Pneumonectomy

Pneumonectomy

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The lungs are highly dynamic thoracic structures that are essential for respiration, pH equilibrium, enzyme production, and host defense, among many other functions. Thus, the lungs are susceptible to a wide variety of pathologic conditions, both malignant and benign, that may require pneumonectomy (complete resection of a lung). [1, 2]

Extrapleural pneumonectomy is an expanded procedure that includes resection of the parietal and visceral pleurae, diseased lung, ipsilateral hemi-diaphragm, ipsilateral pericardium, and mediastinal lymph nodes. [6, 7] While the procedure carries a risk of morbidity, including cardiac and pulmonary complications, it can be beneficial in patients with malignant mesothelioma and extensive thymomas. [1, 2, 4, 5, 6] This surgical approach is often coupled with radiation and chemotherapy to improve survival in both diseases. [2, 3, 4]

Sarot described the first extrapleural pneumonectomy in 1949, [1] and it was initially used in the treatment of tuberculosis empyema but became more commonly used in the 1980s and 1990s in the treatment of mesothelioma. [2]

In general, pneumonectomy is indicated for both malignant and benign diseases.

Malignant indications for pneumonectomy include the following: [1]

Pulmonary metastasis (uncommon)

Non-small cell lung carcinoma

Benign indications for pneumonectomy include the following: [2]

Chronic lung infection (multiple abscesses, bronchiectasis, fungal infection, tuberculosis)

Traumatic lung injury

Bronchial obstruction with destroyed lung

Congenital lung disease

While the most common indication for an extrapleural pneumonectomy is malignant mesothelioma, the technique can also be used to treat disseminated thymomas and occasionally tuberculosis in a more limited fashion. [3, 4, 5]

The patient’s pulmonary function should be assessed and a ventilation-perfusion scan considered for any patient with a forced expiratory volume in 1 second (FEV1) of less than 2 L. The combined results of these tests can be used to adequately predict postoperative lung function. Patients with a predicted postoperative FEV1 of less than 0.8 L are often treated with other means and not considered for pneumonectomy. Although surgeons base candidacy for extrapleural pneumonectomy on pulmonary function studies, patients should be individualized and performance status taken into account for resection.

Echocardiography may also be performed before the procedure to evaluate for valvular disease, pulmonary hypertension, and ventricular function. Severe valvular disease, confirmed severe pulmonary hypertension, and poor ventricular function may preclude surgery.

Positron emission tomography and CT scanning of the chest are used to assess the extent of disease involvement. [1, 2, 8] Surgery is prohibited in patients with disease extending past the diaphragm to be intra-abdominal, to the contralateral hemithorax, invading into structures of the mediastinum or, most commonly, invading the ribs. Since chest MRI and CT scanning are unreliable determinates of chest wall invasion, this is also assessed intraoperatively. [1, 2]

The lungs are two in number in the thorax and are separated by the mediastinum. The left lung is divided into two lobes, an upper and lower, by an oblique fissure, while the right lung is divided into 3 lobes (superior, middle, inferior) by an oblique and horizontal fissure. The right lung is heavier and has a larger capacity than the left lung yet is shorter in consequence of the liver.

Each lung is lined directly by serous membrane, creating the visceral portion of the pleura. The inner lining of the thorax is lined by the parietal portion of the pleura.

The hilum of the lung is a triangular depression on the mediastinal surface of each lung. It consists of pulmonary vessels, bronchi, and bronchial vessels and lymph nodes.

A low volume of fluid is administered. The pulmonary artery and vein are carefully controlled.

Mortality rates of 2%-7% have been reported.

Potential complications of pneumonectomy and extrapleural pneumonectomy include the following:

Atrial fibrillation

Cardiac herniation

Tamponade

Diaphragmatic/pericardial patch dehiscence

Bronchopleural fistula

Deep venous thrombosis

Pulmonary embolism

Pneumonia

Pulmonary edema

Respiratory insufficiency

Myocardial infarction

Bleeding

Wound infection

Urinary tract infection

Sepsis

Postpneumonectomy syndrome

Empyema [1, 2]

James, TW, Faber, LP. Pneumonectomy for malignant disease. Chest Surg Clin N Am 1999; 9:291.

Conlan, AA, Kopec, SE. Pneumonectomy for benign disease. Chest Surg Clin N Am 1999; 9:311.

Beckles MA, Spiro SG: The physiologic evaluation of patients with lung cancer being considered for resectional surgery, Chest. 2003 Jan; 123(1s):105s-114s.

Harpole, DH, Liptay, MJ, DeCamp, MM, et al. Prospective analysis of pneumonectomy: Risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996; 61:977.

Romano, PS, Mark, DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992; 101:1332.

Pain Control after Thoracic Surgery. A Review of Current Techniques. Kavanagh B et al. Anesthesiology, 81: 737-759, 1994.

A Randomised Comparison of Intravenous vs. Lumbar and Thoracic Epidural Fentanyl for Analgesia after Thoracotomy. Guinard J et al. Anesthesiology, 77:1108-1115, 1992.

Stephan F et al. Pulmonary Complications Following Lung Resection. A Comprehensive Analysis of Incidence and Possible Risk Factors. Chest 2000; 118(5):1263-70.

Kopec, SE, Irwin, RS, Umali-Torres, CB, et al. The postpneumonectomy state. Chest 1998; 114:1158.

Foroulis, CN, Kotoulas, C, Lachanas, H, et al. Factors associated with cardiac rhythm disturbances in the early post-pneumonectomy period: a study on 259 pneumonectomies. Eur J Cardiothorac Surg 2003; 23:384.

Hollaus, PH, Setinek, U, Lax, F, Pridun, NS. Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter. Thorac Cardiovasc Surg 2003; 51:162.

Kelly, RF, Hunter, DW, Maddaus, MA. Postpneumonectomy syndrome after left pneumonectomy. Ann Thorac Surg 2001; 71:701.

Argote-Greene LM, Chang MY, Sugarbaker DJ. Extrapleural pneumonectomy for malignant pleural mesothelioma. Available at http://ctsnetjournals.org.

Shields TW, Locicero J, Ponn RB, Rusch VW, Ed. Chang MY, Sugarbaker, DJ. “Technique of Extrapleural Pneumonectomy for Diffuse Malignant Pleural Mesothelioma.” General Thoracic Surgery. PA: Lippincott Williams & Wilkins; 2005. 1(6): 922-929.

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Shannon K Powell Lake Erie College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Pneumonectomy

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