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

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Presentation on theme: "Complications and Post-operative Care of Pulmonary Resection Department of Surgery, Division of General Thoracic Surgery, Veterans General Hospital Kaohsiung."— Presentation transcript:

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

3 2 Surgical candidate of pulmonary resection Age. Age. Pulmonary function: Pulmonary function: PaO2: > 50 mmHg. PaO2: > 50 mmHg. PaCO2: < 50 mmHg PaCO2: < 50 mmHg FEV1: > 0.8 L FEV1: > 0.8 L Vital capacity > 15ml/kg Vital capacity > 15ml/kg DLCO: > 40% DLCO: > 40% Pulmonary artery < 40 mmHg Pulmonary artery < 40 mmHg

4 3 A. INTRAOPERATIVE COMPLICATIONS The 3 major intraoperative complications: The 3 major intraoperative complications: 1. Injury to the large vessel with massive 1. Injury to the large vessel with massive bleeding bleeding 2. Arrhythmia and myocardial ischemia 2. Arrhythmia and myocardial ischemia 3. Contralateral pneumothorax 3. Contralateral pneumothorax

5 4 A. INTRAOPERATIVE COMPLICATIONS Other complications are not lethal immediately but cause morbidity: Other complications are not lethal immediately but cause morbidity: injury of the intrathoracic nerve, thoracic injury of the intrathoracic nerve, thoracic duct, esophagus, spinal cord and dura. duct, esophagus, spinal cord and dura. * Tumor embolism is rare but lethal. It is not diagnosed immediately intraoperatively.

6 5 A. INTRAOPERATIVE COMPLICATIONS Injury to a Major Pulmonary Vessel Prevention: Prevention: Proximal control Proximal control Exposed intrapericardially Exposed intrapericardially

7 6 A. INTRAOPERATIVE COMPLICATIONS Intraoperative Cardiac Complications * Intraopeative arrhythmias and myocardial * Intraopeative arrhythmias and myocardial ischemia are often seen in patients with ischemia are often seen in patients with underlying heart diseases. underlying heart diseases. * Preoperative identifications are necessary. * Preoperative identifications are necessary. A Swan-Ganz catheter, preoperative and A Swan-Ganz catheter, preoperative and intraoperative medication may be indicated. intraoperative medication may be indicated.

8 7 A. INTRAOPERATIVE COMPLICATIONS Intraoperative Cardiac Complications * Excessive manipulation of the heart can * Excessive manipulation of the heart can induce arrhythmia. induce arrhythmia. * Rietchie et al. noted that prophylactic * Rietchie et al. noted that prophylactic digitalization has No effect to reduce digitalization has No effect to reduce inptraoperative arrhythmia. inptraoperative arrhythmia. * Amar et al. noted that the effect of Ca-channel * Amar et al. noted that the effect of Ca-channel blocker to prevent postoperative supraventricular blocker to prevent postoperative supraventricular arrhythmia is unknown. arrhythmia is unknown.

9 8 A. INTRAOPERATIVE COMPLICATIONS Contralateral Pneumothorax Its incidence is 0.8%. Its incidence is 0.8%. It may occur during ultra-radical lymph It may occur during ultra-radical lymph node dissection with perforation of node dissection with perforation of mediastinal pleura. mediastinal pleura.

10 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. 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 FEV 1 were associated with postoperative complications after pneumonectomy. Mitsudomi et al. suggested that high LDH level and low predicted FEV 1 were associated with postoperative complications after pneumonectomy.

11 10 B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION After pneumonectomy, the incidence of nonfatal complication varies from 15% to 60%. 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 majority of complications after pneumonectomy are cardiac dysrhythmias, pulmonary infection, respiratory insufficiency, empyema, bronchopleural fistula and hemothorax.

12 11 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 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. The complication is seen more often in men than in women.

13 12 B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION Keagy et al noted that 41% of patients undergoing lobectomy had nonfatal complications→ Keagy et al noted that 41% of patients undergoing lobectomy had nonfatal complications→ 1/3 of patients: cardiac complications 1/3 of patients: cardiac complications 1/3 of patients: pleural complications 1/3 of patients: pleural complications 1/3 of patients had respiratory complications and require prolonged ventilation 1/3 of patients had respiratory complications and require prolonged ventilation

14 13 B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION After wedge and segmentectomy, the complication is similar to that in lobectomy. 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 major complications of segmentectomy are prolonged air leak, peripheral fistula, empyema.

15 14 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 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% The mortality rate of pneumonectomy is 3-5% Renal failure may be a major cause in old patients. Renal failure may be a major cause in old patients.

16 15 B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION The major causes mortality of lobectomy are septic complications and cardiopulmonary insufficiency. The major causes mortality of lobectomy are septic complications and cardiopulmonary insufficiency. The mortality rate of lobectomy is 1-3% The mortality rate of lobectomy is 1-3% Fatal pulmonary embolism is infrequent. Fatal pulmonary embolism is infrequent. UGI hemorrhage occurs occasionally. UGI hemorrhage occurs occasionally.

17 16 B. POSTOPERATIVE COMPLICATIONS: MORBIDITY AND MORTALITY AFTER PULMONARY RESECTION The mortality rate of segmentectomy is about 1%. The mortality rate of segmentectomy is about 1%.

18 17 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Hemorrhage complications Postoperative hemorrhage Postoperative hemorrhage 1. It is the result of inadequate hemostasis of the 1. It is the result of inadequate hemostasis of the bronchial artery or a systemic vessel in the bronchial artery or a systemic vessel in the chest wall. chest wall. 2. Infrequently, slipping of a ligature or an 2. Infrequently, slipping of a ligature or an un-recognized injury is a cause. un-recognized injury is a cause.

19 18 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Hemorrhage complications Postoperative hemorrhage Postoperative hemorrhage 3. Bleeding related to coagulation is rare. 3. Bleeding related to coagulation is rare. 4. When a chest tube is placed, drainage 4. When a chest tube is placed, drainage more than 200 ml/hr for 4 to 6 hours more than 200 ml/hr for 4 to 6 hours indicates massive bleeding. indicates massive bleeding.

20 19 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Hemorrhage complications Postoperative hemorrhage Postoperative hemorrhage Re-exploration is indicated if Re-exploration is indicated if (1)failed response to blood replacement (1)failed response to blood replacement (2)a large amount of blood in the hemithorax (2)a large amount of blood in the hemithorax (3)persistent massive bleeding from the chest (3)persistent massive bleeding from the chest tube tube

21 20 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Brochovascular fistula 1. It is rare. 1. It is rare. 2. 3% of patients undergoing 2. 3% of patients undergoing bronchoplasty had the complication. bronchoplasty had the complication. 3. It is avoided by placing a tissue flap 3. It is avoided by placing a tissue flap between the bronchial stump and vascular between the bronchial stump and vascular suture line. suture line.

22 21 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac Herniation 1. It is rare but usually follows 1. It is rare but usually follows pneumonectomy. pneumonectomy. 2. Opening the pericardial sac on the left 2. Opening the pericardial sac on the left down to the diaphragm prevents left- down to the diaphragm prevents left- side herniation, but opening of pericardium side herniation, but opening of pericardium on the right does not do so. on the right does not do so.

23 22 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac Herniation 3. Right side herniation an be detected on 3. Right side herniation an be detected on PA or AP view and left side herniation can PA or AP view and left side herniation can be detected on lateral view of CXR. be detected on lateral view of CXR. 5. EKG change may mimic MI. 5. EKG change may mimic MI. 6. Prompt surgical repair is necessary. 6. Prompt surgical repair is necessary. 7. Mortality rate is 50%. 7. Mortality rate is 50%.

24 23 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac Tamponade 1. When the pericardium was opened 1. When the pericardium was opened and then closed, undetected bleeding and then closed, undetected bleeding may cause the complication. may cause the complication. 2. Diagnosis is established by Echo, 2. Diagnosis is established by Echo, radiograph and right side wedge pressure. radiograph and right side wedge pressure.

25 24 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac dysrhythmia Cardiac tachydysrhythmia occurs in 18 Cardiac tachydysrhythmia occurs in 18 % of patients of noncardiac surgery and % of patients of noncardiac surgery and it is most common in pneumonectomy. it is most common in pneumonectomy. The dysrhythmia occur most common The dysrhythmia occur most common in patients aged 60 years or older. in patients aged 60 years or older. Atrial fibrillation is the most common. Atrial fibrillation is the most common.

26 25 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac complications Cardiac dysrhythmia Cardiac dysrhythmia VT: VT: lidocaine IV bolus 50 to 100 mg then lidocaine IV bolus 50 to 100 mg then infusion 1 to 3 mg/min infusion 1 to 3 mg/min Bradyarrhythmia Bradyarrhythmia * atropine, isoproterenol * atropine, isoproterenol * cardiac pacing is indicated in 3° A-V block * cardiac pacing is indicated in 3° A-V block or SSS. or SSS.

27 26 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Cardiac complications Myocardial ischemia and Myocardial infarction Myocardial ischemia and Myocardial infarction 1. Transient myocardial ischemia is 1. Transient myocardial ischemia is uncommon. uncommon. 2. Myocardial infarction rate is about 2. Myocardial infarction rate is about 1.2%. 1.2%. 3. Preoperative cardiac evaluation is necessary. 3. Preoperative cardiac evaluation is necessary.

28 27 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pleural complications Persistent Residual Air Space Persistent Residual Air Space 1. frequently after a lobectomy 1. frequently after a lobectomy 2. More in older patients and 2. More in older patients and granulomatous disease granulomatous disease 3. Apex is more common. 3. Apex is more common.

29 28 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pleural complications Empyema Empyema % of pneumonectomy % of pneumonectomy 2. Inflammatory disease, residual space, 2. Inflammatory disease, residual space, gross contamination during operation, re- gross contamination during operation, re- operation, bronchial leak and postoperative operation, bronchial leak and postoperative mechanical ventilation can increase mechanical ventilation can increase the risk. the risk. 3. Initial treatment is drainage and systemic antibiotics. 3. Initial treatment is drainage and systemic antibiotics.

30 29 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pleural complications Chylothorax Chylothorax 1. Incidence is 0.05%. 1. Incidence is 0.05%. 2. Initial treatment is drainage and TPN 2. Initial treatment is drainage and TPN or low-fat diet and median-chain TG for 7- or low-fat diet and median-chain TG for days. 14 days. 3. If leak of 300 ml/day( pneumonectomy ) or 3. If leak of 300 ml/day( pneumonectomy ) or 500 ml/day( lobectomy ) then surgery is indicated 500 ml/day( lobectomy ) then surgery is indicated

31 30 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Postpneumonectomy Pulmonary Edema( PPE ) Postpneumonectomy Pulmonary Edema( PPE ) % of pneumonectomy( usually right ) % of pneumonectomy( usually right ) 2. High mortality 2. High mortality 3. Overhydration is the etiology. 3. Overhydration is the etiology. 4. Therapy: fluid restriction, morphine, diuretics 4. Therapy: fluid restriction, morphine, diuretics and mechanical ventilation with PEEP. and mechanical ventilation with PEEP.

32 31 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Massive Atelectasis Massive Atelectasis 1. Severe atelectasis is more common 1. Severe atelectasis is more common after RUL or RUL& RML after RUL or RUL& RML bilobectomy. bilobectomy. 2. S/S: fever, SOB, HR↑ 2. S/S: fever, SOB, HR↑ 3. CXR and PE can be diagnostic. 3. CXR and PE can be diagnostic.

33 32 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Lobar Torsion and Gangrene Lobar Torsion and Gangrene 1. Torsion is more common with a free RML. 1. Torsion is more common with a free RML. 2. Suture to a remaining lung can reduce 2. Suture to a remaining lung can reduce the incidence of torsion. the incidence of torsion. 3. CXR can reveal incomplete expansion and 3. CXR can reveal incomplete expansion and opacity. opacity.

34 33 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Lobar Torsion and Gangrene Lobar Torsion and Gangrene 4. Bronchoscopy is indicated if lack of 4. Bronchoscopy is indicated if lack of expansion after tracheobronchal suction. expansion after tracheobronchal suction. 5. Bronchoscopy can reveal a compressed 5. Bronchoscopy can reveal a compressed bronchus( fishmouth-like ). bronchus( fishmouth-like ). 6. Perfusion scan, angiography and CT scan are 6. Perfusion scan, angiography and CT scan are diagnostic but not necessary for torsion. diagnostic but not necessary for torsion.

35 34 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Postoperative Pneumonia Postoperative Pneumonia 1. Etiologic factors: prolonged 1. Etiologic factors: prolonged mechanical ventilation, retention of mechanical ventilation, retention of secretions and atelectasis secretions and atelectasis 2. Treatment: nutrition, antibiotics, 2. Treatment: nutrition, antibiotics, tracheobronchial toilet tracheobronchial toilet

36 35 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Bronchopleural fistula Bronchopleural fistula 1. 1 to 4 % of pneumonectomy or 1. 1 to 4 % of pneumonectomy or lobectomy lobectomy 2. More common in inflammatory disease 2. More common in inflammatory disease 3. Risk factors: DM, pneumonectomy, tumor in 3. Risk factors: DM, pneumonectomy, tumor in brinchial stump and pre-OP irradiatiion. brinchial stump and pre-OP irradiatiion.

37 36 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Pulmonary complications Bronchopleural fistula Bronchopleural fistula 5. Treatment 5. Treatment antibiotics antibiotics drainage drainage re-operation re-operation Eloesser flap Eloesser flap Clagett maneuver Clagett maneuver

38 37 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Esophageal injury 1. When confirmed during operation, it 1. When confirmed during operation, it must be repaired. must be repaired. 2. Late-recognized esophageal injury 2. Late-recognized esophageal injury results in empyema and mediastinitis. It has results in empyema and mediastinitis. It has high morbidity and mortality. high morbidity and mortality.

39 38 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Wound Complications * wound infection * wound infection rare; antibiotics and open drainage rare; antibiotics and open drainage * wound dehiscence * wound dehiscence less common than wound infection less common than wound infection * subcutaneous emphysema * subcutaneous emphysema no specific therapy except drainage no specific therapy except drainage most are benign except a bronchopleural fistula most are benign except a bronchopleural fistula

40 39 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Thoracic Neurologic complications Injury to the intrathoracic nerve Injury to the intrathoracic nerve * phrenic nerve: rare * phrenic nerve: rare * recurrent laryngeal nerve * recurrent laryngeal nerve usually in left, when dissecting A-P usually in left, when dissecting A-P window window hoarseness and aspiration may occur. hoarseness and aspiration may occur.

41 40 C. EARLY COMPLICATIONS AFTER PULMONARY RESECTION Complications Not Unique to Pulmonary Resection DVT DVT 1. It is more common in adenocarcinoma, 1. It is more common in adenocarcinoma, large tumor, major resection and large tumor, major resection and advanced stage. advanced stage. 2. Ziomek: 19% of incidence 2. Ziomek: 19% of incidence

42 41 D. LATE COMPLICATIONS Postpneumonectomy Syndrome Left( right ) Postpneumonectomy Syndrome: Left( right ) Postpneumonectomy Syndrome: 1. (counter)clockwise rotation of great 1. (counter)clockwise rotation of great vessels and trachea→compression of vessels and trachea→compression of right(left) main bronchus and right(left) right(left) main bronchus and right(left) pulmonary artery. pulmonary artery. 2. treatment: prosthetic device in ipsilateral 2. treatment: prosthetic device in ipsilateral hemithorax hemithorax

43 42 D. LATE COMPLICATIONS Superimposed Late Infection late empyema late empyema residual space or bronchopleural residual space or bronchopleural fistula( due to tumor recurrence ) fistula( due to tumor recurrence ) fungal empyema fungal empyema Aspergilus fumigatus is most common. Aspergilus fumigatus is most common.

44 Thank You!


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