Post-Pneumonectomy Complications - A few short notes – Alan D L Sihoe

General complications Operation-specific complications Remember: General complications Vs Operation-specific complications Also: Early vs Late complications

Post-pneumonectomy complications 30-day post-op mortality 6-8% (Right > Left) Risk factors for mortality: Advanced age* Bronchopleural fistula* Cardiovascular disease+ Hematologic disease+ Right pneumonectomy+ Extended resection+ Pre-op adjuvant therapy+ Respiratory failure$ Sepsis$ Male sex$ * Eur J Cardiothorac Surg 2001; 20: 476-80 + J Thorac Cardiovasc Surg 2001; 121: 1076-82 $ Am Surg 2001; 67: 318-21 Causes of death: Respiratory failure Pneumonia BP fistula Empyema Myocardial Infarct Pulmonary embolism

1. Respiratory complications Respiratory failure: 50-100% mortality Prevention most important e.g. pre-op chest physio, optimise COAD Mx etc. Smoking (Ann Thorac Surg 2001; 72: 1662-7) Only factor associated with Major Pulmonary Event With MPE: mortality rate increased almost 20x e.g. aspiration, pneumonia, empyema Smoking: MD Anderson Cancer centre – Ann Thorac Surg Feb 02 - 257 pts who developed Major Pulm Event after pneumonectomy - factors such as age, side of OT, adjuv Tx analysed - ONLY factor associated: smoking within 1 month of OT - when MPE developed: mortality rate increased from 2.1% to 39.3% !!

1. Respiratory complications Remember: only one functional lung left i pulmonary reserve to cope with infection etc. Post-op care: Aggressive chest physio Early mobilisation Adequate analgesia Bronchial toileting if necessary Consider mini-tracheostomy

2. Cardiac complications Cardiac dysrhythmias: ~ 40% Esp. Atrial fibrillation Can you think why ? Myocardial infarction often similar risk factors (e.g. age, smoking) Mx of early post-op post-pneumonectomy BP fistulae: - drain +/- ventil support - prevent infection of space - assess by b’scopy - if small: conservative - if large: consider OT

3. Bronchopleural fistula 3-6% of lung resections Esp. post-pneumonectomy >> lobectomy Factors: Ann Thorac Surg 2001; 72: 1662-7 Technique (long stump) Medical co-morbidities (COAD & poor FEV1, DM) Adjuvant therapies (steroid) Ventilation/BiPAP [also: Infection, Tumour]

3. Bronchopleural fistula Presentation: SOB Cough fluid from post-pneumonectomy space Bubbling from chest drain (if one present) Decreased fluid level on CXR Confirm diagnosis by bronchoscopy

3. Bronchopleural fistula Management: Resuscitation & oxygen Lie with pneumonectomy side DOWN Insert chest drain (if one not in situ already) Broad-spectrum antibiotic cover Consider double-lumen tube Consider why we do each of these ! Low threshold for Surgical Repair

4. Post-pneumonectomy syndrome Herniation of heart, mediastinal contents towards pneumonectomy space kinking/distortion of vascular structures cardiovascular collapse May require surgical correction ?fixing during initial op if problem anticipated Note: hence controversy over whether to leave chest drain in situ after pneumonectomy

5. Post-pneumonectomy infection High mortality ?also develop other complications during prolonged treatment (e.g. infection) Difficult to eradicate warm, moist space antibiotics cannot reach Meticulous aseptic technique required during surgery Consider antibiotic lavage

5. Post-pneumonectomy infection Management options: Drainage & antibiotics Lavage via chest drain Surgical drainage & decortication Open drainage / thoracostomy Thoracoplasty