Sequelae & Complications of Pneumonectomy

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Sequelae and Complications Sequelae and Complications
of Pneumonectomyof Pneumonectomy
By Nabil Ali By Nabil Ali
Assisstant LecturerAssisstant Lecturer
Chest Department, Banha University. Chest Department, Banha University.

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Introduction:Introduction:
Pneumonectomy, or surgical removal of an Pneumonectomy, or surgical removal of an
entire lung, is performed most frequently for entire lung, is performed most frequently for
management of bronchogenic carcinoma. management of bronchogenic carcinoma.
Pneumonectomy may rarely be required for Pneumonectomy may rarely be required for
pulmonary metastases or for a variety of forms pulmonary metastases or for a variety of forms
of benign disease, such as inflammatory lung of benign disease, such as inflammatory lung
disease (eg, pulmonary tuberculosis, fungal disease (eg, pulmonary tuberculosis, fungal
infections, and bronchiectasis), traumatic lung infections, and bronchiectasis), traumatic lung
injury, congenital lung disease, and bronchial injury, congenital lung disease, and bronchial
obstruction with a destroyed lung. obstruction with a destroyed lung.

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Preoperative EvaluationPreoperative Evaluation
Because of the significant loss of lung Because of the significant loss of lung
function following pneumonectomy as well function following pneumonectomy as well
as the fact that many patients undergoing as the fact that many patients undergoing
lung resection have abnormal lungs prior lung resection have abnormal lungs prior
to surgery, it is critical to assess a to surgery, it is critical to assess a
patient's functional reserve and the patient's functional reserve and the
predicted pulmonary function following predicted pulmonary function following
pneumonectomy. pneumonectomy.

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Guidelines:Guidelines:
Patients with a preoperative FEV1 of greater than 2
L appear to be at low risk and require no further
testing, provided there is no clinical or radiographic
evidence of pulmonary hypertension.
Patients with a preoperative FEV1 of less than 2 L
should have their predicted postoperative FEV1
(ppoFEVI) estimated. This is performed by
multiplying the patient's preoperative FEV1 by the
percentage of perfusion to the remaining lung, as
determined by a quantitative lung perfusion scan.
Patients with a ppoFEV1 greater than or equal to
800 mL, or greater than 40 percent of predicted,
have an estimated mortality rate of approximately
15 percent.

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Patients with ppoFEV1 values less than 800 mL have typically Patients with ppoFEV1 values less than 800 mL have typically
been excluded from participating in studies assessing the risk been excluded from participating in studies assessing the risk
of death due to pneumonectomy. However, it is not of death due to pneumonectomy. However, it is not
necessarily to exclude any patient from undergoing necessarily to exclude any patient from undergoing
pneumonectomy for potentially curable disease solely on the pneumonectomy for potentially curable disease solely on the
basis of preoperative pulmonary function testing for three basis of preoperative pulmonary function testing for three
reasons: reasons:
1• A prospective study has yet to be performed to determine 1• A prospective study has yet to be performed to determine
the mortality rate in patients with ppoFEV1 values below 800 the mortality rate in patients with ppoFEV1 values below 800
mL.mL.
2• There have been retrospective reports of low mortality rates 2• There have been retrospective reports of low mortality rates
in the older literature in patients who almost certainly had in the older literature in patients who almost certainly had
ppoFEV1 below 800 mL following pneumonectomy.ppoFEV1 below 800 mL following pneumonectomy.
3• It cannot be assumed that the ppoFEV1 is consistently 3• It cannot be assumed that the ppoFEV1 is consistently
accurate. accurate.

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Some authors have suggested that Some authors have suggested that
Cardiopulmonary exercise testing be used to Cardiopulmonary exercise testing be used to
determine if a patient can survive lung determine if a patient can survive lung
resection, particularly in those patients with resection, particularly in those patients with
relatively low or borderline ppoFEV1. relatively low or borderline ppoFEV1.
Cardiopulmonary exercise testing has the Cardiopulmonary exercise testing has the
theoretical advantage of assessing the theoretical advantage of assessing the
patient's cardiopulmonary function and patient's cardiopulmonary function and
reserve. However, the studies addressing reserve. However, the studies addressing
exercise testing have not been definitive. exercise testing have not been definitive.

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Most studies support the conclusion that Most studies support the conclusion that
patients with a preoperative maximum patients with a preoperative maximum
oxygen consumption (VO2max) less than 10 oxygen consumption (VO2max) less than 10
mL/kg/min are at high risk of death (>30 mL/kg/min are at high risk of death (>30
percent), while those with a preoperative percent), while those with a preoperative
VO2max greater than 15 mL/kg/min have an VO2max greater than 15 mL/kg/min have an
acceptable risk (<15 percent). acceptable risk (<15 percent).

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MORTALITY RATES AND RISK MORTALITY RATES AND RISK
FACTORSFACTORS
• • A right-sided pneumonectomy is associated A right-sided pneumonectomy is associated
with a higher mortality rate, ranging from 10 to with a higher mortality rate, ranging from 10 to
12 percent compared with 1 to 3.5 percent for 12 percent compared with 1 to 3.5 percent for
left-sided pneumonectomy. While the reasons left-sided pneumonectomy. While the reasons
are not certain, likely factors include several life-are not certain, likely factors include several life-
threatening complications that are encountered threatening complications that are encountered
more frequently after right pneumonectomy (eg, more frequently after right pneumonectomy (eg,
postpneumonectomy space empyema, postpneumonectomy space empyema,
bronchopleural fistula, and postpneumonectomy bronchopleural fistula, and postpneumonectomy
pulmonary edema).pulmonary edema).

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 • • The specific type of surgical resection is The specific type of surgical resection is
an independent risk factor for mortality. an independent risk factor for mortality.
As an example, pleuropneumonectomy As an example, pleuropneumonectomy
with chest wall resection are associated with chest wall resection are associated
with a 3-fold increase in mortality with a 3-fold increase in mortality
compared to a simple pneumonectomy. In compared to a simple pneumonectomy. In
contrast, completion pneumonectomy (ie, contrast, completion pneumonectomy (ie,
a reoperation to remove the remaining a reoperation to remove the remaining
portion of a previously, partially resected portion of a previously, partially resected
lung) has not been found to be a lung) has not been found to be a
significant risk factor. significant risk factor.

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 • • Pneumonectomy performed emergently for Pneumonectomy performed emergently for
trauma or massive hemoptysis is associated with trauma or massive hemoptysis is associated with
a mortality rate exceeding 35 percent, likely a mortality rate exceeding 35 percent, likely
reflecting the severity of the underlying process.reflecting the severity of the underlying process.
 • • Several comorbid medical illnesses have Several comorbid medical illnesses have
been identified as risk factors for increased been identified as risk factors for increased
mortality. These include underlying lung disease, mortality. These include underlying lung disease,
coronary artery disease, congestive heart failure, coronary artery disease, congestive heart failure,
atrial fibrillation, hypertension, hemiplegia, atrial fibrillation, hypertension, hemiplegia,
active cigarette smoking, and weight loss active cigarette smoking, and weight loss
greater than 10 percent within the 6 months greater than 10 percent within the 6 months
preceding surgery. preceding surgery.

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 • • While some studies have demonstrated While some studies have demonstrated
that increased age (eg, >60 to 75 years) that increased age (eg, >60 to 75 years)
is a risk factor for increased mortality with is a risk factor for increased mortality with
pneumonectomy, others have not.pneumonectomy, others have not.
 • • The level of experience of the surgeon The level of experience of the surgeon
performing the operation may affect the performing the operation may affect the
mortality rate. A lower mortality rate for mortality rate. A lower mortality rate for
lung cancer resection has been lung cancer resection has been
demonstrated when the surgery is demonstrated when the surgery is
performed by a thoracic surgeon rather performed by a thoracic surgeon rather
than a general surgeon.than a general surgeon.

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ANATOMIC CHANGESANATOMIC CHANGES

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Immediately following pneumonectomy, air Immediately following pneumonectomy, air
fills the space previously occupied by the fills the space previously occupied by the
lung (ie, the postpneumonectomy space, or lung (ie, the postpneumonectomy space, or
PPS). PPS).
Unlike the situation with most other forms Unlike the situation with most other forms
of thoracic surgery, a chest tube is not of thoracic surgery, a chest tube is not
inserted following pneumonectomy, and the inserted following pneumonectomy, and the
air is therefore not evacuated. air is therefore not evacuated.

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Over time, a number of changes result in Over time, a number of changes result in
a decrease in the size of the PPS, a decrease in the size of the PPS,
including elevation of the hemidiaphragm, including elevation of the hemidiaphragm,
hyperinflation of the remaining lung, and hyperinflation of the remaining lung, and
shifting of the mediastinum towards the shifting of the mediastinum towards the
PPS. PPS.
At the same time, there is progressive At the same time, there is progressive
resorption of air in the PPS and resorption of air in the PPS and
replacement with fluid. replacement with fluid.

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Chest radiographic findings immediately Chest radiographic findings immediately
after surgery demonstrate the trachea to be after surgery demonstrate the trachea to be
midline and the PPS to be filled with air. midline and the PPS to be filled with air.
Within 24 hours the ipsilateral Within 24 hours the ipsilateral
hemidiaphragm becomes slightly elevated, hemidiaphragm becomes slightly elevated,
the mediastinum shifts slightly towards the the mediastinum shifts slightly towards the
PPS, and fluid starts accumulating in the PPS, and fluid starts accumulating in the
PPS. As a general rule, fluid accumulates at PPS. As a general rule, fluid accumulates at
a rate of approximately two rib spaces per a rate of approximately two rib spaces per
day. After two weeks, 80 to 90 percent of day. After two weeks, 80 to 90 percent of
the PPS is filled with fluid.the PPS is filled with fluid.

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Complete opacification of the hemithorax Complete opacification of the hemithorax
after pneumonectomy takes an average of after pneumonectomy takes an average of
approximately approximately 44 months, with a range from months, with a range from
3 weeks to 7 months. 3 weeks to 7 months.
Only a minority of patients have complete Only a minority of patients have complete
obliteration of their PPS, with most patients obliteration of their PPS, with most patients
having residual fluid and/or air. having residual fluid and/or air.
Unexpectedly rapid accumulation of fluid into Unexpectedly rapid accumulation of fluid into
the PPS in the immediate postoperative the PPS in the immediate postoperative
period should raise concerns for hemorrhage period should raise concerns for hemorrhage
into the PPS, infection of the PPS, or the into the PPS, infection of the PPS, or the
development of a chylothorax. development of a chylothorax.

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The location of vital organs such as the heart The location of vital organs such as the heart
and great vessels, liver, and spleen changes and great vessels, liver, and spleen changes
significantly following pneumonectomy as a significantly following pneumonectomy as a
consequence of mediastinal shift and consequence of mediastinal shift and
elevation of the hemidiaphragm. elevation of the hemidiaphragm.
Extreme care must be taken prior to inserting Extreme care must be taken prior to inserting
a needle or chest tube into the PPS, due to a needle or chest tube into the PPS, due to
the risk of injury to vital organs that have the risk of injury to vital organs that have
shifted position following the surgery. An shifted position following the surgery. An
imaging study such as ultrasound or CT scan imaging study such as ultrasound or CT scan
to help locate vital organs prior to draining to help locate vital organs prior to draining
the PPS is recommended. the PPS is recommended.

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PULMONARY FUNCTION FOLLOWING PULMONARY FUNCTION FOLLOWING
PNEUMONECTOMYPNEUMONECTOMY
 • • Postpneumonectomy lung volumes fall, Postpneumonectomy lung volumes fall,
but typically less than expected for but typically less than expected for
removal of approximately 50 percent of removal of approximately 50 percent of
the original lung tissue. This is especially the original lung tissue. This is especially
true for residual volume and is a true for residual volume and is a
consequence of overexpansion of the consequence of overexpansion of the
remaining lung. However, despite this remaining lung. However, despite this
overexpansion, there is no pathological overexpansion, there is no pathological
evidence of emphysema in the remaining evidence of emphysema in the remaining
lung.lung.

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 • • Forced expiratory volume in one second Forced expiratory volume in one second
(FEV1) and forced vital capacity (FVC) (FEV1) and forced vital capacity (FVC)
usually decrease by less than 50 percent.usually decrease by less than 50 percent.
 • • Diffusing capacity for carbon monoxide Diffusing capacity for carbon monoxide
(DLCO) also decreases by less than 50 (DLCO) also decreases by less than 50
percent, and is usually normal when percent, and is usually normal when
corrected for lung volume.corrected for lung volume.
 • • Lung compliance decreases, airway Lung compliance decreases, airway
resistance increases, and dead space may resistance increases, and dead space may
either increase or decrease. either increase or decrease.

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 • • Arterial oxygen saturation, PO2, and PCO2 at Arterial oxygen saturation, PO2, and PCO2 at
rest do not change in those patients with little or no rest do not change in those patients with little or no
disease in the remaining lung.disease in the remaining lung.
There is little subsequent decline in lung function There is little subsequent decline in lung function
that can be attributed to pneumonectomy beyond that can be attributed to pneumonectomy beyond
one year after the procedure. one year after the procedure.
Long-term studies have demonstrated minimal Long-term studies have demonstrated minimal
further change in FEV1 up to 20 years after further change in FEV1 up to 20 years after
pneumonectomy, with annual decrements in FEV1 pneumonectomy, with annual decrements in FEV1
that are 3 to 4 ml per year, which is less than that that are 3 to 4 ml per year, which is less than that
expected for the general population.expected for the general population.

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CARDIOVASCULAR FUNCTION CARDIOVASCULAR FUNCTION
FOLLOWING PNEUMONECTOMYFOLLOWING PNEUMONECTOMY
Right ventricular ejection fraction decreases Right ventricular ejection fraction decreases
by about 20%, right ventricular end-diastolic by about 20%, right ventricular end-diastolic
volume increases by 20%, and left volume increases by 20%, and left
ventricular function does not change after ventricular function does not change after
pneumonectomy. pneumonectomy.
As long as the remaining lung is relatively As long as the remaining lung is relatively
normal, there is no significant change in normal, there is no significant change in
resting values of systolic pulmonary artery resting values of systolic pulmonary artery
pressure, pulmonary vascular resistance, or pressure, pulmonary vascular resistance, or
central venous pressure after lung resection. central venous pressure after lung resection.

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PULMONARY COMPLICATIONSPULMONARY COMPLICATIONS

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Postpneumonectomy pulmonary edemaPostpneumonectomy pulmonary edema
Although the pathogenesis is unknown Although the pathogenesis is unknown
and probably multifactorial, it is thought to and probably multifactorial, it is thought to
represent a form of the acute respiratory represent a form of the acute respiratory
distress syndrome (ARDS). It does not distress syndrome (ARDS). It does not
appear to be a complication of cardiac appear to be a complication of cardiac
dysfunction, sepsis, pneumonia, or dysfunction, sepsis, pneumonia, or
aspiration. aspiration.

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Postpneumonectomy pulmonary edema is Postpneumonectomy pulmonary edema is
characterized clinically by respiratory distress and characterized clinically by respiratory distress and
hypoxemia within 72 hours of surgery. Treatment hypoxemia within 72 hours of surgery. Treatment
is supportive, including avoidance of fluid is supportive, including avoidance of fluid
overload. Mortality rates exceed 50 percent. overload. Mortality rates exceed 50 percent.
One review of postpneumonectomy pulmonary One review of postpneumonectomy pulmonary
edema suggests that the underlying mechanism of edema suggests that the underlying mechanism of
injury may be due to high inspired oxygen injury may be due to high inspired oxygen
concentrations, associated with single-lung concentrations, associated with single-lung
ventilation or ischemic and reperfusion injury to ventilation or ischemic and reperfusion injury to
the remaining lung.the remaining lung.

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Postpneumonectomy syndromePostpneumonectomy syndrome
Postpneumonectomy syndrome reflects extrinsic Postpneumonectomy syndrome reflects extrinsic
compression of the distal trachea and mainstem compression of the distal trachea and mainstem
bronchus due to shifting of the mediastinum and bronchus due to shifting of the mediastinum and
hyperinflation of the remaining lung. hyperinflation of the remaining lung.
It occurs more than 6 months following surgery It occurs more than 6 months following surgery
and has even been reported 35 years after surgery. and has even been reported 35 years after surgery.
It is more common in patients who undergo It is more common in patients who undergo
surgery in childhood and is almost exclusively seen surgery in childhood and is almost exclusively seen
after right pneumonectomy. after right pneumonectomy.

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The syndrome is characterized by The syndrome is characterized by
development of progressive dyspnea, cough, development of progressive dyspnea, cough,
inspiratory stridor, and recurrent pneumonia inspiratory stridor, and recurrent pneumonia
in patients at least 6 months after surgery. It in patients at least 6 months after surgery. It
can be fatal if left untreated.can be fatal if left untreated.

Treatment consists of surgical repositioning Treatment consists of surgical repositioning
of the mediastinum and filling of the PPS of the mediastinum and filling of the PPS
with a non-absorbable material.with a non-absorbable material.

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Intraoperative spillageIntraoperative spillage
In patients undergoing pneumonectomy for In patients undergoing pneumonectomy for
suppurative lung disease, purulent material can spill suppurative lung disease, purulent material can spill
into the unoperated lung at the time of surgery. into the unoperated lung at the time of surgery.
Respiratory failure and death have been reported Respiratory failure and death have been reported
from this complication. from this complication.
Prevention of intraoperative spillage is therefore Prevention of intraoperative spillage is therefore
critically important, and includes such measures as critically important, and includes such measures as
endobronchial separation with a double-lumen endobronchial separation with a double-lumen
endotracheal tube, prone positioning, and endotracheal tube, prone positioning, and
perioperative bronchoscopy to remove secretions. perioperative bronchoscopy to remove secretions.

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PLEURAL SPACE COMPLICATIONSPLEURAL SPACE COMPLICATIONS

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Postpneumonectomy empyemaPostpneumonectomy empyema
Empyema in the postpneumonectomy space occurs Empyema in the postpneumonectomy space occurs
with a frequency of approximately 5 percent. with a frequency of approximately 5 percent.
Early empyema occurs within 10 to 14 days of Early empyema occurs within 10 to 14 days of
surgery and is commonly associated with a surgery and is commonly associated with a
bronchopleural fistula. bronchopleural fistula.
Late empyema, in which infection is most often Late empyema, in which infection is most often
acquired via a hematogenous route, occurs more acquired via a hematogenous route, occurs more
than 3 months after pneumonectomy and has been than 3 months after pneumonectomy and has been
reported even up to 40 years following surgery.reported even up to 40 years following surgery.

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Chest radiographs may be helpful in Chest radiographs may be helpful in
suggesting the diagnosis. Specific suggesting the diagnosis. Specific
radiographic findings include a shift of the radiographic findings include a shift of the
mediastinum away from the PPS, failure of mediastinum away from the PPS, failure of
the mediastinum to shift normally in the the mediastinum to shift normally in the
immediate postoperative period, immediate postoperative period,
development of a new air-liquid level, or a development of a new air-liquid level, or a
sudden change in a preexisting air-liquid sudden change in a preexisting air-liquid
level. level.
The diagnosis is confirmed by image guided The diagnosis is confirmed by image guided
sampling and analyzing the fluid in the PPS.sampling and analyzing the fluid in the PPS.

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Bronchopleural fistulaBronchopleural fistula
Bronchopleural fistula occurs with a frequency Bronchopleural fistula occurs with a frequency
ranging from 1.5 to 4.5 percent, and is associated ranging from 1.5 to 4.5 percent, and is associated
with a mortality ranging from 29 to 79 percent. with a mortality ranging from 29 to 79 percent.
Bronchopleural fistulas occurring within one week Bronchopleural fistulas occurring within one week
of surgery are not necessarily associated with an of surgery are not necessarily associated with an
empyema, whereas those occurring more than two empyema, whereas those occurring more than two
weeks after surgery are associated with an weeks after surgery are associated with an
empyema. empyema.
Risk factors for formation of a bronchopleural Risk factors for formation of a bronchopleural
fistula include right-sided procedures, residual fistula include right-sided procedures, residual
tumor, concurrent radiation therapy or tumor, concurrent radiation therapy or
chemotherapy, age greater than 60 years, and poor chemotherapy, age greater than 60 years, and poor
wound healing. wound healing.

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Esophagopleural fistulaEsophagopleural fistula
Esophagopleural fistula formation occurs with a Esophagopleural fistula formation occurs with a
frequency of 0.5 percent and is more common after frequency of 0.5 percent and is more common after
right-sided procedures. right-sided procedures.
Most develop at least a year after pneumonectomy Most develop at least a year after pneumonectomy
and are due to recurrent tumor eroding into the and are due to recurrent tumor eroding into the
esophagus. Because esophagopleural fistulas are esophagus. Because esophagopleural fistulas are
always associated with an empyema, symptoms are always associated with an empyema, symptoms are
identical to those accompanying a late identical to those accompanying a late
postpneumonectomy empyema. postpneumonectomy empyema.
Diagnosis can be confirmed by performing a barium Diagnosis can be confirmed by performing a barium
swallow.swallow.

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ChylothoraxChylothorax
Chylothorax, which occurs with a frequency less Chylothorax, which occurs with a frequency less
than one percent, develops within 15 days of than one percent, develops within 15 days of
surgery, usually in those patients who undergo surgery, usually in those patients who undergo
concurrent lymph node resection. The diagnosis concurrent lymph node resection. The diagnosis
should be considered when there is rapid filling of should be considered when there is rapid filling of
the PPS in the immediate postoperative period. the PPS in the immediate postoperative period.
Asymptomatic patients with slow accumulation of Asymptomatic patients with slow accumulation of
chyle can be treated conservatively with bowel rest, chyle can be treated conservatively with bowel rest,
and the chylothorax eventually resolves and the chylothorax eventually resolves
spontaneously. spontaneously.
Patients with signs and symptoms of elevated Patients with signs and symptoms of elevated
central venous pressure, tachycardia, dyspnea, and central venous pressure, tachycardia, dyspnea, and
hypotension as well as radiographic evidence of hypotension as well as radiographic evidence of
rapid filling of the PPS require drainage and surgical rapid filling of the PPS require drainage and surgical
repair.repair.

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Acute hemothoraxAcute hemothorax
Rapid filling of the PPS with blood can occur within Rapid filling of the PPS with blood can occur within
24 hours of surgery. This complication is more 24 hours of surgery. This complication is more
common after pleuropneumonectomy or common after pleuropneumonectomy or
pneumonectomy for suppurative lung disease. pneumonectomy for suppurative lung disease.
The clinical presentation may be with hypotension The clinical presentation may be with hypotension
and shock due to the loss of intravascular blood and shock due to the loss of intravascular blood
volume. The mainstay of treatment is surgical re-volume. The mainstay of treatment is surgical re-
exploration and control of bleeding sources. exploration and control of bleeding sources.

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Contralateral pneumothoraxContralateral pneumothorax
Contralateral pneumothorax is a rare complication Contralateral pneumothorax is a rare complication
that is usually seen in the immediate postoperative that is usually seen in the immediate postoperative
period. period.
Proposed mechanisms have included intraoperative Proposed mechanisms have included intraoperative
damage to the contralateral mediastinal pleura, or damage to the contralateral mediastinal pleura, or
rupture of preexisting blebs or bullae. rupture of preexisting blebs or bullae.
Signs and symptoms include sudden onset of Signs and symptoms include sudden onset of
dyspnea and hypoxemia, and the diagnosis is dyspnea and hypoxemia, and the diagnosis is
confirmed by chest radiography. confirmed by chest radiography.
Management includes evacuation of the air in the Management includes evacuation of the air in the
pleural space in order to achieve re-expansion of the pleural space in order to achieve re-expansion of the
underlying lung. Mortality is approximately 50 underlying lung. Mortality is approximately 50
percent.percent.

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CARDIOVASCULAR COMPLICATIONSCARDIOVASCULAR COMPLICATIONS
Arrhythmias:Arrhythmias:
Cardiac arrhythmias occur in approximately 20 Cardiac arrhythmias occur in approximately 20
percent of cases, with most cases (80 percent) percent of cases, with most cases (80 percent)
presenting within 72 hours of surgery. Over 65 presenting within 72 hours of surgery. Over 65
percent of these arrhythmias are atrial fibrillation. percent of these arrhythmias are atrial fibrillation.
Risk factors for development of an arrhythmia Risk factors for development of an arrhythmia
include age greater than 65 years, right include age greater than 65 years, right
pneumonectomy, pre-existing coronary artery pneumonectomy, pre-existing coronary artery
disease, and hypertension. disease, and hypertension.
Amiodarone has been shown to be safe and Amiodarone has been shown to be safe and
effective in convert patients with postoperative effective in convert patients with postoperative
atrial fibrillation back into sinus rhythm after lung atrial fibrillation back into sinus rhythm after lung
resection. resection.

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Myocardial infarction:Myocardial infarction:
Myocardial infarction following pneumonectomy Myocardial infarction following pneumonectomy
occurs with a frequency of 1.5 to 5 percent. occurs with a frequency of 1.5 to 5 percent.
Management follows the usual considerations for Management follows the usual considerations for
management of myocardial infarction in other management of myocardial infarction in other
settings. Mortality from this complication following settings. Mortality from this complication following
pneumonectomy is in excess of 50 percent.pneumonectomy is in excess of 50 percent.
Pulmonary embolism:Pulmonary embolism:
Pulmonary embolism following pneumonectomy can Pulmonary embolism following pneumonectomy can
originate from several sources. In addition to the originate from several sources. In addition to the
deep venous system of the lower extremities, deep venous system of the lower extremities,
thromboembolism can rarely originate from the thromboembolism can rarely originate from the
pulmonary artery stump. Air embolism after pulmonary artery stump. Air embolism after
pneumonectomy is rare and can usually be avoided pneumonectomy is rare and can usually be avoided
by using a split-bronchus endotracheal tube and by using a split-bronchus endotracheal tube and
only ventilating the non-operated lung. only ventilating the non-operated lung.

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Cardiac herniation:Cardiac herniation:
Herniation of the heart through the defect in the Herniation of the heart through the defect in the
pericardium and into the empty pleural pericardium and into the empty pleural
(postpneumonectomy) space can result in torsion (postpneumonectomy) space can result in torsion
and twisting of the heart.and twisting of the heart.
Usually seen within 3 days of surgery, presenting Usually seen within 3 days of surgery, presenting
as sudden onset of hypotension and shock, as sudden onset of hypotension and shock,
cyanosis, chest pain, and superior vena cava cyanosis, chest pain, and superior vena cava
syndrome. syndrome.
Treatment involves emergent surgery to reposition Treatment involves emergent surgery to reposition
the heart and close the pericardial defect to the heart and close the pericardial defect to
prevent recurrence. Cardiac herniation may be prevent recurrence. Cardiac herniation may be
prevented by primary closure of the pericardial prevented by primary closure of the pericardial
defect at the time of pneumonectomy, or by defect at the time of pneumonectomy, or by
suturing the edges of the pericardial defect to the suturing the edges of the pericardial defect to the
myocardium.myocardium.

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MISCELLANEOUS COMPLICATIONSMISCELLANEOUS COMPLICATIONS
Postpneumonectomy scoliosis:Postpneumonectomy scoliosis:
Ninety percent of patients develop mild Ninety percent of patients develop mild
thoracic scoliosis after pneumonectomy due thoracic scoliosis after pneumonectomy due
to shrinkage of the thoracic cage after to shrinkage of the thoracic cage after
surgery. Associated symptoms have not been surgery. Associated symptoms have not been
reported in the postoperative period.reported in the postoperative period.

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Postpneumonectomy paralysis:Postpneumonectomy paralysis:
Postpneumonectomy paralysis is a rare Postpneumonectomy paralysis is a rare
complication due to intraoperative injury to the left complication due to intraoperative injury to the left
lower intercostal arteries. These vessels feed the lower intercostal arteries. These vessels feed the
arteria magna, which in turn provides much of the arteria magna, which in turn provides much of the
blood supply to the thoracolumbar region of the blood supply to the thoracolumbar region of the
spinal cord. This complication can also result from spinal cord. This complication can also result from
development of an epidural hematoma. development of an epidural hematoma.
Pneumopericardium:Pneumopericardium:
In some cases it may be complicated by In some cases it may be complicated by
development of cardiac tamponade. Diagnosis can development of cardiac tamponade. Diagnosis can
be suggested by a pericardial "crunch" on physical be suggested by a pericardial "crunch" on physical
examination or by a chest radiograph; treatment examination or by a chest radiograph; treatment
requires emergent surgery.requires emergent surgery.

47. NABIL ALINABIL ALI 4747
Gastric volvulus:Gastric volvulus:
Gastric volvulus is a rare complication that Gastric volvulus is a rare complication that
has been seen more than one year has been seen more than one year
following surgery. It probably occurs as a following surgery. It probably occurs as a
result of anatomic changes after surgery.result of anatomic changes after surgery.

48. NABIL ALINABIL ALI 4848
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