Pneumonectomy
Introduction
Pneumonectomy, an invasive surgical procedure involving the removal of an entire lung, is primarily indicated for patients with both malignant and non-malignant lung diseases. The first successful pneumonectomy was performed by Evarts A. Graham in 1933 to treat lung carcinoma.[1]
[2] Malignancy is the most common indication for pneumonectomy, particularly when a tumor is located in the main stem bronchus or extends across a major fissure. However, pneumonectomy is rarely performed for metastatic lung cancer. Among non-malignant conditions, the most frequent indication for this procedure is severe inflammatory lung disease. Pneumonectomy may also be required in cases of lung trauma, such as severe blunt or penetrating injuries that result in major lung lacerations or tracheobronchial disruptions.[1]
Certain contraindications must be considered before proceeding with pneumonectomy such as patients with a estimated postoperative FEV1 less than 0.8 L are not eligible for pneumonectomy.[3] Pulmonary function tests are essential to assess the estimated postoperative risk of mortality and morbidity. If the predicted postoperative forced expiratory volume in one second (FEV1) or diffusing capacity of the lungs for carbon monoxide (DLCO) is less than 40%, the risk of complications is significantly elevated. In such cases, additional functional assessments, such as cardiopulmonary exercise testing to measure maximal oxygen consumption (VO₂ max), should be considered to better evaluate the patient’s suitability for surgery.[1]
Indications
- Lung cancer
- Metastatic lung cancer (rarerly)
- Chronic lung infection (e.g multiple abscesses, bronchiectasis, fungal infection, tuberculosis)
- Traumatic lung injury
- Bronchial obstruction with destroyed lung
- Congenital lung disease [4]
Complications
The most common complications following pneumonectomy are:
- Atrial fibrilitation
- Pneumonia
- Vocal cord paralysis [5]
- Cardiac herniation
- Respiratory failure
- Bronchopleural fistula
- Injury to the diaphragm, liver, spleen, or a major vessel
- Pulmonary edema
- Multiorgan dysfunction
- Acute lung injury
- Acute respiratory distress syndrome (ARDS)
- Postoperative acute kidney injury.[1]
Pneumonectomy carries a significant risk of morbidity and mortality.[6] According to the British Thoracic Society (BTS) guidelines, patient age should be carefully considered when determining suitability for the procedure. The guidelines also suggest that if the FEV1 is greater than 2 liters, and there is no evidence of interstitial lung disease or unexplained shortness of breath, additional respiratory function tests may not be necessary to evaluate a patient’s candidacy for pneumonectomy. Numerous studies have shown that right-sided lung resections are associated with a higher incidence of complications and increased mortality compared to left-sided resections..[7]
Postoperative Care
Post-pneumonectomy management requires a multidisciplinary approach involving the surgical team, chest physiotherapists, and other respiratory specialists. Key aspects of management include:
- Preventing and Treating Infections: Antibiotics and prompt treatment of infections to reduce the risk of complications.
- Optimising Respiratory Function: Implementing respiratory physiotherapy techniques to promote lung expansion and prevent respiratory complications such as atelectasis.
- Effective Pain Management: Administering analgesics to manage post-operative pain.
- Fluid Management: Maintaining adequate hydration while avoiding fluid overload to prevent pulmonary edema.
- Monitoring and Early Detection of Complications: Regular monitoring of vital signs and oxygen saturation to promptly identify and address complications.
- Rehabilitation Interventions: Incorporating physical and pulmonary rehabilitation to enhance recovery, restore mobility, and improve respiratory function.
This coordinated approach ensures comprehensive care, promotes recovery, and minimises the risk of post-operative complications.[8]
References
- ↑ 1.0 1.1 1.2 1.3 Beshara M, Bora V. Pneumonectomy. [Updated 2023 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555969/
- ↑ Video-assisted thoracoscopic surgery (VATS), left pneumonectomy for a left main stem mass. Available on: https://www.youtube.com/watch?v=bSCbdqGjAZ0 (accessed 21 September 2024)
- ↑ James TW, Faber LP. Indications for pneumonectomy. Pneumonectomy for malignant disease. Chest Surgery Clinics of North America. 1999 May 1;9(2):291-309.
- ↑ Conlan AA, Kopec SE. Indications for pneumonectomy. Pneumonectomy for benign disease. Chest surgery clinics of North America. 1999 May 1;9(2):311-26.
- ↑ Campisi A, Bertolaccini L, Luo J, Stella F, Fang W. Management of medical complications after pneumonectomy. Shanghai Chest. 2020 Apr 10;4.
- ↑ Brunswicker A, Taylor M, Grant SW, Abah U, Smith M, Shackcloth M, Granato F, Shah R, Rammohan K, North West Thoracic Surgery Collaborative (NWTSC)† Argus Leah Michael Sarah Mason Sabrina Bhullar Dilraj Obale Emmanuel Fritsch NilsCristopher. Pneumonectomy for primary lung cancer: contemporary outcomes, risk factors and model validation. Interactive CardioVascular and Thoracic Surgery. 2022 Jun 1;34(6):1054-61.
- ↑ Powell, E. S., Pearce, A. C., Cook, D., Davies, P., Bishay, E., Bowler, G. M., Gao, F., & UKPOS Co-ordinators (2009). UK pneumonectomy outcome study (UKPOS): a prospective observational study of pneumonectomy outcome. Journal of cardiothoracic surgery, 4, 41. https://doi.org/10.1186/1749-8090-4-41
- ↑ Imran M, Ali N, Ehsan Z, ur Rehman J, Hameed J, Ashraf MS. Post-Operative Complications of Pneumonectomy and It’s Management. National Editorial Advisory Board. 2024 Mar 30;35(3).