Complications and Post-operative Care of Pulmonary Resection Department of Surgery, Division of General Thoracic Surgery, Veterans General Hospital Kaohsiung. Chou Yi-Pin, MD.

Surgical candidate of pulmonary resection Age. Pulmonary function: PaO2: > 50 mmHg. PaCO2: < 50 mmHg FEV1: > 0.8 L Vital capacity > 15ml/kg DLCO: > 40% Pulmonary artery < 40 mmHg

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

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.

A. INTRAOPERATIVE COMPLICATIONS Injury to a Major Pulmonary Vessel Prevention: Proximal control Exposed intrapericardially

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.

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.

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

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.

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.

The complication is seen more often in men than in women. 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.

1/3 of patients: cardiac complications 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

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.

The mortality rate of pneumonectomy is 3-5% 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.

The mortality rate of lobectomy is 1-3% 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.

The mortality rate of segmentectomy is about 1%. B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION The mortality rate of segmentectomy is about 1%.

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.

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.

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

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.

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.

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%.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Bronchopleural fistula 5. Treatment antibiotics drainage re-operation Eloesser flap Clagett maneuver

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.

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

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.

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

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

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

Thank You!