dissection with perforation of
  
• mediastinal pleura.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• Factors influence the incidence and type of
  complication after lung resection include age,
  physical status and procedure.
• Mitsudomi et al. suggested that high LDH level
  and low predicted FEV1 were associated with
  postoperative complications after pneumonectomy.
  

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• After pneumonectomy, the incidence of nonfatal
  complication varies from 15 to 60.
• The majority of complications after pneumonectomy
  are cardiac dysrhythmias, pulmonary infection,
  respiratory insufficiency, empyema,
  bronchopleural fistula and hemothorax.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• The morbidity rate of lobectomy is frequently
  higher and associated with disease process
  Carcinoma or inflammatory.
• The complication is seen more often in men than
  in women.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• Keagy et al noted that 41 of patients undergoing
  lobectomy had nonfatal complications?
• 1/3 of patients cardiac complications
• 1/3 of patients pleural complications
• 1/3 of patients had respiratory complications
  and require prolonged ventilation

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• After wedge and segmentectomy, the complication
  is similar to that in lobectomy.
• The major complications of segmentectomy are
  prolonged air leak, peripheral fistula, empyema.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• The major causes mortality of pneumonectomy are
  respiratory insufficiency, septic complications,
  pulmonary edema, myocardial infarction and
  pulmonary embolism.
• The mortality rate of pneumonectomy is 3-5
• Renal failure may be a major cause in old
  patients.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• The major causes mortality of lobectomy are
  septic complications and cardiopulmonary
  insufficiency.
• The mortality rate of lobectomy is 1-3
• Fatal pulmonary embolism is infrequent.
• UGI hemorrhage occurs occasionally.

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B. POSTOPERATIVE COMPLICATIONS MORBIDITY AND
MORTALITY AFTER PULMONARY RESECTION

• The mortality rate of segmentectomy is about 1.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Hemorrhage complications
• Postoperative hemorrhage
• 1. It is the result of inadequate
  hemostasis of the
• bronchial artery or a systemic vessel
  in the
• chest wall.
• 2. Infrequently, slipping of a ligature or
  an
• un-recognized injury is a cause.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Hemorrhage complications
• Postoperative hemorrhage
• 3. Bleeding related to coagulation is rare.
• 4. When a chest tube is placed, drainage
• more than 200 ml/hr for 4 to 6 hours
• indicates massive bleeding.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Hemorrhage complications
• Postoperative hemorrhage
• Re-exploration is indicated if
• (1)failed response to blood replacement
• (2)a large amount of blood in the hemithorax
• (3)persistent massive bleeding from the
  chest
• tube

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Brochovascular fistula
• 1. It is rare.
• 2. 3 of patients undergoing
• bronchoplasty had the complication.
• 3. It is avoided by placing a tissue
  flap
• between the bronchial stump and
  vascular
• suture line.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac Herniation
• 1. It is rare but usually follows
• pneumonectomy.
• 2. Opening the pericardial sac on the
  left
• down to the diaphragm prevents left-
  
• side herniation, but opening of
  pericardium
• on the right does not do so.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac Herniation
• 3. Right side herniation an be detected
  on
• PA or AP view and left side
  herniation can
• be detected on lateral view of CXR.
• 5. EKG change may mimic MI.
• 6. Prompt surgical repair is necessary.
• 7. Mortality rate is 50.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac Tamponade
• 1. When the pericardium was opened
• and then closed, undetected bleeding
• may cause the complication.
• 2. Diagnosis is established by Echo,
• radiograph and right side wedge
  pressure.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac dysrhythmia
• Cardiac tachydysrhythmia occurs in 18
• of patients of noncardiac surgery
  and
• it is most common in pneumonectomy.
• The dysrhythmia occur most common
• in patients aged 60 years or older.
• Atrial fibrillation is the most common.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac complications
• Cardiac dysrhythmia
• VT
• lidocaine IV bolus 50 to 100 mg
  then
• infusion 1 to 3 mg/min
• Bradyarrhythmia
• atropine, isoproterenol
• cardiac pacing is indicated in 3
  A-V block
• or SSS.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Cardiac complications
• Myocardial ischemia and Myocardial
  infarction
• 1. Transient myocardial ischemia is
• uncommon.
• 2. Myocardial infarction rate is about
• 1.2.
• 3. Preoperative cardiac evaluation is
  necessary.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pleural complications
• Persistent Residual Air Space
• 1. frequently after a lobectomy
• 2. More in older patients and
• granulomatous disease
• 3. Apex is more common.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pleural complications
• Empyema
• 1. 1-3 of pneumonectomy
• 2. Inflammatory disease, residual space,
  
• gross contamination during
  operation, re-
• operation, bronchial leak and
  postoperative
• mechanical ventilation can increase
  
• the risk.
• 3. Initial treatment is drainage and
  systemic antibiotics.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pleural complications
• Chylothorax
• 1. Incidence is 0.05.
• 2. Initial treatment is drainage and TPN
• or low-fat diet and median-chain TG
  for 7-
• 14 days.
• 3. If leak of 300 ml/day( pneumonectomy )
  or
• 500 ml/day( lobectomy ) then surgery
  is indicated

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Postpneumonectomy Pulmonary Edema( PPE )
• 1. 2-5 of pneumonectomy( usually right
  )
• 2. High mortality
• 3. Overhydration is the etiology.
• 4. Therapy fluid restriction, morphine,
  diuretics
• and mechanical ventilation with PEEP.
  

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Massive Atelectasis
• 1. Severe atelectasis is more common
• after RUL or RUL RML
• bilobectomy.
• 2. S/S fever, SOB, HR?
• 3. CXR and PE can be diagnostic.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Lobar Torsion and Gangrene
• 1. Torsion is more common with a free
  RML.
• 2. Suture to a remaining lung can reduce
  
• the incidence of torsion.
• 3. CXR can reveal incomplete expansion
  and
• opacity.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Lobar Torsion and Gangrene
• 4. Bronchoscopy is indicated if lack of
• expansion after tracheobronchal
  suction.
• 5. Bronchoscopy can reveal a compressed
• bronchus( fishmouth-like ).
• 6. Perfusion scan, angiography and CT
  scan are
• diagnostic but not necessary for
  torsion.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Postoperative Pneumonia
• 1. Etiologic factors prolonged
• mechanical ventilation, retention of
  
• secretions and atelectasis
• 2. Treatment nutrition, antibiotics,
• tracheobronchial toilet

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Bronchopleural fistula
• 1. 1 to 4 of pneumonectomy or
• lobectomy
• 2. More common in inflammatory disease
• 3. Risk factors DM, pneumonectomy,
  tumor in
• brinchial stump and pre-OP
  irradiatiion.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Pulmonary complications
• Bronchopleural fistula
• 5. Treatment
• antibiotics
• drainage
• re-operation
• Eloesser flap
• Clagett maneuver

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Esophageal injury
• 1. When confirmed during operation, it
• must be repaired.
• 2. Late-recognized esophageal injury
• results in empyema and mediastinitis.
  It has
• high morbidity and mortality.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Wound Complications
• wound infection
• rare antibiotics and open drainage
• wound dehiscence
• less common than wound infection
• subcutaneous emphysema
• no specific therapy except drainage
• most are benign except a
  bronchopleural fistula

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Thoracic Neurologic complications
• Injury to the intrathoracic nerve
• phrenic nerve rare
• recurrent laryngeal nerve
• usually in left, when dissecting
  A-P
• window
• hoarseness and aspiration may occur.

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C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION

• Complications Not Unique to Pulmonary Resection
• DVT
• 1. It is more common in adenocarcinoma,
• large tumor, major resection and
• advanced stage.
• 2. Ziomek 19 of incidence

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D. LATE COMPLICATIONS

• Postpneumonectomy Syndrome
• Left( right ) Postpneumonectomy Syndrome
• 1. (counter)clockwise rotation of great
• vessels and trachea?compression of
• right(left) main bronchus and
  right(left)
• pulmonary artery.
• 2. treatment prosthetic device in
  ipsilateral
• hemithorax

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D. LATE COMPLICATIONS

• Superimposed Late Infection
• late empyema
• residual space or bronchopleural
• fistula( due to tumor recurrence )
• fungal empyema
• Aspergilus fumigatus is most common.

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Thank You!