Ann Thorac Surg 2000;69:1002-1005
© 2000 The Society of Thoracic Surgeons
ORIGINAL ARTICLES: GENERAL THORACIC
Lobectomy for destroyed lung in quadriplegic patients
Gaetano Rocco, MDa,
Claudio Della Pona, MDa,
Fabio Massera, MDa,
Mario Robustellini, MDa,
Gerolamo Rossi, MDa,
Adriano Rizzi, MDa
a Division of General Thoracic Surgery, Azienda Ospedaliera "Morelli," Sondalo (Sondrio), Italy
Address reprint requests to Dr Rocco, Via Agricoltura 20, 23037 Tirano (Sondrio) Italy
e-mail: grocco{at}novanet.it
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Abstract
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Background. Sixty-seven percent of quadriplegic patients after spinal cord injury (SCI) develop respiratory complications, which leads to death in one third. Preventive measures may fail to avoid parenchymal destruction and possible septic complications.
Methods. Three quadriplegic patients (C3-C6 level), with destroyed lower lobes and incontrollable septic symptoms, were subjected to lobectomy.
Results. Neither operative morbidity nor mortality was observed. All patients were discharged home without ventilatory assistance, and were symptom-free.
Conclusions. When the endobronchial chronic infection calls for repeated fiberoptic bronchoscopies to clear the bronchial tree, the parenchymal destruction is limited to one lobe of the lung, and there is evidence of impending septic complications, lobectomy may be indicated in quadriplegics to eradicate the source of infection.
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Introduction
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Respiratory complications in quadriplegic patients with spinal cord injury (SCI) can seriously affect their survival [1, 2]. Resorting to pulmonary resection for a destroyed lobe in 3 patients with SCI has prompted us to review the literature and discuss the indications for lobectomy in these patients.
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Patients and methods
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Patient 1
In October 1997, a 24-year-old male patient with acute posttraumatic high (C3 level) spinal cord injury was admitted to the intensive care unit. One month later, he developed a left-sided pleural effusion and a right-sided pneumothorax treated by tube thoracostomy. Phrenic stimulation yielded a bilateral minimal and inconsistent diaphragmatic response. Repeated fiberoptic bronchoscopies of the tracheobronchial tree were needed to clear the purulent secretions. High grade fever (39°C) and leukocytosis ensued, while cultures from the right-sided bronchial aspirate grew methicillin-resistant Staphylococcus aureus. A chest computed tomographic scan showed bibasilar parenchymal condensation and right lower lobe focal bronchiectatic changes (Fig 1). Based on these findings and the deteriorated clinical condition, a decision was made to perform a right lower lobectomy to eliminate the most obvious source of infection. On January 9, 1998, he underwent a technically challenging right lower lobectomy for the presence of perihilar sclerosis, fused fissures, and hypertrophic bronchial vessels. The postoperative course was uneventful, and the only minor complication was thoracotomy wound breakdown. He was then transferred to the spinal unit where he underwent physical rehabilitation and reconditioning of the accessory respiratory muscles of the neck. In September 1998, the patient was dismissed home without ventilatory assistance (Fig 2). He did well until June 18, 1999, when he died from a suspected episode of pulmonary embolism.
Patient 2
In February 1998, a 51-year-old male quadriplegic patient (C4-C5 level) was referred from the rehabilitation unit of our hospital for recurrent dyspnea and unrelenting fever. Chest roentgenogram showed right lung atelectasis with ipsilateral deviation of the trachea.
Bronchofiberoscopy demonstrated a significant amount of purulent secretions from the right bronchial tree. Cultures grew methicillin-resistant Staphylococcus aureus. Despite sensitivity-oriented antibiotics, high grade fever and shortness of breath recurred.
A chest computed tomographic scan was done, showing parenchymal condensation and bronchiectatic changes in the right lower lobe and middle lobe pneumonia (Fig 3). One month later, a right lower lobectomy was performed. Intraoperatively, the absence of fissural delimitations and the presence of enlarged, inflammatory perihilar nodes were noted. Postoperatively, repeated bronchofiberoscopies were needed to clear the secretions accumulated in the tracheobronchial tree, due to the poor coughing reflex developed by the patient. Nevertheless, the patient could be dismissed from the hospital 2 weeks after the operation. He continues to do well at more than 1 year from the operation without fever or respiratory distress being observed since (Fig 4).
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Fig 3. Chest computed tomographic scan showing irreversible parenchymal changes in the right lower lobe (patient 2).
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Fig 4. Postoperative chest roentgenogram demonstrating good reexpansion of the residual right lung (patient 2).
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Patient 3
In June 1998, a 35-year-old male patient was admitted to the intensive care unit after a spinal cord injury (C6 level) resulting from a fall from a tree. Left lung atelectasis, due to main stem bronchial plugging likely resulting from aspiration of gastric contents, was immediately noted. Repeated bronchoscopic disobstructions failed to resolve the left lower lobe atelectasis. A concurrent left pleural effusion developed requiring chest tube drainage. A tracheostomy was placed to enable clearing of a significant amount of purulent bronchial secretions. Cultures from the bronchial aspirate grew methicillin-resistant Staphylococcus aureus. A chest computed tomographic scan demonstrated irreversible parenchymal derangements in the left lower lobe (Fig 5). On August 5, 1998, a left lower lobectomy was performed. At operation, extremely thickened perihilar tissues were found, creating a multilayered coat on the bronchovascular elements of the hilum. The postoperative course was uneventful, and mechanical ventilation was discontinued 2 weeks later (Fig 6). More than 1 year from the operation he is breathing spontaneously without residual respiratory symptoms.
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Comment
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A SCI is defined as an acute, traumatic lesion of the spinal cord, including trauma to the nerve roots, causing varying degrees of motor and/or sensory deficit or paralysis [1]. For patients with SCI who survive the first year, the anticipated 10 and 20 year survival rates are 87% and 78%, respectively [1]. Of the paraplegic patients younger than 35 years who survive the first year, 80% are expected to be alive at 10 years [1].
In a recent multicentric study [2], respiratory complications following SCI were observed in 67% of the 261 enrolled patients. Of these patients, 79% had a neurologically complete lesion and almost 70% had a neurological injury at a level comprised between C1 and C8. The most frequent respiratory complication was atelectasis (36%), followed by pneumonia (31%), ventilatory failure (23%), pleural effusion (22%), and pneumo/hemothorax (16%). These complications were reported to occur within 3 weeks of the injury, with the earliest being ventilatory failure and aspiration, pulmonary edema, and pneumo/hemothorax [1]. The mean duration of these complications was at least 2 weeks, and reached 1 month for patients with ventilatory failure [1]. Several authors include the respiratory complications among the major contributing factors of morbidity and mortality in SCI patients with pneumonia and septicemia, accounting for 31% to 44% of all causes of death [2–5].
Quadriplegics seem to incur a higher incidence of pulmonary complications, as opposed to paraplegics, this being due to the stepwise loss of the abdominal, intercostal, and diaphragm muscles with higher level of injury [3, 6]. Lower lobes are most frequently affected by atelectasis and pneumonia in the acute period after SCI due to the expected changes in ventilatory pattern (ie, low expiratory flow rates), the reduced capacity of clearing bronchial secretions, and the suboptimal postural drainage achieved in these patients [3].
Moreover, the enhanced production of tenacious secretions in quadriplegic patients is responsible for reiterated mucus plugging and the irreversible anatomic changes in the most dependant areas of the lung [7, 8]. Manual-assisted cough and training of the accessory muscles have been used in the attempt at improving the cough mechanism in SCI patients, who usually present low expiratory flow rates [9]. Chest physical therapy has also proved more effective in clearing proximal as opposed to distal airways. In this setting, postural drainage could serve as a useful adjunct if only a semiprone position could be adopted in the acute posttraumatic period [3]. Unfortunately, the concurrent presence of an unstable spine often advises against pronating the patient [3].
In our limited experience, the indications for pulmonary resection in quadriplegic patients have included a combination of the following: (1) evidence of a localized destruction of the pulmonary parenchyma; (2) failure of repeated bronchofiberoscopies to effectively clear secretions from the affected lobe; and (3) evidence of an impending risk for local (ie, empyema) or systemic septic complications in the setting of antibiotic resistance or lack of effective antibiotic coverage. The timing of operation is often dictated by the clinical scenario. In our patients, at least 4 weeks have elapsed from the referral to the operation. A computed tomographic evaluation of the chest is mandatory when there is evidence that aggressive pulmonary toilet by chest physiotherapy and bronchoscopy fails to prevent anatomical derangements.
Preoperative functional evaluation may be limited, and a major emphasis is put on clinical expertise and arterial blood gas analysis to roughly determine the surgical risk. One should always keep in mind that pulmonary resection is likely to improve gas exchange, due to the removal of the considerable shunt effect caused by the destroyed lobe.
As with patients with complicated pulmonary infections, the surgeon is faced with a most challenging surgical field [10]. Pleural thickening, reactive hilar adenopathy, hypertrophic bronchial vessels, fused fissures, and perivascular fibrosis may all concur to hasten the surgical maneuvers [10]. Postoperatively, the forced decubitus in the supine position poses an increased risk of dehiscence to the thoracotomy wound. Early chest tube removal should be accomplished, and chest physiotherapy reinstituted, in order to obtain a timely reactivation of accessory respiratory muscles [9, 11].
When needed, bronchoscopic toilet of the tracheobronchial tree should not be deferred. An aggressive attitude toward clearing endobronchial secretions in these patients should be maintained for at least 2 weeks postoperatively.
In conclusion, pulmonary resection for localized irreversible derangements of the pulmonary parenchyma in quadriplegic patients, is a viable option when the destroyed lung poses the patient at significant risk for septic complications.
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Acknowledgments
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This work is dedicated to the memory of Giovanni Cassar.
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References
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Accepted for publication September 21, 1999.
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Abstract
Introduction
