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Ann Thorac Surg 1995;59:408-411
© 1995 The Society of Thoracic Surgeons

Pneumonectomy for Chronic Infection: Fraught With Danger?

Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina

Accepted for publication September 28, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Pneumonectomy for chronic lung infections has been avoided because of potential intraoperative and postoperative complications. A retrospective review of 13 cases requiring pneumonectomy for aspergillus (8), Mycobacterium tuberculosis (2), actinomycosis, Pseudomonas aeruginosa, and bronchiectasis revealed increased operating time, blood loss, and transfusion requirements. Operative records documented problems with dense adhesions, lack of an extrapleural plane, and distortion of hilar structures. Although mortality was acceptable (8%), early and late morbidity (total, 38%), especially bronchopleural fistula (23%), was significant. It is concluded that when justified, pneumonectomy for complete resection of chronic infection can be performed with acceptable risk. However, specific problems should be anticipated. This review has led to modifications in operative technique.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Pneumonectomy for chronic pulmonary infection usually is avoided because of technical hazards and postoperative complications. Risks include hemorrhage, respiratory failure, bronchopleural (BP) fistula, and empyema. Recent reports [1–6] of resection for pulmonary aspergilloma have included a small number of pneumonectomies. Several authors [2, 7] have concluded that the procedure should not be performed. We retrospectively reviewed our experience with pneumonectomy for chronic infection to assess the operative and postoperative complications and to identify possible factors or techniques that could be modified to improve outcome.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From 1980 to 1993, 13 patients admitted to the thoracic service of the Medical University of South Carolina (Charleston, SC) underwent pneumonectomy (6 right, 7 left) for chronic pulmonary infection. The hospital and clinic records and operative reports were retrospectively reviewed. The operative time, blood loss, mortality, length of hospital stay, and immediate and late complications were recorded. The operative notes were studied to assess the extent of the disease process and technical problems encountered.

There were 12 men and 1 woman with an average age of 54 years (range, 23 to 68) at the time of operation. The infecting agent was aspergillus in 8, Mycobacterium tuberculosis in 2, actinomycosis in 1, Pseudomonas aeruginosa in 1, and unknown in 1. Seven pneumonectomies were primary and six were completion pneumonectomies. In 1 case (actinomycosis with cavitation of right upper lobe), the planned procedure was lobectomy, but conversion to pneumonectomy was required secondary to involvement of the entire lung with the inflammatory process. Twelve pneumonectomies were elective and one operation for hemoptysis was urgent.

Patients undergoing completion pneumonectomy are summarized in Table 1. The chest roentgenograms or bronchograms revealed cavitation or saccular bronchiectasis of the remaining lung.

The predominant reason for operation was hemoptysis in 7 and continued symptomatic infection in 6. Two patients with hemoptysis underwent embolization, which failed. One patient with massive hemoptysis required intubation, and bronchoscopy revealed a clot in the left main bronchus. He underwent urgent operation. One patient with drug-sensitive cavitary Mycobacterium tuberculosis had development of hemoptysis requiring resection, and 1 patient underwent completion pneumonectomy for bronchiectasis and active drug-resistant Mycobacterium tuberculosis. These patients were receiving multiple antituberculous agents preoperatively. Only 1 patient with aspergillosis received perioperative amphotericin B.

All patients underwent pulmonary function testing except the patient undergoing urgent pneumonectomy. Forced expiratory volumes in 1 second ranged from 17% to 80% of predicted (mean, 47%). Ventilation-perfusion scans were performed in 4 patients, and 77% to 100% of perfusion was to the unoperated lung.

All operations were performed using the posterolateral approach. One-lung ventilation was achieved by endobronchial blocker or double-lumen endotracheal tube. The bronchus was closed with a stapling device and was not routinely covered. In the majority of cases, a clamped chest tube connected to a balanced drainage system was used for 24 hours. No intrapleural antifungal or antibiotic solutions were instilled.

Statistical analysis was performed using the Student's t test with a p value of 0.05 or less considered significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Operative time ranged from 3 to 10.5 hours with a mean of 5.7 ± 0.6 hours. The mean estimated blood loss was 2,083 ± 519 mL (range, 800 to 7,000 mL). Intraoperative transfusion ranged from 1 to 21 units of packed cells (mean, 6.2 ± 1.8 units). Excessive bleeding (defined as greater than or equal to 1,000 mL) was noted in 9 cases (69%). Three caval tears occurred, one requiring cardiopulmonary bypass for repair.

Review of the operative notes were notable for several consistent findings. All cases were characterized by dense adhesions with obliteration of the pleural space and extension into the endothoracic fascia. Although extrapleural dissection was performed, it was seldom helpful. Most reports indicated greatest difficulty with the lung apex. Cavities were frequently entered. More than half of the operative reports commented on scarring or distortion of the hilar structures. Intrapericardial dissection was performed in 7 cases, and in two instances difficulty still was encountered with retraction and scarring.

There was 1 30-day death (mortality, 7.6%) caused by respiratory failure. Two other patients had respiratory complications. One patient required reintubation for pulmonary edema and 1 required prolonged ventilation and tracheostomy for respiratory failure. Two patients were noted to have rapid filling of the postpneumonectomy space thought secondary to significant chest wall ooze. In 1 patient, the space was drained partially by unclamping the chest tube left in place for equilibration, and chest tube removal was delayed until 48 hours postoperatively. In the other patient, expectant observation sufficed. Neither patient had hemodynamic compromise. Mean time from operation to discharge was 17 ± 3 days (median, 14 days; range, 8 to 41 days). There was no significant difference in operative or postoperative parameters between patients undergoing primary and completion pneumonectomy.

Delayed complications occurred in 3 cases. One patient presented 1 month postoperatively with postpneumonectomy empyema requiring rib resection and drainage. There was a ``pinhole'' BP fistula present. The empyema eventually was controlled with a thoracoplasty. He died 4 years later secondary to emphysema without evidence of recurrent infection. In 2 other patients a small air pocket developed in the postpneumonectomy space, one 3 months and one 2 years after resection. Bronchoscopy in these cases revealed no clear evidence of fistula and cultures of the pleural space remained negative. Mean follow-up was 5 years (range, 1 to 14 years), and no patient in the series had recurrent infection in the remaining lung.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Resection for pulmonary infection became a less frequent problem for the thoracic surgeon with the advent of anti-tuberculous drugs, increasingly potent antibiotics, and antifungal agents. However, the reemergence of resistant tuberculosis as a health care threat and the growing number of immunocompromised hosts suggest that the thoracic surgeon still will be asked to assess the value and feasibility of resection in certain patients.

There is a paucity of literature relating to the role of pneumonectomy in complex cases of infectious etiology. Most series have included pneumonectomy patients with those undergoing lobectomy and lesser procedures. Reports of resection for aspergilloma have included no [7] or few [2–6] pneumonectomies. A review of published series of surgical procedures for tuberculosis totaling 500 cases included only 20 pneumonectomies [8–13]. A notable exception is the report by Pomerantz and colleagues [14], which included 40 pneumonectomies. However, there was little detail about operative findings or technique. Surgical resection for bronchiectasis is rare, and the report by Annest and associates [15] included only three pneumonectomies out of 24 procedures.

Several cases of chronic infection requiring pneumonectomy for complete resection prompted this review. Study of operative notes and intraoperative parameters confirmed that pneumonectomy is technically difficult and potentially hazardous. Lengthened operating time, mean blood loss of 2,083 mL, and increased transfusion requirements are indicative of the dense fibrosis encountered with obliteration of the pleural space, extension beyond the extrapleural plane of dissection, and distortion of hilar structures. Mediastinal vessels are at risk, and the apex of the lung is frequently the most difficult area to dissect, secondary to predilection of the inflammatory disease process to commence in this region and to lack of good visualization. In this series, there was no significant difference in operative difficulty between primary and completion pneumonectomies. Few data are available regarding operative detail in previous series, but Massard and co-workers [2] reported that four of five pneumonectomies for pulmonary aspergilloma incurred excessive blood loss (>1,500 mL).

Postoperative complications are common after pneumonectomy for chronic infections. Morbidity has been particularly high in any resection for complex aspergilloma, 78% in the series reported by Daly and colleagues [6], and 64% in that of Battaglini and associates [3]. Stamatis and Greschuchna [1] noted that BP fistula with empyema was the most common complication after resection for complex aspergilloma, occurring often in patients after pneumonectomy. Massard and co-workers [2] reported that empyema thoracis developed in 4 of 5 patients undergoing pneumonectomy; these patients were hospitalized for more than 30 days. Mortality after resection for complex aspergilloma was 34% in the Daly and colleagues series [6] but it was unclear how many patients had undergone pneumonectomy. The most common complication after pneumonectomy for resistant Mycobacterium tuberculosis and other mycobacterial infections reported by Pomerantz and co-workers [14] was a BP fistula (9/40, 22.5%). Four deaths resulted from BP fistulas and subsequent respiratory complications.

Our 30-day morbidity included respiratory failure in 2 patients (15.7%) and one BP fistula with empyema (8%). Two small, delayed BP fistulas became evident at 3 months and 2 years, respectively, but did not require treatment. Median length of hospital stay after pneumonectomy was 14 days.

I conclude that pneumonectomy for complete resection of chronically infected lung can be accomplished with low mortality. However, increased intraoperative difficulty should be expected and the postoperative complication of BP fistula (which was 23% in the series) should be anticipated.

After the retrospective review, certain modifications in technique and preparation have been made. The preferred approach is now through median sternotomy with exposure aided by a special internal mammary artery retractor. The hilum is more easily approached, and I prefer intrapericardial dissection in all cases. Exposure of the apex, where scarring is often most intense and vascular structures are most at risk, is improved over the posterolateral thoracotomy approach by use of the mammary artery retractor. Should cardiopulmonary bypass become necessary, it is instituted easily. The wide anatomic exposure and easy manipulation of hilar structures has been noted by others [16, 17]. Although left lower lobectomy is considered difficult through a median sternotomy, pneumonectomy has not presented a technical problem [16]. I have not found difficulty with the left hilum dissected intrapericardially. Pulmonary function may be better preserved using the median sternotomy approach [18], and several authors have noted reduced postoperative pain [16, 18, 19] with this approach. Many of the patients requiring pneumonectomy in this series had compromised pulmonary function.

Protection of the contralateral lung by placement of a double-lumen endotracheal tube or endobronchial blocker is routine. A cell-saving device is placed in the operating room. Dissection of dense adhesions often results in significant chest wall ooze, and an argon beam coagulator is used for hemostasis of the pleural wall at the conclusion of the case. Transposition of muscle or pericardial fat to the bronchial stump should be routine, but as noted by others [14], it will not entirely prevent BP fistulization. Application of the above modifications in two recent pneumonectomies for infection has resulted in a loss of 500 to 700 mL of blood and no transfusion requirement.

Although fraught with danger, pneumonectomy for chronic infection should not be avoided when necessary. Anticipation of known intraoperative and postoperative complications has the potential to improve outcome.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Reed, Division of Cardiothoracic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carolyn E. Reed Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reed, C. E. Search for Related Content PubMed PubMed Citation Articles by Reed, C. E.