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Ann Thorac Surg 1996;61:977-982
© 1996 The Society of Thoracic Surgeons
Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Accepted for publication November 27, 1995.
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Abstract |
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Methods. There were 81 patients (60%) with non--small cell lung cancer (standard pneumonectomy) and 55 patients (40%) with malignant pleural mesothelioma (extrapleural pneumonectomy).
Results. Four perioperative deaths occurred (3%) with no identifiable associated risk factors. Twenty-three patients (17%) had a major complication with an increase in the median length of stay from 7 to 11 days (p < 0.01). Age greater than 65 years, right-sided procedures, and dysrhythmias were associated with an increased risk of a major complication (p < 0.05). Thirty-two patients (24%) had supraventricular dysrhythmias, which occurred on postoperative days 1 to 2 (n = 8), 3 to 4 (n = 13), 5 to 6 (n = 6), and 7 to 12 (n = 5). The median length of stay increased from 8 to 11 days with dysrhythmias (p < 0.05). Factors associated with an increased risk of dysrhythmias (p < 0.05) included age greater than 65 years, intrapericardial or extrapleural pneumonectomy, right-sided procedure, and any major complication.
Conclusions. Pneumonectomy can be performed safely in selected patients with cancer. Supraventricular dysrhythmia was the most common complication noted with a peak incidence at 3 to 4 days after resection.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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This current study concentrated on the 136 patients (mean age, 56 ± 10 years; range, 27 to 74 years) who had undergone a pneumonectomy for non--small cell lung cancer (NSCLC; n = 81) or malignant pleural mesothelioma (n = 55).
Indications for pneumonectomy in NSCLC included central lesions invading the hilar structures, lesions that spanned the fissure (left side), or those involving both right upper and lower lobes. Although a bronchoplastic ``sleeve'' lobectomy was attempted in several patients, extensive involvement of the hilar structures required a pneumonectomy for an adequate tumor margin. (Twelve other patients underwent a successful ``sleeve'' resection during the study period.) Extrapleural pneumonectomy was performed in selected patients with malignant pleural mesothelioma if preoperative staging (documented by computed tomography and magnetic resonance imaging) revealed disease limited to the hemithorax in the absence of vital mediastinal structure invasion.
Exclusion criteria for pneumonectomy included age older than 75 years, poor Karnofsky performance status (<80), unstable cardiac disease (defined by an abnormal exercise test and echocardiogram), carbon dioxide tension greater than 50 mm Hg, resting pulse oximetry less than 90% or 6-minute exercise oximetry less than 88%, and a low body surface area--corrected, predicted postoperative forced expiratory volume in 1 second (FEV1). No patient who had undergone a previous contralateral pulmonary resection was considered for a pneumonectomy. However, a median sternotomy for prior coronary bypass procedures (n = 4) was not a contraindication.
Complete prospective data were recorded on these 136 study patients, including sex, age, presenting signs and symptoms, forced vital capacity, FEV1, rest and exercise pulse oximetry, room air arterial blood gas, and computed tomography of the head, chest, and abdomen. Predicted postoperative FEV1 was calculated as follows: For patients with preoperative FEV1 greater than 2.0 L, left pneumonectomy postoperative FEV1 = 0.55 x preoperative FEV1, and right pneumonectomy postoperative FEV1 = 0.45 x preoperative FEV1. For patients with preoperative FEV1 less than 2.0 L, a radionuclide ventilation/perfusion scan was obtained: postoperative FEV1 = (1 - % of ventilation in pneumonectomy) x preoperative FEV1.
A baseline cardiac assessment was performed, which included a cardiac history and physical examination and a 12-lead electrocardiogram. Data collected after admission to the hospital included the operative procedure, pathologic description, pathologic staging, any postoperative complications, the timing and type of dysrhythmia, and hospital length of stay. Serum potassium, magnesium, and calcium levels, hematocrit, blood pressure, and oxygen saturation were recorded at the onset of atrial dysrhythmia.
Operative Technique
Pneumonectomy for NSCLC was accomplished through a serratus-sparing posterolateral thoracotomy in the fifth intercostal space. Intrapericardial dissection was undertaken for an adequate vascular margin or for control of the ipsilateral main pulmonary artery if significant hilar scarring or adenopathy was evident. A pericardial fat pad was used to cover the stapled bronchial stump. Extrapleural pneumonectomy was accomplished through a full posterolateral thoracotomy with excision of the sixth rib. The tumor was resected en bloc with the lung, parietal pleura, diaphragm, and pericardium. A pericardial fat pad was used to cover the bronchial stump. The pericardium was reconstructed (right-sided tumors) with 0.1-mm Gore-Tex membrane (W. L. Gore & Assoc, Flagstaff, AZ), whereas the diaphragm was reconstructed with 2-mm Gore-Tex membrane [7].
Statistical Analysis
Analysis of variance was used to assess a difference in complications and dysrhythmias between the operative procedures. Fisher's exact test was used to assign significance of any association between any recorded variables and the presence of a major complication or cardiac dysrhythmia. A temporal relationship for postoperative dysrhythmias was assessed using the Pearson 
2 method. Because of the limited population size, subset analysis and multivariate analyses were not undertaken.
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Results |
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Mortality
Data recorded after pneumonectomy revealed four perioperative deaths (3%). One patient died of a myocardial infarction on postoperative day 1. Postmortem examination revealed an occult 75% stenosis of the left main coronary artery and an acute anterior myocardial infarction. The remaining 3 patients died of sepsis and adult respiratory distress syndrome due to pneumonia from 14 to 30 days after operation. There were no other in-hospital deaths. Analysis revealed no identifiable factors associated with mortality.
Minor Complications
Thirty-three patients (24%) had minor complications, including atrial dysrhythmias, wound infections, bronchoscopy for secretions, contralateral pneumothorax, or a urinary tract infection (Table 1
). Transient or permanent vocal cord paralysis was also included; however, 2 of the 5 patients with vocal cord paralysis required deliberate sacrifice of the recurrent nerve due to tumor involvement (see Table 1). The median hospital length of stay was significantly increased with a minor complication (7 to 9 days; p < 0.007).
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Univariate analysis was undertaken to define factors that might be associated with major complications. No association was found for any forced vital capacity range, FEV1 measurement (2.27 ± 0.60 L; range, 1.1 to 4.0 L), predicted postoperative FEV1 estimates (1.15 ± 0.29 L; range, 0.72 to 2.0 L), carbon dioxide tension (range, 30 to 54 mm Hg), oxygen tension (range, 62 to 102 mm Hg) or creatinine levels (Table 2). All patients with a marginal predicted postoperative FEV1 and a good performance status underwent exercise testing to verify adequate oxygen consumption with exercise. There were 5 patients with a predicted postoperative FEV1 less than 0.8 L (1 man, 0.76 L; 4 women, 0.72 to 0.77 L). These patients were small (body surface area--corrected values were in the normal range), and there was no increased rate of complications or dysrhythmias in this subset of patients. The type of resection (extrapleural for mesothelioma or standard pneumonectomy for NSCLC), intrapericardial dissection for NSCLC, the status of lymph node involvement, or the presence of a nondysrhythmic minor complication did not increase the risk of a major complication. However, age greater than 65 years, right-sided procedures, and the presence of a dysrhythmia were associated with major complications (see Table 2).
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Biochemical and physiologic parameters analyzed during the onset of atrial arrhythmias included blood pressure, oxygen saturation, serum potassium, magnesium, and calcium levels, and hematocrit (Table 3). No single biochemical or physiologic variable was significantly associated with the occurrence of atrial dysrhythmias after pneumonectomy. The parameters studied suggest a multifactorial basis for the onset of dysrhythmia in these patients. Thirty-two patients (24%) had supraventricular dysrhythmias, which occurred on postoperative days 1 to 2 (n = 8), 3 to 4 (n = 13), 5 to 6 (n = 6), and 7 to 12 (n = 5) (Fig 1). Treatment consisted of rate control with digoxin (n = 28) and electrical cardioversion (150 to 200 joules) after digoxin (n = 4). All digoxin patients were also treated with procainamide or diltiazem after rate control had been achieved. ß-Blockers were not used in this group of patients with impaired pulmonary status. Administration of antiarrhythmic medications was discontinued at 6 weeks after operation. Length of stay was significantly increased from a median of 8 to 11 days with the presence of supraventricular dysrhythmias (p < 0.05). All measured variables were tested for an association with dysrhythmias (Tables 4, 5). No risk groups could be defined by preoperative spirometry or predicted postoperative pulmonary function, preoperative arterial blood gas measurements, or creatinine level. A significantly increased incidence of dysrhythmias was observed for age greater than 65 years, extrapleural or intrapericardial pneumonectomy, and right-sided procedures. A significant association was observed for the presence of a major complication and supraventricular dysrhythmia.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Because most of the data regarding pneumonectomy in the literature are older and retrospective, the goals of this study were to use a contemporary cohort of cancer patients to define prospectively factors that might have an impact on perioperative mortality, major complications, or cardiac dysrhythmias after pneumonectomy.
The risk of mortality and morbidity is greater for pneumonectomy compared with smaller pulmonary resections. A multicenter, prospective series of 569 pneumonectomies from the Lung Cancer Study Group observed a perioperative mortality rate of 6.2% [9]. However, in the modern era of accurate preoperative assessment, pulmonary rehabilitation, thoracic anesthesia, and careful postoperative management, the 30-day mortality rate would be expected to decline. Our 3% operative mortality obtained over a 5-year period supports this expectation and is favorable when compared with most series published in the literature over the last five decades (Table 6) [1, 3--6, 10--18]. The major morbidity rate in our series of 136 patients was 17% and did not affect overall survival. This rate of complications after pneumonectomy is comparable with the major morbidity rates of 12% to 36% published in the literature [12, 16, 17, 19, 20].
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Several other studies that compared the rate of complications and dysrhythmias in patients who had undergone lobectomy or pneumonectomy have shown an increased rate of major complications and dysrhythmias after pneumonectomy as compared with lobectomy, cancer resections compared with operations for a benign disease, and larger resections (extrapleural pneumonectomy) compared with standard pneumonectomy [12, 13, 15, 17, 19, 20]. Patient data collected at our institution during this 5-year study found a significantly higher rate of morbidity and mortality for the 136 pneumonectomy patients compared with 361 lobectomy patients. Because all analyses were performed on patients with resections for cancer, no comparisons were made with resections for benign disease. Extrapleural pneumonectomy has been viewed by some as a procedure associated with a prohibitive mortality and morbidity. In the present series, the mortality and morbidity rates for extrapleural pneumonectomy were 4% and 16%, whereas mortality and morbidity rates for standard pneumonectomy were 2% and 24% (p = not significant), signifying that an extrapleural pneumonectomy can be performed with reasonable safety in appropriately selected patients.
A prior history of significant cardiac disease has been previously associated with postoperative complications and atrial dysrhythmias (see Table 6
) [1, 3--6, 10--18]. Although 4 of our 136 patients had undergone a previous coronary bypass procedure and several others had stable angina (proven with an adequate ECG stress test), no historical factor could be associated with major morbidity or dysrhythmias. However, we did observe an increased rate of complications and dysrhythmias for patients more than 65 years of age (see Tables 2, 5). Similar to previous reports, an increased rate of dysrhythmias was observed for the patients with an extrapleural or intrapericardial pneumonectomy and those who had a right-sided procedure. Both the resection of pericardium and resection of the right lung, which is in proximity to the sinoatrial node, can cause postoperative atrial irritation. The rate of intrapericardial dissection for the patients with NSCLC was 46 of 81 (57%). This is attributed to the high rate of neoadjuvant therapy given to patients in the intrapericardial group (32 of 46; 70%).
No association was observed between atrial dysrhythmias and mortality for our study of 136 patients. However, several authors have noted a significant mortality (up to 30%) for patients who had sustained or recurrent dysrhythmias, emphasizing the importance of early diagnosis and treatment [13, 17].
In our study, continuous ambulatory ECG monitoring was used to make sure that no rhythm disturbances were missed. This may explain the 24% rate observed in this population, which is slightly higher than the rate quoted from retrospective series in the literature (see Table 6) [1, 3--6, 10--18]. However, the incidence of ventricular ectopy was very low (1 of 136 pneumonectomy patients; <1%). Continuous monitoring documented the timing of the dysrhythmias. We observed a peak incidence at 3 to 4 days after operation (see Fig 1), confirming a need for ambulatory ECG telemetry during hospitalization and counseling against early discharge of the pneumonectomy patient. Continuous ECG monitoring also allowed prospective documentation of physiologic or biochemical parameters at the onset of the arrhythmia. Results demonstrated that no single factor was associated with atrial dysrhythmias (see Table 3). A larger patient population would allow subset analyses, which can define factors that covary with dysrhythmias. Importantly, only 2 patients were discharged in atrial fibrillation, and no patient was in atrial fibrillation at 6 weeks. We do not anticoagulate patients and usually discontinue administration of antiarrhythmic medications 6 to 8 weeks after operation, provided the patient has been maintained in sinus rhythm.
In summary, pneumonectomy can be performed with acceptable risk for selected patients with localized NSCLC and malignant pleural mesothelioma. Factors associated with an increased risk of major morbidity were age greater than 65 years and the presence of supraventricular dysrhythmias. Supraventricular dysrhythmias are the most common complication of pneumonectomy (24%), with a peak incidence 1 to 5 days after resection, suggesting the need for ambulatory telemetry ECG monitoring after operation. Factors that were associated with a greater risk of supraventricular dysrhythmias were age greater than 65 years, intrapericardial or extrapleural pneumonectomy, right-sided procedures, and the presence of any other postoperative complication. No single physiologic or biochemical factor was associated with the onset of dysrhythmias, signifying a multifactorial etiology.
Although the rate of major complications and supraventricular dysrhythmias is acceptable, the length of stay was significantly increased with their presence. The present population of patients can act as a model for a multicenter analysis. The results from such a study should aid in defining risk factors that have a significant association with major complications and dysrhythmias, thereby identifying subgroups of patients appropriate for prophylactic interventions before a planned pneumonectomy.
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D. Cardinale, A. Martinoni, C. M. Cipolla, M. Civelli, G. Lamantia, C. Fiorentini, and M. Mezzetti Atrial fibrillation after operation for lung cancer: clinical and prognostic significance Ann. Thorac. Surg., November 1, 1999; 68(5): 1827 - 1831. [Abstract] [Full Text] [PDF]
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D. H. Sterman, L. R. Kaiser, and S. M. Albelda Advances in the Treatment of Malignant Pleural Mesothelioma Chest, August 1, 1999; 116(2): 504 - 520. [Abstract] [Full Text] [PDF]
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J. J. Curtis, B. M. Parker, C. A. McKenney, C. C. Wagner-Mann, J. T. Walls, T. L. Demmy, and R. A. Schmaltz Incidence and predictors of supraventricular dysrhythmias after pulmonary resection Ann. Thorac. Surg., November 1, 1998; 66(5): 1766 - 1771. [Abstract] [Full Text] [PDF]
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J. A. Melendez and R. Barrera Predictive respiratory complication quotient predicts pulmonary complications in thoracic surgical patients Ann. Thorac. Surg., July 1, 1998; 66(1): 220 - 224. [Abstract] [Full Text] [PDF]
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S. Halezeroglu, M. Keles, A. Uysal, M. Celik, C. Senol, G. Haciibrahimoglu, and B. Arman Factors Affecting Postoperative Morbidity and Mortality in Destroyed Lung Ann. Thorac. Surg., December 1, 1997; 64(6): 1635 - 1638. [Abstract] [Full Text]
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D. Amar Postoperative Cardiac Arrhythmias: Prevention and Management Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 1997; 1(3): 256 - 263. [Abstract] [PDF]
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D. Amar, N. Roistacher, M. E. Burt, V. W. Rusch, M. S. Bains, D. H. Y. Leung, R. J. Downey, and R. J. Ginsberg Effects of Diltiazem Versus Digoxin on Dysrhythmias and Cardiac Function After Pneumonectomy Ann. Thorac. Surg., May 1, 1997; 63(5): 1374 - 1381. [Abstract] [Full Text]
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D. B. Campbell Malignant Mesothelioma Ann. Thorac. Surg., May 1, 1997; 63(5): 1503 - 1505. [Full Text]
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