Lung resection

1
Lung resection

• Nattachai Anantasit

2
In Ramathibodi hospital (1983-1997, N 20)

• Indication for lung resection
• Congenital cystic disease 45
• Persistent pneumonia and/or 25 atelectasis
  with bronchiectasis
• Lung abscess 20
• Abnormal mass with 10
• recurrent hemoptysis

Srisan P. A thesis submitted for the diploma of
thai subboard of pediatric pulmonology 1998.
3
Lung resection

• Pneumonectomy Surgical removal of an entire lung
• Lobectomy Surgical excision of a lobe
• Segmentectomy Surgical excision of segment of
  lung
• Wedge resection A surgical procedure to remove a
  triangle-shaped slice of tissue. It may be used
  to remove a tumor and a small amount of normal
  tissue around it

4
Preoperative evaluation

• Pulmonary function
• Calculation of predicted postoperative pulmonary
  function
• Measurement of gas exchange
• Exercise testing

5
Pulmonary function test

• FEV1 lt60predicted was strongest predictor of
  postoperative complication
• DLCO

6
Current guidelines

• Preoperative FEV1 gt80predicted can tolerate
  pneumonectomy
• Exertional dyspnea or coexistent interstitial
  lung disease ? DLCO
• Preoperative FEV1 and DLCO gt 80 predicted ? not
  need further testing

Colice GL, et al. Chest 2007
7
Predicted postoperative PFTs

• Combination of Preoperative spirometry and
  quantitative perfusion lung scanning to estimate
  the degree of functional loss

8
Predicted postoperative PFTs

• FVCc FVCpreop x S x 5.26/100
• FVCc FVC calculated
• FVCpreop FVC pre operation
• S segment left

9
Predicted postoperative PFTs

• FVCa 0.109 1.185FVCc
• (R2 91.30, p lt0.0001)
• FEV1a 0.006 1.138FEV1c
• (R2 87.97, p lt0.0001)
• FEF25-75a -0.186 1.053FEF25-75
• (R2 70.32, p lt0.0001)

Srisan P. A thesis submitted for the diploma of
thai subboard of pediatric pulmonology 1998.
10
Current guidelines

• Increased risk for lung resection with predicted
  postoperative values for either FEV1 or DLCO lt
  40 predicted
• Preoperative exercise testing is recommended

Colice GL, et al. Chest 2007
11
Gas exchange

• PaO2 not important predictor of postoperative
  complication
• PaCO2 not correlate with postoperative
  complication

Marshall MC, et al. Clin Chest Med 1993. Wyser C,
et al. Am J Respir Crit Care Med 1999.
12
Cardiopulmonary exercise testing (CPET)

• Correlate with postoperative complication
• Maximal oxygen consumption (VO2max)
• VO2max lt 15ml/kg/min or lt 50predicted ?
  correlated with postop complication1

1Walsh GL, et al. Ann Thorac Surg 1994.
13
Current guidelines

• VO2 max lt 10 ml/kg/min
• or
• VO2 max lt 15ml/kg/min and both predicted
  postoperative FEV1 and DLCO lt 40 predicted
• ? increase risk of perioperative death and
  complication

Colice GL, et al. Chest 2007
14
Physiology of lung resection
Olsen GN. Chest 1998.
15
Postoperative lung
resection
16
Postoperative lung
resection
Insert ICD ?
17
Postoperative lung
resection
Pleurocentesis ?
18
Anatomic changes

• Immediately
• air fills the space previously occupied by lung
• Chest tube is not inserted
• Over time
• Elevation of hemidiaphragm, hyperinflation of the
  remaining lung and shifting of mediastinum to
  postpneumonectomy space (PPS)
• Fluid accumulating in PPS (2 rib space per day)

19
Anatomic changes

• Complete opacification of hemithorax after
  pneumonectomy (3wks-7mo)
• Unexpected rapid accumulation of fluid ?
  hemorrhage, infection or chylothorax
• Vital organs shifted position

20
Anatomic changes
Day 1
Day 2
Day 14
Day 30
Chae EJ, et al. RSNA 2006.
21
Early mortality

• 30 days mortality 2.4-11.6
• Risk factors for early mortality
• Right-sided pneumonectomy
• Specific type of surgical resection
• Underlying disease
• Emergency surgery
• The level of experience of surgeon

22
Postoperative pulmonary outcome

• FEV1, FVC are decreased
• DLCO is decreased but normal corrected DLCO/lung
  volume ratio
• Lung compliance is decreased, airway resistance
  is increased
• Arterial oxygen saturation, PO2, PCO2 not changed
  

23
Postoperative cardiovascular outcome

• Right pneumonectomy
• Rt.ventricular end diastolic volume is low but
  left ventricular function is normal
• Left pneumonectomy
• Opposite Rt.pneumonectomy

Smulders SA, et al. Ann Thorac Surg 2007.
24
Postoperative quality of life

• Quality of life scores (pain, physical function
  and dyspnea) decrease after pneumonectomy
• Lobectomy and wedge resection are normal

Balduyck B, et al. Lung Cancer 2007.
25
Postoperative complication

• Hemorrhage complication
• Cardiac complications
• Pulmonary complications

26
Postoperative complication

• Hemorrhage complication
• Inadequate hemostasis of the bronchial artery or
  a systemic vessel in the chest wall
• Infrequently, slipping of a ligature or an
  un-recognized injury is a cause
• Bleeding related to coagulation is rare
• Re-exploration is indicated if
• failed response to blood replacement
• a large amount of blood in the hemithorax
• persistent massive bleeding from the chest tube

27
Postoperative complication

• Cardiac complications
• arrhythmias, cardiac herniation, cardiac
  temponade
• Pulmonary complications

28
Postoperative pulmonary complication

• Early complications
• Pulmonary edema, ARDS
• Bronchopleural fistula
• Postpneumonectomy empyema
• Pneumonia of contralateral lung
• Late complications
• Postpneumonectomy syndrome
• Late onset bronchopleural fistula
• Infections

29
Postpneumonectomy pulmonary oedema (PPO)

• Incidence 5 but high mortality gt50
• Histopathology
• The first 5 day endothelial integrity lost with
  extravasation of fluid, protein and inflammatory
  cells into alveolar spaces
• First few days marked proliferation of
  fibroblasts and type II pneumocytes
• After 10 days interstitial and intraalveolar
  fibrosis, thrombotic and obliterative change

Jordan S, et al. Eur Respir J 2000.
30
Postpneumonectomy pulmonary oedema (PPO)
Jordan S, et al. Eur Respir J 2000.
31
Postpneumonectomy pulmonary oedema (PPO)

• Risk factors
• Fluid balance ?

Jordan S, et al. Eur Respir J 2000.
32
Postpneumonectomy pulmonary oedema (PPO)

• A dog pneumonectomy model
• Higher fluid input and urine output not
  developing PPO if left heart filling pressure
  remained normal
• An intraoperative fluid input gt 2L ? risk of PPO1