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Ann Thorac Surg 1998;66:1165-1169
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Completion pneumonectomy: analysis of operative mortality and survival

^a Departments of Cardiothoracic Surgery and Pulmonary Diseases, St Antonius Hospital, Nieuwegein, the Netherlands

Accepted for publication May 1, 1998.

Address reprint requests to Dr Brutel de la Rivière, Department of Cardiothoracic Surgery, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands

Abstract

Background. A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome.

Methods. A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period.

Results. Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease.

Conclusions. Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.

Completion pneumonectomy is defined as the operative procedure in which what is left of a previously, partially resected lung is removed [1]. It is a more complex operation than a single-stage pneumonectomy because dense adhesions are often present. The indication for completion pneumonectomy is rather rare. Moreover, there is a wide variety of indications for either the primary operation and the completion pneumonectomy, making interpretation of early and late results difficult.

McGovern and colleagues [2] were the first to report a detailed analysis of indications and results of completion pneumonectomy. Since then, many investigators have published their experience with completion pneumonectomy [3–9]. Hospital mortality for different groups of indications varies widely between these studies. We have analyzed our experience with completion pneumonectomy during the past 20 years.

Material and methods

All hospital charts and outpatient data of 138 consecutive patients who underwent a completion pneumonectomy in the St Antonius Hospital between January 1, 1975, and January 1, 1996, were reviewed. Variables analyzed included primary indication for operation, histology, operative complications, operative findings, and hospital mortality, as well as late death. Appropriate statistical methods were used to compare proportions (ie, 70% confidence intervals; ² test for multiple group comparison). Follow-up was complete, and was obtained from the patient’s physician or from governmental agencies. Follow-up closed on January 1, 1996. Survival estimates were calculated using the Kaplan-Meier product limits method. Hospital mortality and survival of all patients who underwent a single-stage pneumonectomy during the same period were analyzed for comparison.

Definitions
Completion pneumonectomy is the operation during which the remainder of a lung is removed, after one or more ipsilateral resections of lung parenchyma. A single-stage pneumonectomy is the operation in which an entire lung is removed without previous ipsilateral resection of lung tissue. The primary operation was defined as the first ipsilateral operation in which lung tissue was removed. Hospital mortality included all intraoperative and postoperative deaths during hospitalization or within 30 days after operation. Tumor histology was classified according to the World Health Organization histologic typing of lung tumors [10]. All lung cancers were staged with the TNM classification system [11]. Recurrent lung cancer and second primary lung cancer were discriminated using the criteria proposed by Martini and colleagues [12]. Primary lung cancer was the indication for completion pneumonectomy if lung cancer had not been the indication for the primary operation or if completion pneumonectomy was performed during the same hospitalization as the primary operation because of a positive resection margin, or an unexpected malignancy in the primary operative specimen. The indication for completion pneumonectomy was considered an early complication of the primary operation if the patient was not discharged between the two operations (transfer between hospitals was not a discharge) or the interval was less than 30 days.

Patients
From January 1975 through December 1995, 138 patients underwent a completion pneumonectomy. There were 116 men and 22 women. Mean age at the time of the primary operation was 54.4 years (range, 1.8 to 79.2 years). Mean age at the time of completion pneumonectomy was 60.1 years (range, 9.1 to 79.2 years). The operation was done on the right side in 80 patients, and on the left in 58. During the same period, 760 single-stage pneumonectomies have been performed. Thus, completion pneumonectomies represented 15.3% of all pneumonectomies performed.

Results

Primary operation
The primary operation was performed in another hospital in 26.8% of the patients. Indications included lung cancer in 101 patients (73%), benign lung disease in 34 (25%), and other malignancies in 3 patients. The indications for primary operation are as follows: lung cancer (squamous cell carcinoma, 71; adenocarcinoma, 15; adenosquamous carcinoma, 4; large cell carcinoma, 8; small cell carcinoma, 1; carcinoid tumor, 2), benign lung disease (bronchiectasis, 11; tuberculosis, 9; benign lung nodule, 9; aspergillosis, 2; hemoptysis, 1; arteriovenous aneurysms, 1; Scimitar syndrome, 1), and other malignancies (leiyomyosarcoma, 1; Hodgkin’s lymphoma, 1; metastasis of renal carcinoma, 1).

Lobectomy was performed in 83 patients, bilobectomy in 21, sleeve lobectomy in 19, segmentectomy in 14, and enucleation (of a hamartoma) in 1 patient. In all but 5 patients the operation was performed through a posterolateral incision. Five patients had a median sternotomy, for combined aortocoronary bypass in 2, for bilateral lung resections in 2, and for thymectomy with concomitant lung resection in 1 patient. Other additional procedures were performed in 5 patients.

The postsurgical staging results were stage I (n = 66; 25 T1 N0 M0, 41 T2 N0 M0), stage II (n = 25; 2 T1 N1 M0, 23 T2 N1 M0), stage IIIa (n = 6; 1 T2 N2 M0, 5 T3 Nx M0), and unknown (n = 4). Resection was complete in 85 patients (84%). Microscopic residual tumor was found in 13 patients, macroscopic residual tumor in 2, and unknown in 1 patient.

There were 69 complications in 57 patients (43.1%), including empyema with bronchopleural fistula (n = 19), empyema without bronchopleural fistula (n = 3), prolonged air leak (n = 12), persistent pneumothoraces (n = 12), recurrent atelectases (n = 9), and other complications (n = 14).

Postoperative adjuvant therapy was given to 10 patients. Six patients received chemotherapy and 4, radiation therapy.

Completion pneumonectomy
The mean interval between the primary operation and the completion pneumonectomy was 5.8 years (range, 3 days to 43.8 years). Indications for completion pneumonectomy included lung cancer in 76 patients, benign lung disease in 58, and other malignancies in 4 patients and are as follows: lung cancer (squamous cell carcinoma, 49; adenocarcinoma, 12; adenosquamous carcinoma, 8; large cell carcinoma, 4; small cell carcinoma, 2; carcinoid tumor, 1), benign lung disease (bronchopleural fistula, 22; bronchostenosis, 16; bronchiectasis, 8; aspergillosis, 5; anastomotic dehiscence, 2; hemoptysis, 1; venous infarction, 1; pachypleura, 1; arteriovenous aneurysms, 1; Scimitar syndrome, 1), and other malignancies (leiyomyosarcoma, 1; fibrosarcoma, 1; metastasis of renal carcinoma, 1; lymphangitis carcinomatosa, 1).

In 46 patients (33%) a complication of the primary operation resulted in completion pneumonectomy, an early complication in 16, including bronchopleural fistula with concomitant empyema in 12, and a late complication in 30 patients.

Completion pneumonectomy was performed through a median sternotomy in 1 patient after thoracoplasty for bronchopleural fistula. All other operations were performed through a posterolateral thoracotomy. Twenty-two patients (15.9%) had undergone more than one previous ipsilateral operation. Dense adhesions between the pleurae were present in 49.3%, at the pulmonary hilum in 19.6%, at the diaphragm in 13.0%, in the pericardium in 3.6%, and in the esophagus in 1 patient.

There were 35 major vascular lesions in 29 patients (21.0%). Intrapericardial ligation of the pulmonary artery or vein was performed in 82 patients. Extrapleural dissection of the lung was necessary in 38 patients. Nonvascular intraoperative lesions occurred in 23 patients: 10 deliberate and 2 unintentional phrenic nerve transections, 3 deliberate and 3 unintentional recurrent nerve transections, 2 esophageal lesions, and 3 others.

Indication for completion pneumonectomy included lung cancer in 55% of the patients. Of these 76 patients, 21 had recurrent lung cancer (28%), 39 had a second primary lung cancer (51%), 8 patients had a positive resection margin at the first operation (11%), 6 had new primary lung cancer (8%), and 2 patients had an unexpected malignancy at definitive microscopy (2%).

Postoperative staging of 76 lung cancer patients included stage I (n = 32; 14 T1 N0 M0, 18 T2 N0 M0), stage II (n = 18; 3 T1 N1 M0, 15 T2 N1 M0), stage IIIa (n = 21; 4 T2 N2 M0, 17 T3 Nx M0), and stage IIIb (n = 5; T4). Resection was complete in 57 patients (75%).

Adjuvant therapy was given to 12 patients. Preoperative chemotherapy in 1 patient, postoperative chemotherapy in 4, and postoperative radiotherapy in 7 patients.

Major postoperative complications occurred in 58 patients (42%), and were fatal in 19 (cardiac arrhythmia, 13; respiratory insufficiency, 12; empyema without bronchopleural fistula, 8; excessive postoperative bleeding needing rethoracotomy, 7; empyema with bronchopleural fistula, 6; recurrent nerve paralysis, 6; intraoperative death, 4; wound infection, 3; colonic perforation, 2; gastric bleeding, heart failure, atrial septal defect becoming symptomatic needing operative closure, pulmonary embolism, ureterlithiasis, urinary tract infection, textiloma needing rethoracotomy, fulminant cerebral metastasis, bleeding from thoracostomy for bronchopleural fistula, and chylothorax, 1 each). A bronchopleural fistula developed in 6 patients (4.3%).

Hospital mortality
Four patients died intraoperatively and 15 after operation for an overall hospital mortality of 13.8%. Causes of death are as follows: intraoperative deaths (fatal bleeding, 3; luxatio cordis after closure of thoracotomy, 1), and postoperative deaths (multiple organ failure, 10; cardiac arrest with cerebral hypoxemia, 3; fulminant cerebral metastasis, 1; fatal bleeding from thoracostomy for bronchopleural fistula, 1). Hospital mortality for lung cancer indications was 13.2%, and for benign disease 15.5% (p > 0.05) (Table 1 ). Hospital mortality for early complications was 37.5%, and for late complications 13.3%, compared with 9.8% for noncomplication indications (p = 0.01).

View larger version (22K): [in this window] [in a new window]   Fig 1. Estimates of actuarial survival using the Kaplan-Meier method after completion pneumonectomies done for lung cancer, for benign lung disease, or for other malignancies.

Completion pneumonectomy is an infrequent procedure. In our department it represented 15.3% of all pneumonectomies, whereas other investigators have reported an incidence of 8.3% [9] and 4.8% [6]. Two reasons may explain this high incidence in our institution. First, more than 25% of the patients were primarily operated in another hospital, and referred only for completion pneumonectomy. Second, we perform sleeve resections rather frequently [13], and in 19 patients a completion pneumonectomy was performed after initial sleeve resection. In 2 patients, this was considered an early complication. Other surgeons perform sleeve resections only in patients with poor respiratory reserve, and prefer pneumonectomy for lung cancer as a more radical procedure [6].

Many different indications for either the primary operation or the completion pneumonectomy result in a rather heterogenous patient population. Moreover, the study spans 21 years. Hospital mortality decreased from 16.0% to 9.8% (Table 2). During the past 11 years it was comparable with hospital mortality for single-stage pneumonectomy in our unit, and with results from the literature [14]. All intraoperative deaths have occurred in the first 6 years of the study period.

Because of the heterogeneity of indications and the differences in selection criteria for completion pneumonectomy, comparing results from the literature with our own results is difficult. Probably because of the differences in patient populations, a rather wide variation in results reported is found (Table 3 ). Overall hospital mortality varies between 2.6%, and 16.2%. Most researchers reported a higher hospital mortality for benign indications than for lung cancer [2, 3, 7–9]. This is in contrast with the results of Grégoire and colleagues [5], who found their hospital mortality to be twice as high for cancer indications as for benign indications. We found no difference in hospital mortality between these two groups of indications.

Dense hilar and intrapericardial adhesions as a result of previous operation or radiation therapy (or a combination) are often correlated to intraoperative deaths [2, 5–7]. Although 2 patients with dense intrapericardial adhesions died of exsanguination, and in another patient cardiopulmonary bypass was successfully used to control a major laceration of the pulmonary artery, we favor direct intrapericardial approach to control the vessels. On the right side, dissection and ligation of the pulmonary artery medial to the superior vena cava is our preferred method. On the left side, transection of Botallo’s ligament will result in extra mobility, facilitating securing the pulmonary artery. However, the extent and localization of the most dense adhesions will dictate the safest approach, either more anterior or more posterior, dividing the venous return at the level of the left atrium first, and dissecting in a retrograde fashion the pulmonary artery. In cases of pericardial obliteration, some surgeons first divide the bronchus, and take a posterior approach to the vessels [1, 15]. This was only used four times in our patients. Median sternotomy as the standard approach for completion pneumonectomy to improve control of the pulmonary vessels is advocated by Watanabe and colleagues [16], but we have no experience with this practice.

Postoperative in-hospital deaths were mainly attributable to multiple organ failure. Postoperative morbidity is substantial, but long-term outcome is good. For lung cancer indications, 5-year survival was 32%, which compares favorably with the mean 5-year survival reported as being 28.5% (Table 3). Long-term results justify complete work-up of patients with a lesion in the remainder of a partially resected lung, and treatment should be surgical, if possible.

Acknowledgments

This study was supported by a grant from the Dr Sander Schaepkens van Riempst Foundation.

References

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