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Ann Thorac Surg 1996;62:1033-1037
© 1996 The Society of Thoracic Surgeons
Department of Thoracic Surgery, University Hospital of Strasbourg, Strasbourg, France
Accepted for publication May 21, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. Twenty-five patients aged 41 ± 15 years underwent pneumonectomy (three completions) for chronic infection: sequelae of tuberculosis, 15; cystic bronchiectasis, 9; and radiation pneumonitis, 1. Eight patients had aspergilloma (7 after tuberculosis, 1 with radiation pneumonitis).
Results. Operative mortality was 4%. Operative blood loss was estimated at 1,983 ± 1,424 mL, ranging from 150 to 5,600 mL. A single patient required reexploration. Eight patients (32%) had empyema, and a further 3 (12%) had bronchopleural fistula; thoracoplasty was required for 10 (40%). Sequelae of tuberculosis heralded increased operative bleeding (t = 2.884; p < 0.005). Incidence of empyema or bronchopleural fistula was increased in patients with sequelae of tuberculosis (
2 = 3.896; p < 0.05), patients with aspergilloma (2 = 4.588; p < 0.05), patients in whom the parenchymal cavities were entered (2 = 11.5; p < 0.001), and those in whom blood loss was in excess of 1,000 mL (2 = 4.911; p < 0.05).
Conclusions. We conclude that pneumonectomy is a high-risk procedure, especially in patients with sequelae of tuberculosis.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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On rare occasions, pneumonectomy is required to provide cure to patients with benign lung disease. Mainly, four groups of patients are concerned. Ongoing multidrug-resistant Mycobacterium tuberculosis and atypical mycobacterial infection have been classic indications, which have been reemphasized recently because of their regrowing incidence [1]. Diffuse parenchymal sequelae of tuberculosis are prone to repeated superinfections, in particular mycetoma; relapsing infections or massive hemoptysis eventually mandate surgical intervention [2, 3]. Conservative treatment of bronchogenic cancer may leave the oncologically cured patient with a variety of complications such as radiation pneumonitis and bronchostenosis after sleeve lobectomy [4, 5]. A final group includes congenital malformation and acquired bronchiectasis, which may be amenable to pneumonectomy in case of diffuse unilateral disease [6]; surgeons have lost interest in this latter group owing to the advent of lung transplantation.
Since the pioneering years of thoracic surgery, when virtually all procedures were performed for tuberculosis, it has been known that it is critical to achieve bronchial stump healing in the presence of granulomatous infection, and that preexisting active pleuropneumonic sepsis places the pneumonectomy space in serious jeopardy [7]. In a review of our experience with aspergilloma, we underlined the tremendously high intraoperative and postoperative complication rate after pneumonectomy and recommended that this procedure be avoided whenever possible [3]. Recent reports have highlighted the risk of lung resection for benign disease; most of them, however, were restricted to the issue of tuberculosis [8–10].
The purpose of this study was to evaluate the operative risk of pneumonectomy for benign disease in the light of a single institution's experience over a recent time period, and to identify potential indicators for postoperative complications. We further intended to raise admonitions against a potentially deleterious procedure based on some less optimistic results than those recently published [6, 9, 10].
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Chronic infection was a sequela of pulmonary tuberculosis in 15 patients. Twelve of them had diffusely destroyed lungs with secondary bronchiectases, and 3 had large sequellary excavations. Three of them presented with empyema: 2 had been previously treated with artificial pneumothorax, and a third suffered a spontaneous bronchopleural fistula. Nine patients suffered from cystic bronchiectases without specific origin, some of which were probably polycystic congenital malformations. A final patient had radiation pneumonitis. Aspergillus disease was identified in 8 patients: 7 had pulmonary mycetoma (metatuberculous cavitation, 6; radiation pneumonitis, 1), and a final patient had Aspergillus empyema.
Four patients had undergone open operations previously: right upper lobectomy for aspergilloma, right upper lobectomy for cavitary tuberculosis, left lower lobectomy for bronchiectasis, and thoracotomy for resection of a pleural metastasis of a synovialosarcoma.
Symptoms and Rationale for Operation
Seventeen patients suffered relentless bronchopulmonary infections. Owing to Aspergillus infection, or to aspecific inflammatory hypervascularity, 5 patients had important hemoptysis, which was the single symptom in 2. Three patients had pleural empyema: 2 of them had been treated previously with artificial pneumothorax, and 1 had a spontaneous bronchopleural fistula. Two patients were poorly symptomatic and had minor bronchopulmonary infections. Twenty-three patients were operated on mainly because of symptoms that were not controlled by other treatments. Two patients underwent operation on an elective basis to prevent further complications: 1 had a huge aspergilloma resulting from radiation pneumonitis, and the other had a large left-sided cavitation after tuberculosis.
Operative Technique
All procedures were performed through a classic posterolateral thoracotomy. Pneumolysis was made either in the extrapleural or in the intrapleural plane according to the easiest way to proceed. Bronchial closure was preferentially achieved with a stapling device, and the bronchial stump was routinely covered with adjacent tissues. The chest was routinely drained for 48 hours with a 28F chest tube connected to a balanced drainage system.
Methods
Charts were reviewed for the following items: rationale for pneumonectomy, operative problems, and postoperative surgical and medical complications. Intraoperative problems were further documented by intraoperative blood loss. Surgical complications included postoperative hemorrhage, parietal sepsis, empyema, and bronchopleural fistula developing up to the eighth postoperative week. Operative mortality was defined as any death occurring during the first 30 days postoperatively, or during the initial hospital stay.
Subgroups were created for comparison of the incidence of intraoperative bleeding and of postoperative empyema: previous tuberculosis versus others, right versus left pneumonectomies, presence of Aspergillus infection versus others, and age groups.
Statistics
Numbers were expressed as mean ± standard deviation and range. Comparisons were made with the 2 test and with Student's t test for unpaired samples, as appropriate. Statistical significance was admitted for any value of p less than 0.05.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Most patients had extensive pleural adhesions. Extrapleural dissection had to be performed in all patients, but quite often even the extrapleural plane was obliterated by dense and vascularized adhesions, especially in the apical area. Operative difficulties are best quantified by the substantial intraoperative blood loss, averaging 1,983 ± 1,424 mL (range, 150 to 5,600 mL; median, 1,800 mL). Hilar dissection was hazardous on 9 occasions, requiring intrapericardial dissection in 6; 2 of these were completion pneumonectomies. In a single patient, a second thoracotomy located in the eight intercostal space was required to take down diaphragmatic adhesions. The diaphragm was severed in 4 patients; all tears were recognized and repaired intraoperatively. Two vascular tears occurred (azygos vein, 1; right pulmonary artery, 1) but were easily controlled. Parenchymal cavities were entered in 9 patients. Bronchial stump closure was performed with staples in 22 and with absorbable manual sutures in 3 patients.
Postoperative Complications
A single patient died during the immediate postoperative course (4%). Empyema with right bronchopleural fistula developed in him by postoperative day 15 and was managed with immediate thoracoplasty and tracheostomy. He required ventilation with selective intubation to reduce air leaks, and ultimately died on the 59th postoperative day with a left bronchial stenosis. At autopsy, the bronchial dehiscence had sealed.
A second patient's death, which occurred 16 weeks after pneumonectomy, was related to the treatment. He was readmitted 10 weeks postoperatively after failure of ambulatory management of empyema, and eventually died after thoracoplasty [11]. Thus, the true mortality rate is 8%.
Most patients were extubated early after the procedure (mean duration of artificial ventilation, 7.3 ± 11.1 hours; range, 0 to 50 hours; median, 4 hours). Two patients were ventilated for 24 hours, and a single patient was ventilated up to 50 hours postoperatively.
Despite the overall substantial intraoperative hemorrhage, a single patient required reexploration.
Empyema developed in 8 patients (32%) during the first 8 postoperative weeks, and a bronchial stump dehiscence developed in a further 3 (12%). Microbiologic examination identified Staphylococcus aureus in 4, Staphylococcus epidermidis in 2, and Streptococcus species, Pseudomonas aeruginosa, Serratia, Escherichia coli, and Aspergillus fumigatus in 1 each. All patients were initially managed with tube thoracostomy, and lavages were initiated as soon as a bronchopleural fistula had been ruled out by fiberoptic bronchoscopy. A single patient was cured with lavages alone. Another patient underwent immediate thoracoplasty for a bronchial stump dehiscence. Nine patients eventually underwent a large thoracoplasty to obliterate the pleural space, and the bronchopleural fistula as well if present, 10 to 156 weeks after pneumonectomy.
The total social cost of operation and its complications is approximated by the prolonged initial hospital stay of 34 ± 22 days (range, 15 to 107 days; median, 22 days). However, many patients were discharged to another hospital and readmitted several times for management of complications.
Empyema developed in a final patient 3 years after pneumonectomy and was treated with thoracoplasty. This case has not been taken into account for statistical comparisons.
Indicators of Prognosis
Two obvious indicators of bad prognosis have been identified: previous history of tuberculosis and Aspergillus disease. Intraoperatively, patients with sequelae of tuberculosis bled significantly more than others. Aspergillus infection in itself did not significantly influence blood loss; similarly, when restricting the comparison to patients with sequelae of tuberculosis, the presence of Aspergillus disease did not add significantly to blood loss (Table 1
). Intraoperative blood loss was not influenced either by age or by side of operation. The incidence of empyema or bronchopleural fistula was increased in patients with sequelae of tuberculosis when compared to patients with no history of tuberculosis. The presence of Aspergillus infection was also significantly related to a higher complication rate. However, when considering only patients with previous tuberculosis, Aspergillus disease did not increase the risk. Further, intraoperative spillage heralded empyema in most patients (Table 2). No complication occurred when blood loss was less than 1,000 mL. Age above or below the median, side of pneumonectomy, and intraoperative blood loss above or below the median were not related to the occurrence of empyema or bronchopleural fistula.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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All authors agree that pneumonectomy for chronic infection is a real technical challenge. Reed [12] reported a mean operative time of 5.7 hours, a mean blood loss of 2,083 ± 519 mL, and a mean transfusion of 6.2 units; bleeding was in excess of 1,000 mL in 9 of 13 patients, and three caval tears occurred intraoperatively. The most challenging difficulties are apical adhesions and perihilar scarring. Hilar dissection is particularly demanding during completion pneumonectomy: in the Mayo Clinic experience, four intraoperative deaths occurred owing to hilar bleeding in patients with radiation pneumonitis [4]. The time-honored principle of intrapericardial control of pulmonary artery and veins is often frustrated by an obliteration of the intrapericardial plane.
Intraoperative problems herald a complicated postoperative outcome. Nevertheless, mortality appears to be reasonable: 2.5% for Pomerantz and associates [1] and Conlan and colleagues [6], 4% in the present series, and 7.6% for Reed [12]. In completion pneumonectomy, however, a mortality rate as high as 27.6% has been reported [4]. On the other hand, most authors relate a variable, but always consistent incidence of serious complications. Completion pneumonectomy has resulted in a 55.2% complication rate [4]. The incidence of empyema, alone or associated with bronchopleural fistula, has been close to 25% in three recent reports [1, 12, 13]. A remarkably low complication rate of 14.8% was reported by Rizzi and colleagues [10]. The relatively high complication rate we observed may be related to the high proportion of patients presenting with the association of aspergilloma and major sequelae from tuberculosis, because empyema or bronchopleural fistula developed in 5 of 7 patients in this context. On the other hand, such complications developed in only 1 of nine patients (11%) with neither sequelae of tuberculosis nor aspergilloma. Pomerantz and colleagues [1] noticed a significant difference between patients with active Mycobacterium tuberculosis infection (a single fistula in 23 cases) and patients with atypical mycobacterial infection (8 fistulas in 17 cases). Potential risk factors for empyema and bronchopleural fistula are previous radiation therapy, completion procedure, sputum positive for mycobacteria, preoperative polymicrobial contamination of the lung, and Aspergillus infection [1, 4, 13].
A variety of technical modifications have been recommended to prevent complications. In patients with proven mycobacterial infection, preoperative treatment with an optimal drug regimen maintained for 3 months is advisable [1]. When excessive apical neovascularization of systemic origin is present, embolization has proved to be ineffective [3]; therefore, Niwa and colleagues [14] have advocated ligation of the branches of the subclavian artery before pneumonectomy. Use of a double-lumen tube or bronchial blockers during anesthesia is obviously mandatory to protect the opposite lung [6]. Although most authors still use a classic posterolateral thoracotomy, Reed [12] advocates a sternotomy. Arguments in favor of the latter incision are the improved respiratory tolerance, the ease of intrapericardial dissection of the vessels, improved apical exposure with the use of a mammary retractor, and the possibility to initiate cardiopulmonary bypass expeditiously when required. However, in our opinion, a large posterolateral thoracotomy provides the most complete exposure of the hemithorax and even of the apex. Like others, we are concerned with the spread of infection to the sternum when cavities are entered [13]. Further, use of cell-saving devices is questionable for the same reason.
Intrapericardial dissection is theoretically the safest way to proceed when extensive perihilar adhesions are present. However, the intrapericardial plane may be obliterated, especially after previous radiation therapy [4]. Especially on the right side, one should remember the "bronchus-first" technique. In extreme situations, Utley [15] has recommended avoiding the intrapericardial space to prevent the spread of infection, securing the hilum by transfixing mattress sutures, and obliterating the pleural space with immediate thoracoplasty. To prevent bronchopleural fistula, most authors agree on the necessity to ideally divide the bronchus flush with the carina, or at least to leave a stump as short as possible. The suture line should be carefully covered with viable adjacent tissues as available; otherwise, a pedicled flap should be tailored [16]. Pomerantz and colleagues [1] further stress the need for a muscle flap cover when sputum is positive for mycobacteria. With respect to our experience, we now consider that a muscle flap should be prepared routinely; the muscle-sparing posterolateral thoracotomy saves both the latissimus dorsi and the serratus anterior muscle [17]. In case of gross intraoperative pleural spillage, continuous postoperative irrigation and drainage seems advisable; however, empyema still occurred in 7 of 10 patients despite this care in a recent series [6]. We have no experience with the Eloesser flap procedure, which might be carried out at the end of the pneumonectomy in this context.
Once pneumonectomy-specific complications such as empyema and bronchopleural fistula occur, the management may differ according to the local surgical heritage. We do not perform the popular open-window thoracostomies [6]; until recently, our standard approach has been drainage-lavage with a tube thoracostomy, followed by a large thoracoplasty (at least seven ribs including the first) when sepsis persists. We consider that thoracoplasty has the advantage to provide a definite one-stage cure. Thoracoplasty including the first rib or not has also been the preferred treatment for other teams [18, 19]. Alternatives to this aggressive management might be early empyemectomy with either intrapleural fibrinolytic enzymes or thoracoscopic debridement, followed by a 2- to 4-week course of lavages [20, 21]. Prevention of empyema might also include routine thoracoscopic removal of intrapleural clots by the end of the first postoperative week; this hypothesis, however, requires prospective evaluation.
Some optimistic results recently published have downgraded expectations of postoperative complications after pneumonectomy for chronic infection. In our experience, which is probably "contaminated" with a relatively high load of cases with aspergilloma, we have observed a tremendously high complication rate, with empyema developing in 32% and bronchopleural fistula in 12% of patients. In our opinion, pneumonectomy for chronic infection remains a high-risk procedure; therefore, the indication should be limited to patients in whom there is no alternative but resection.
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Acknowledgments |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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