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Ann Thorac Surg 1997;64:1635-1638
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Factors Affecting Postoperative Morbidity and Mortality in Destroyed Lung

Heybeliada Chest Disease and Chest Surgery Center, Istanbul, Turkey

Accepted for publication June 27, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. The presence of specific risk factors can increase the postoperative complication rate of pneumonectomy for destroyed lung.

Methods. Our experience in 118 consecutive patients who underwent pneumonectomy for destroyed lung over a 10-year period was retrospectively analyzed to evaluate the effect of specific risk factors on postoperative complications. The significance of tuberculosis, right pneumonectomy, preoperative empyema, and duration of illness longer than 36 months was examined by univariate analyses.

Results. The most common underlying diseases were nonspecific bronchiectasis (n = 52) and tuberculosis (n = 43). Sixty-day or in-hospital morbidity and mortality rates were 11.9% and 5.9%, respectively. The combined morbidity and mortality rate was significantly higher in patients with preoperative empyema (p < 0.003), tuberculosis (p < 0.03), and right pneumonectomy (p < 0.03). The prevalence of bronchopleural fistula was higher in patients with preoperative empyema (p < 0.02) and patients with tuberculosis (p < 0.03).

Conclusions. The postoperative complication rate of pneumonectomy for destroyed lung is acceptably low. However, it is increased by preoperative empyema, tuberculosis, and right-sided resection.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Complications associated with destroyed lung such as massive hemoptysis, secondary fungal infections, secondary amyloidosis, or pulmonary–systemic shunting mandate a pneumonectomy in a select group of patients [1–6]. Not every patient with radiologic signs of destroyed lung is a candidate for pneumonectomy. The goal of operation in destroyed lung is to resolve complications and to improve the patient's quality of life. Surgical removal of destroyed lung tissue harboring a large number of bacilli protected from antibiotics by a poor blood supply has also been considered helpful by rendering the sputum negative and preventing relapse [7].

Firm pleural adhesions and high fibrous thickening around the hilum cause some intraoperative difficulties. In addition, the underlying cause of destroyed lung and the compromised clinical status of the patient make the postoperative period a critical time. However, acceptably low complication rates after pneumonectomy for chronic pulmonary infections have been reported [2–7]. Most of these reports have dealt with the importance of risk factors such as tuberculosis and aspergilloma as the causative factor, right-sided disease, and positive sputum. This retrospective study was undertaken to assess the significance of the risk factors on the postoperative outcome of 118 patients who underwent pneumonectomy for destroyed lung at our center.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
During the 10-year period January 1986 to March 1996, 118 patients underwent pneumonectomy for destroyed lung. Patients who had a completion pneumonectomy were not included in the study. All patients were referred from the chest disease departments of the hospital. Patients were divided into cohorts on the basis of the underlying disease causing lung destruction (tuberculosis and other), the side of operation, the presence or absence of preoperative empyema, and the duration of illness (longer and shorter than 36 months). Patient demographics are displayed in Table 1.

Eligibility for Operation
Two categories of criteria were used for patient selection. Disease characteristics included the following: progressive behavior and resistance to medical treatment; involvement of only one lung; purulent discharge of less than 100 mL/day; and for tuberculosis, no evidence of intrabronchial disease at bronchoscopy. Patient characteristics were as follows: history of massive hemoptysis (more than 600 mL/day), frequent hospitalizations, or disabling symptoms that interfere with the patient's life-style; suitable Karnofsky performance status; forced expiratory volume in 1 second greater than 1,400 mL (because the diseased lung has a minimal contribution to total ventilation) or predicted postoperative forced expiratory volume in 1 second greater than 800 mL; carbon dioxide tension less than 50 mm Hg; and for patients with tuberculosis, 12 months of antituberculosis therapy before operation. A sputum culture negative for Mycobacterium tuberculosis was also very desirable.

Computed tomographic scanning of the chest was routinely performed to obtain unilateral localization. Patients with bronchiectasis were evaluated by bilateral bronchography or recently by high-resolution computed tomography. Bronchoscopy was performed to rule out intrabronchial disease. In patients with sputum positive for Mycobacterium tuberculosis (n = 5), both bronchial systems were selectively lavaged at bronchoscopy, and the material was sent for bacteriologic examination to ensure that the contralateral lung was free from disease.

Most patients underwent preoperative alimentation. The patients with empyema were managed by only closed tube drainage and lavages (in the absence of bronchopleural fistula [BPF]).

Operative Procedures
All of the operations were elective. Of the 118 patients, 102 (86.4%) underwent left pneumonectomy and 16 (13.6%), right pneumonectomy. A double-lumen endotracheal tube was used in all adult patients to avoid any spillage of infected material into the contralateral bronchus. A comparatively longer posterolateral thoracotomy was performed, and not uncommonly, one or two ribs were removed to establish the extrapleural plane. Extrapleural dissection was attempted at the beginning of the operation to avoid contamination of the intrathoracic cavity by suppurative lung tissue, but in only 11 patients (9.3%) could it be achieved throughout the operation. Once an adequate extrapleural plane was developed, separation was begun most often from the pericardial surface.

In some patients with dense perihilar fibrosis, the bronchus was dissected first, and then the vessels were dissected and divided. Intrapericardial pneumonectomy was rarely performed. Care was taken to preserve the perihilar structures so as not to disturb the bronchial vasculature. The bronchus was closed by hand suturing with polyglactin 910 or polypropylene in 107 patients (90.7%) and by stapling devices in 11 (9.3%). The bronchial stump was routinely covered by adjacent mediastinal pleura, pericardium, intercostal muscle, or a combination of these. A chest tube was routinely placed into the pleural cavity and removed on the first or second postoperative day in most patients. The postpneumonectomy space was irrigated (through a catheter introduced at the end of the operation) with isotonic saline solution or 5% dextrose solution containing fluconazole or cephalosporin for 4 to 7 days in patients with aspergilloma or suppurative lung tissue.

After 7 and 11 months of hospitalization, 2 of the 17 patients with pulmonary tuberculosis and empyema underwent thoracomyoplasty concomitantly with pneumonectomy. Seven patients (5.9%) underwent thoracomyoplasty for the management of BPF 35 days to 12 months after pneumonectomy.

Statistical Analysis
Right pneumonectomy, tuberculosis, duration of illness, and presence of preoperative empyema were analyzed as risk factors. Duration of 36 months was selected arbitrarily in dividing patients into cohorts for duration of illness. Because of limited numbers, aspergilloma (n = 7), extrapleural pneumonectomy (n = 11), use of stapling devices (n = 11), and sputum positive for Mycobacterium tuberculosis (n = 5) were not analyzed separately.

Data were collected from the patients' charts, operation notes, and pathology reports and entered into a single database. For univariate analysis of any association between the risk factors and the mortality and morbidity rates, Fisher's exact test or ² test was used, when appropriate. Because of the limited population size, multivariate analysis was not undertaken.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Because of the chronic nature of the underlying diseases, postoperative complications occurred in many instances later than 30 days. Therefore, postoperative complications were included on either a 60-day or in-hospital basis.

There were no intraoperative deaths. The combined postoperative morbidity and mortality rate was 17.8% (21/118). Seven patients (5.9%) died, and 14 (11.9%) sustained major postoperative morbidity (Table 2). Correlative analysis of the postoperative morbidity and mortality rates with the risk factors displayed dissimilar results (Table 3). Nearly half of the combined morbidity and mortality (10/21) occurred in patients with preoperative empyema, a group comprising less than one fourth of the patients (27/118) (p < 0.003). Similarly, the combined postoperative morbidity and mortality rate was significantly higher in patients with tuberculosis (p < 0.03) and those with a right pneumonectomy (p < 0.03). There was no intraoperative or postoperative mortality and morbidity among the 11 patients who underwent extrapleural pneumonectomy. Postoperative morbidity occurred in only 1 of 19 patients who had had the disease for less than 36 months (p = not significant).

Bronchopleural fistula was the most common postoperative complication; it developed within 3 weeks after pneumonectomy in 11 of 12 patients. The prevalence of BPF increased in patients with empyema (p < 0.02) and patients with tuberculosis (p < 0.03) (Table 4). Four patients with postoperative BPF died before surgical intervention could be attempted. Two of seven thoracomyoplasty procedures to close the BPF failed, and both patients died of resultant sepsis and contralateral pneumonia. One patient with a minor BPF and a small postpneumonectomy space is now being considered for myoplasty after 23 months of open drainage.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The present study shows that the unfavorable outcome after pneumonectomy for destroyed lung is closely related to the presence of preoperative empyema, tuberculosis, and a right-sided resection. The greatest incidence of postoperative complications is observed in patients with preoperative empyema. The prevalence of postpneumonectomy BPF formation increases in patients with tuberculosis and in those with preoperative empyema.

Because of the high postoperative complication rate of pneumonectomy in patients with preoperative empyema, consideration should be given to retention of underlying destroyed lung by a myoplasty, an Eloesser procedure, or a limited thoracoplasty instead of pneumonectomy. However, when removal of destroyed lung tissue becomes unavoidable because of life-threatening complications, all attempts should be made to reduce the empyema before the operation.

The increased complication rate after right pneumonectomy has been well recognized [8, 9]. Total lung destruction is more common on the left side than on the right [2, 8, 10]. Also, the low number of patients with right-sided destroyed lung in our series can be explained by the fact that the high postoperative complication rate of right pneumonectomy influenced our decision for operation in these patients.

Pneumonectomy for tuberculosis is one of the highest-risk operations [3, 7, 11–13]. There are three main reasons why the complication rate increases after pneumonectomy in patients with tuberculosis. First, tuberculosis commonly occurs in individuals with poor health status, but it progresses to destroyed lung in those in even worse general status. Second, preoperative empyema is much more commonly associated with tuberculosis than with other underlying diseases of destroyed lung. Third, most patients with tuberculosis have an infected intraparenchymal cavity that adheres firmly to the upper part of the chest wall, and it is sometimes impossible to separate it without perforation. The contamination of the intrathoracic cavity because of the perforation and the rest of the infected lung tissue on the chest wall increase the possibility of empyema and BPF after pneumonectomy.

Extrapleural pneumonectomy remains the method of choice in the patient with inflammatory lung disease [11, 14]. When this method is used, contamination of the intrathoracic cavity is avoided and postoperative complications are minimized. However, because of the firm pleural adhesions, this method can be performed in only a specific group of patients.

Whether the space reduction procedure should be performed concomitantly with pneumonectomy or postponed until BPF develops in patients who are at high risk for postoperative BPF is controversial. In patients with a thin muscular structure as in 2 of our patients, thoracomyoplasty is the single choice for space reduction. Clearly, thoracomyoplasty is an operation that should be performed only in the presence of a life-threatening situation. On the other hand, the chance that a major postpneumonectomy BPF will result in death before any surgical intervention can be accomplished may justify doing a space reduction procedure concomitantly with pneumonectomy.

In conclusion, although postoperative complications after pneumonectomy for destroyed lung have been decreasing steadily, several risk factors—preoperative empyema, tuberculosis, and right-sided disease—need to be considered before any surgical intervention is done. Extrapleural dissection, buttressing the bronchial stump, and irrigation of a potentially dangerous postpneumonectomy cavity can decrease the rate of postoperative complications in destroyed lung. The rate can also be decreased simply by adherence to the patient selection criteria for operation and by careful preoperative preparation.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The statistical assistance provided by Nural Babaoglu, PhD, Marmara University, School of Medicine, is greatly appreciated.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Presented at the Fourth European Conference on General Thoracic Surgery, Cordoba, Spain, Oct 24–26, 1996.

Address reprint requests to Dr Halezeroglu, Kamelya 1-7 Bl no: 16, Atasehir, Tr-81120 Istanbul, Turkey (e-mail: heybeli{at}bnet.net.tr).

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Shields TW, ed. General thoracic surgery. 4th ed. Baltimore: Williams & Wilkins, 1994:968–85.
2. Pomerantz M. Surgery for tuberculosis. Chest Surg Clin North Am 1993;4:723–7.
3. Steven MS, de Villiers SJ, Stanton JJ, Steyn FJ. Pneumonectomy for severe inflammatory lung disease. Results in 64 consecutive cases. Eur J Cardiothorac Surg 1988;2:282–6.[Abstract]
4. Conlan AA, Lukanich JM, Shutz J, Hurwitz SS. Elective pneumonectomy for benign lung disease: modern-day mortality and morbidity. J Thorac Cardiovasc Surg 1995;110:1118–24.[Abstract/Free Full Text]
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9. Harpole DH Jr, Liptay MJ, DeCamp MM Jr, Mentzer SJ, Swanson SJ, Sugarbaker DJ. Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996;61:977–82.[Abstract/Free Full Text]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Semih Halezeroglu Muharrem Celik Canan Senol Gokhan Haciibrahimoglu Bulent Arman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Halezeroglu, S. Articles by Arman, B. Search for Related Content PubMed PubMed Citation Articles by Halezeroglu, S. Articles by Arman, B.