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OBJECTIVE: Recent surgical literature has highlighted the dangers of pneumonectomy for inflammatory lung disease; therefore the assessment of the risk/benefit ratio of our departmental policy. METHODS: Patients undergoing pneumonectomy for inflammatory lung disease during two 2-year periods, 1991-1992 and 1996-1997 inclusive, were retrospectively analyzed. Clinical indications for investigation and surgery, and radiographic findings were determined. Some comparisons between the two periods were drawn. Rates of morbidity and mortality were the principle outcome measures. RESULTS: One hundred and fifty-five patients, 116 males, 39 females, with an average age of 30.2 years ranging from 1-68 years, underwent pneumonectomy for ongoing features of productive cough, haemoptysis (two emergencies) and chronic empyema all with either bronchographic or computed tomography (CT) evidence of destroyed lung. One hundred and fourteen (72%) had or had had tuberculosis at time of surgery. Histology showed bronchiectasis in 53 (34%), end-stage disease in 49 (31.6%) and active tuberculosis in 48 (30.9%). Over 90% of the patients were free of disease at discharge. Mortality was two (1.2%). Morbidity (23%) included post-pneumonectomy empyema 23 (14.8%), bleeding three (1.9%), broncho-pleural fistula three (1.9%), with wound sepsis in one (0.6%) and thoracic duct injury in one (0.6%). Three groups were identified, (1) pneumonectomy through empyema - a risk group, (2) pneumonectomy in active tuberculosis and (3) pneumonectomy in children. Twenty-three post-pneumonectomy empyemas (PPE) occurred with 21 of these following pneumonectomies through empyema (PTE), six PPEs followed 27 PTEs for active tuberculosis. Fourteen of the 21 empyemas following pneumonectomy through empyema were initially sterilized. Finally 15/23 (65%) of all PPEs were sterilized. Pneumonectomy in active tuberculosis did not carry the mortality or morbidity experienced by others. Pneumonectomy in children was remarkably uncomplicated, with one PPE occurring. CONCLUSIONS: This ongoing study shows pneumonectomy for inflammatory lung to be safe, with good results. Tuberculosis, being so common, adequate pre-operative and operative cover with anti-tuberculosis drugs may enhance results.
UNLABELLED: Pneumonectomy continues to be associated with high rates of morbidity and mortality. OBJECTIVE: The aim of this study was to determine the mortality and morbidity rates after pneumonectomy and to analyze perioperative risk factors related to mortality. PATIENTS AND METHODS: The cases of 266 patients undergoing pneumonectomy between January 1986 and December 1997 were reviewed retrospectively: 241 patients with lung cancer, 4 with pulmonary metastasis, 9 with bronchiectasis and 12 with other benign diseases; 13% received neoadjuvant therapy. The bronchial stump was stapled in 92%, sutured in 8%, and covered with autologous tissue in 73%. Intrapericardial pneumonectomy was performed in 32%, pneumonectomy extended to the chest wall or diaphragm in 9%, and completion pneumonectomy was performed in 3%. We collected general demographic data, medical histories, pulmonary function data and surgical technique. Deaths and postoperative complications within the first 30 days after pneumonectomy were also known. RESULTS: Two hundred sixty-six pneumonectomies were performed [right 102 (38%); left 164 (62%)] in 249 men (93%) and 17 women (7%) who were 58 +/- 11 years of age (20 to 79 years). The rate of early postoperative death (30 days) was 5.6%. Mortality rates were higher among patients over 70 years of age (p = 0.045), diabetics (p = 0.038), patients undergoing neoadjuvant therapy (p = 0.031), those with FEV1 under 1,800 ml (p = 0.013), cases of right-sided pneumonectomy (p = 0.001), cases of extended pneumonectomy (p = 0.037) or those without coverage of the bronchial stump (p = 0.005). Mortality was also higher when complications appeared involving the bronchial stump (p < 0.01), heart (p < 0.001), respiration (p < 0.001) or digestion (p = 0.002). Overall morbidity was 40%. Surgical complications developed in 23%: postpneumonectomy empyema (10%), bronchopleural fistula (7%) (with no significant difference related to stapling or suturing), hemothorax (3%) and wound complications (3%). Twelve patients (4.5%) underwent second operations. Cardiac morbidity was 20% (atrial fibrillation in 12%), respiratory morbidity was 8% and other complications appeared in 19% of cases. CONCLUSION: In our experience, mortality after pneumonectomy is 5.6% with an overall complication rate of 40%, mainly due to surgical and cardiac complications. Coverage of the bronchial stump with autologous tissue reduces the risk of postoperative death due to fistula and/or empyema after pneumonectomy.
Pneumonectomy is associated with gross anatomic and physiologic changes of the esophagus. So far, only a few studies have examined the influences of anatomic changes of the esophagus and the resulting physiologic consequences. When pneumonectomy is performed without pulmonary replacement, the esophagus is displaced to the side of pneumonectomy and posteriorly. Indentation of the esophagus by the trachea, bronchus, or aortic arch and dilatation at various levels are present. After pneumonectomy, the peak amplitude of esophageal peristaltic contractions is reduced. This feature is more pronounced in patients who are more than 60 years old and in patients who had their pneumonectomy performed more than 6 years ago. Injury of the vagal nerves, local ischemia, scarring of the esophagus and mediastinum after surgery, and disturbance of the autonomic nervous systems are the major reasons leading to esophageal dysmotility and delayed gastric emptying. Despite the severe morphologic and physiologic changes of the esophagus observed after pneumonectomy, few patients complain of gastrointestinal symptoms after pneumonectomy. Esophageal functional abnormalities may be present in patients with lung cancers before pneumonectomy because of a close anatomic relationship between the esophageal vagal nerve supply and the pulmonary hilum, making the vagal nerves susceptible to disturbances by the tumors or by involved hilar or mediastinal lymph nodes. After pneumonectomy, esophageal dysmotility is exaggerated. After recipient pneumonectomy for thoracic organ transplantation, esophageal dysmotility and delayed gastric emptying are common, but their relationship to gastroesophageal reflux, chronic aspiration, or subsequent development of bronchiectasis and obliterative bronchiolitis is controversial. To reduce the incidence of esophageal dysmotility after pneumonectomy, every effort should be made during surgery to prevent direct injury of the esophagus or the vagal nerves. A prospective study involving a larger patient population is needed to precisely define the problem and its management.
STUDY OBJECTIVES: The measurement of extravascular lung water index by double indicator (EVLWIdi) or the measurement of extravascular lung water index by transpulmonary thermodilution (EVLWItt) could be useful after pneumonectomy. Since pulmonary blood flow and volume are altered after pneumonectomy, the validity of these methods is uncertain. This study has compared measurements of EVLWIdi and EVLWItt with measurement of extravascular lung water index by gravimetry (EVLWIg) in a porcine model of pulmonary edema induced after right pneumonectomy. DESIGN: Randomized laboratory study. SETTING: Animal research laboratory. SUBJECTS: Twenty-seven female pigs; mean weight, 35 +/- 5 kg (+/- SD). INTERVENTIONS: The pigs were anesthetized, placed on mechanical ventilation, and allocated to a two-lung group (n = 10) or a right pneumonectomy group (n = 17). EVLWIdi and EVLWItt were measured at baseline, 60 min after pneumonectomy, and 60 min after IV injection of oleic acid (OA). MEASUREMENTS AND RESULTS: There was a good correlation between EVLWIg and EVLWIdi values (r = 0.96, p < 0.0001 in the two-lung group; and r = 0.81, p = 0.02 in the pneumonectomy group). EVLWIdi underestimated EVLWIg in the two-lung group (- 3 mL/kg; 95% confidence interval [CI], - 7 to + 2 mL/kg) and in the pneumonectomy group (- 0.9 mL/kg; 95% CI, - 3.3 to + 1.5 mL/kg). After pneumonectomy, EVLWItt decreased in mean by 27% and increased in mean by 70% after OA acid. There was a good correlation between EVLWIg and EVLWItt values (r = 0.96, p < 0.0001 in the two-lung group; and r = 0.90, p < 0.0001 after pneumonectomy). EVLWItt slightly overestimated gravimetric value in the two-lung group (+ 1.5 mL/kg; 95% CI, - 1.5 to + 4.2 mL/kg) and largely overestimated gravimetric value after pneumonectomy (+ 5 mL/kg; 95% CI, + 3.4 to + 6.8 mL/kg). CONCLUSION: Double-indicator and transpulmonary thermodilution methods could be useful in monitoring extravascular lung water index (EVLWI) after pneumonectomy, but transpulmonary thermodilution largely overestimates EVLWI.
Malignant pleural mesothelioma is usually a fatal cancer for which operation has been the mainstay of treatment because chemotherapy and radiation are relatively ineffective. The choice of operation for malignant pleural mesothelioma remains controversial. Extrapleural pneumonectomy has been advocated because it allows complete removal of gross tumor and can be associated with long-term survival. To evaluate extrapleural pneumonectomy, we conducted a prospective multiinstitutional trial in patients with biopsy-proved previously untreated malignant pleural mesothelioma. Criteria for extrapleural pneumonectomy were (1) potentially completely resectable unilateral disease by computed tomography scan, (2) predicted postresection forced expiratory volume in 1 second greater than 1 L/sec, and (3) no other major medical problems. Patients who were not candidates for extrapleural pneumonectomy had a more limited operation with or without adjuvant therapy or had nonsurgical treatment. From September 1985 to June 1988 83 eligible patients (64 male, 19 female) were entered. The mean age for all patients was 59.7 years. Only 20 of the 83 patients (24%) underwent extrapleural pneumonectomy. Three of these 20 patients (15%) died postoperatively. The recurrence-free survival was significantly longer for the patients undergoing extrapleural pneumonectomy than for the other two groups (p = 0.03), but there was no difference in overall survival among the three groups. In univariate analyses, epithelial versus sarcomatoid and mixed histologic findings and platelet count less than 400,000 were associated with a better overall survival (p = 0.02), and performance status (Karnofsky less than 80) was predictive of recurrence (p = 0.02). In a multivariate analysis, histologic findings, sex, age, extrapleural pneumonectomy, weight loss, and performance status all had no significant impact on survival. Extrapleural pneumonectomy was associated with a greater likelihood of relapse in distant sites than were limited operation and nonsurgical treatment. We conclude that (1) only a small proportion of all patients with malignant pleural mesothelioma are candidates for extrapleural pneumonectomy, (2) extrapleural pneumonectomy carries a significant operative mortality and does not seem to improve overall survival compared with more conservative forms of treatment, (3) extrapleural pneumonectomy alters the patterns of relapse, and (4) factors previously thought to have an impact on survival in other series did not affect outcome in this trial.
BACKGROUND: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome. METHODS: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period. RESULTS: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease. CONCLUSIONS: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.
OBJECTIVE: The purpose of this study was to compare the outcomes after sleeve lobectomy and pneumonectomy for patients with non-small cell lung cancer distributed according to their nodal involvement status. METHODS: Of 1172 patients in whom primary non-small cell lung carcinoma, including mediastinal lymph nodes, was completely excised, 151 patients underwent sleeve lobectomy and 60 underwent pneumonectomy. For bias reduction in comparison with a nonrandomized control group, we paired 60 patients undergoing sleeve lobectomy with 60 patients undergoing pneumonectomy by using the nearest available matching method. RESULTS: The 30-day postoperative mortality was 2% (1/60) in the pneumonectomy group and 0% in the sleeve lobectomy group. Postoperative complications occurred in 13% of patients in the sleeve lobectomy group and in 22% of those in the pneumonectomy group. Local recurrences occurred in 8% of patients in the sleeve lobectomy group and in 10% of those in the pneumonectomy group. The overall 5- and 10-year survivals for the sleeve lobectomy group were 48% and 36%, respectively, whereas those for the pneumonectomy group were 28% and 19%, respectively (P =.005). Multivariable analysis showed that the operative procedure, T factor, and N factor were significant independent prognostic factors and revealed that survival after sleeve lobectomy was significantly longer than that after pneumonectomy (P =.03). CONCLUSIONS: These data suggest that sleeve lobectomy should be performed instead of pneumonectomy in patients with non-small cell lung cancer regardless of their nodal status whenever complete resection can be achieved because this is a lung-saving procedure with lower postoperative risks and is as curative as pneumonectomy.
BACKGROUND: The advantage of sleeve lobectomy as an alternative to pneumonectomy for preserving lung function is obvious and among other arguments allows operating on patients with lung cancer who would not tolerate pneumonectomy. The purpose of this retrospective, nonrandomized study is to compare the early (30-day mortality) and late (5-year survival) outcomes of both procedures. METHODS: The charts of 310 patients who underwent either pneumonectomy or sleeve lobectomy for lung cancer stages I to IIIA from 1987 to 1997 were reviewed. One hundred ninety-four patients underwent pneumonectomy, and 116 patients underwent sleeve lobectomy. Specific operative complications, i.e., anastomotic leakage versus stump dehiscence, perioperative complications, 30-day or in-hospital mortality, and 5-year survival were registered for comparison of the immediate risk of the respective procedures. RESULTS: In the bronchial sleeve lobectomy group, the incidence of anastomotic leakage was 6.9% (8 of 116 patients) and the operative mortality was 4.3%. The incidence of bronchial stump fistulas after pneumonectomy was 3.6% (7 of 194 patients), and early mortality was 4.6%. All but 6 patients (98%) had a complete resection. Overall 5-year survival after sleeve lobectomy was 39% and after pneumonectomy, 27%. The distribution of 5-year survival stage by stage in either group is presented. Sleeve lobectomy, age younger than 65 years, pN0, and stage I are positive prognostic factors for long-term survival. In the multivariate analysis, pneumonectomy is a negative prognostic factor. CONCLUSIONS: The indication for pneumonectomy versus sleeve lobectomy depends on the localization of the primary tumor on the one hand, and on cardiorespiratory function, which might be more often distinctly impaired in the sleeve group, on the other hand. This could explain why the mortality in the sleeve lobectomy group was identical with that in the pneumonectomy group. However, both techniques are appropriate treatment modalities of advanced lung cancer or patients with critical functional reserve. Therefore, whenever possible, sleeve lobectomy should be performed.
BACKGROUND: Surgically treated, stage I (T1N0 and T2N0) nonsmall cell lung cancer has a relatively favorable prognosis. Our aim was to determine whether performing a pneumonectomy in this group of patients has an impact on survival. METHODS: Four hundred eighty-five patients with stage I nonsmall cell lung cancer undergoing lung resection between 1991 and 2000 were studied. Three hundred seventy-four patients underwent a smaller resection than a pneumonectomy and 111 had a pneumonectomy. RESULTS: Patients undergoing less extensive resections were older (mean age, 65 vs 63 years) (p = 0.01); these patients were also more likely to have a history of chronic obstructive airway disease (9% vs 2%) (p = 0.01) or asthma (10% vs 3%) (p = 0.04), nonsquamous cell type (56% vs 27%) (p < 0.0001), and T1 tumor stage (66% vs 17%) (p = 0.002) than patients having a pneumonectomy. Operative mortality was 2.4% versus 8% (p = 0.01). Overall 1-, 3-, and 5-year Kaplan-Meier survival rates (95% confidence interval [CI]) after less extensive resections were 85% (CI, 82% to 90%), 63% (CI, 56% to 69%), and 50% (CI, 42% to 57%), respectively, and after pneumonectomy the survival rates were 66% (CI, 53% to 73%), 47% (CI, 35% to 57%), and 44% (CI, 32% to 55%), respectively (p = 0.0006). When the Cox proportional hazards model was applied to all study patients (n = 485), pneumonectomy (p = 0.001), T2 stage (p = 0.006), older age (p = 0.03), and male gender (p = 0.03) were independent adverse predictors of survival. When the analysis was limited to the patients having T1N0 disease (n = 145), pneumonectomy (p = 0.0008), older age (p = 0.05), and nonsquamous cell type (p = 0.02) were independent adverse determinants of survival. When only the patients with T2N0 disease were analyzed (n = 340), male gender (p = 0.0005) and pneumonectomy (p = 0.01) were independent negative predictors of survival. CONCLUSIONS: In this study, the patients who underwent pneumonectomy for stage T1N0 or T2N0 nonsmall cell lung cancer had a significantly poorer survival than those patients who underwent smaller lung resections.
To determine the physiologic cardiopulmonary abnormalities leading to death when pneumonectomy is required to stop bleeding in patients in hemorrhagic shock, we compared cardiopulmonary responses to resuscitation in pigs undergoing hemorrhagic shock alone, pneumonectomy alone, and hemorrhagic shock plus pneumonectomy. Four shock-plus-pneumonectomy pigs died acutely from right heart failure. When the five remaining shock-plus-pneumonectomy pigs were compared to the two control groups, pulmonary vascular resistance (PVR) increased to significantly higher levels than would be expected from the increase in PVR noted with resuscitation from shock alone and pneumonectomy alone. Right ventricular compensation maintained cardiac index in the hemorrhage-alone group and the pneumonectomy-alone group but could not maintain cardiac index in the shock-plus-pneumonectomy group, despite maximal increases in right ventricular systolic pressure, heart rate, and right ventricular end diastolic volume. These data indicated that resuscitation from shock plus pneumonectomy cannot be effectively accomplished because increased PVR leads to right ventricular failure, which limits left ventricular preload to levels that are insufficient to maintain cardiac index.