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

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

3. 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:
+ J Thorac Cardiovasc Surg 2001; 121:
$ Am Surg 2001; 67:
Causes of death:
Respiratory failure Pneumonia
BP fistula Empyema
Myocardial Infarct Pulmonary embolism

4. 1. Respiratory complications
Respiratory failure: % mortality
Prevention most important
e.g. pre-op chest physio, optimise COAD Mx etc.
Smoking (Ann Thorac Surg 2001; 72: )
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% !!

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

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