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

2. 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

3. 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

4. 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.

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

6. 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.

7. 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.

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

9. 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.

10. 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.

11. 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.

12. 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

13. 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.

14. 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.

15. 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.

16. 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%.

17. 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.

18. 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.

19. 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

20. 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.

21. 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.

22. 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%.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION
Pleural complications
Empyema
% 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.

29. 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

30. C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION
Pulmonary complications
Postpneumonectomy Pulmonary Edema( PPE )
% of pneumonectomy( usually right )
2. High mortality
3. Overhydration is the etiology.
4. Therapy: fluid restriction, morphine, diuretics
and mechanical ventilation with PEEP.

31. 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.

32. 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.

33. 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.

34. 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

35. 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.

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

37. 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.

38. 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

39. 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.

40. 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

41. 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

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

43. Thank You!