Ann Thorac Surg 2001;71:435-438
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Complications associated with pulmonary resection in lung cancer patients on dialysis
Masanori Tsuchida, MDa,
Yasushi Yamato, MDa,
Tadashi Aoki, MDa,
Takehiro Watanabe, MDa,
Takehisa Hashimoto, MDa,
Hirohiko Shinohara, MDa,
Jun-ichi Hayashi, MDa
a Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Asahimachi, Japan
Accepted for publication August 1, 2000.
Address reprint requests to Dr Tsuchida, Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, 1-757 Asahimachi 951-8510, Japan
e-mail: kentsuchi{at}hotmail.com
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Abstract
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Background. There are few studies available investigating the perioperative problems experienced by lung cancer patients on dialysis undergoing pulmonary resection.
Methods. A retrospective review of 7 patients on dialysis undergoing pulmonary resection for lung cancer was performed.
Results. The patient population consisted of 7 men, with a mean age of 59.9 years. The underlying kidney disease was glomerulonephritis in 5 patients and nephrosclerosis in 2. The mean levels of blood urea nitrogen and serum creatinine were 70.7 mg/dL and 9.4 mg/dL, respectively. Histologic diagnoses were adenocarcinoma in 2 patients and squamous cell carcinoma in 5. Standard lobectomy with lymph node dissection was performed in all cases. There was one operation related death due to pulmonary edema and subsequent development of pneumonia. There were two cases of sputum retention and four of hyperkalemia. One patient died of cerebral bleeding that occurred during dialysis 2 months postoperatively.
Conclusions. In patients on dialysis who undergo pulmonary resection, there is a high incidence of pulmonary complications, in addition to hyperkalemia, hemodynamic instability, and a tendency for postoperative dialysis-associated bleeding.
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Introduction
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Several studies have documented that the frequency of cancer in end-stage renal disease is high [1–4]. An international collaborative study reported high risks associated with cancer of the kidney, bladder, and endocrine organs in patients undergoing dialysis, but no increase in the incidence of cancer of the lung, colorectum, breast, and stomach [1]. The relative risk of lung cancer is reported to be 0.8, and thus no increase in lung cancer was observed in patients undergoing dialysis [2]. However, as the population of patients on dialysis grows, and as the number of surgical procedures continues to increase, the number of lung cancer patients requiring surgery will likely also increase. Moreover, there are few studies available investigating the perioperative problems experienced by lung cancer patients undergoing pulmonary resection. Cardiopulmonary function changes dynamically following pulmonary resection, and such changes may cause complications in certain patients, especially those with a poor cardiopulmonary reservoir. Patients on dialysis represent one group of high-risk patients requiring careful postoperative management.
To this end, we reviewed our experience with surgical procedures in patients on dialysis undergoing pulmonary resection.
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Material and methods
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Between 1980 and 2000, 7 patients with end-stage renal disease underwent pulmonary resection for lung cancer at our institute. Data from medical charts were reviewed retrospectively, and the clinical characteristics of these 7 patients are listed in Table 1. All patients were men, and the underlying renal disease was glomerulonephritis in 5 patients and nephrosclerosis in 2. All patients underwent hemodialysis; the mean duration of dialysis before detection of lung cancer was 31 months. Histologic diagnosis was squamous cell carcinoma in 5 patients and adenocarcinoma in 2. Based on an evaluation of the preoperative images, clinical stage was defined as IA in 2 cases, IB in 3, IIA in 1, and IIIA in 1. As a postoperative pain control, an epidural catheter was placed in all except the earliest patient (patient 1).
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Results
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Preoperative clinical data and lung function findings are listed in Table 1. The mean levels of blood urea nitrogen and serum creatinine were 70.7 mg/mL and 9.4 mg/mL, respectively. The mean hematocrit value was 27.2%. In 2 patients, impairment of lung function was observed (patients 2 and 3). Operative findings are summarized in Table 2. All patients underwent standard lobectomy with systemic lymph node dissections. The pathologic stage was IA in 1 patient, IB in 1, IIIA in 2, and IIIB in 1. The mean duration of surgery was 219 minutes, with a range of 184 minutes to 250 minutes. Mean operative blood loss was 314 mL, and mean fluid replacement volume during surgery was 1,050 mL. The mean serum level of potassium immediately after surgery was 5.2 mEq/mL. Preoperative hemodialysis was carried out on 3 consecutive days to control water and electrolyte conditions in all cases. Postoperative dialysis was resumed immediately after surgery in 1 patient, on the day after surgery in 2 patients, 2 days after surgery in 3 patients, and 3 days after surgery in 1 patient. For anticoagulation therapy during dialysis, nafamostat mesilate was used instead of heparin to avoid bleeding complications. Postoperative complications were observed in all cases. Hyperkalemia (> 6.0 mEq/L) was observed in 4 patients, one of whom required hemodialysis immediately after surgery. Pulmonary complications occurred in 3 patients, 2 of whom experienced sputum retention requiring frequent bronchial toilette using a bronchoscope. One patient suffered pneumonia due to difficulty in water homeostasis, which subsequently progressed into pulmonary edema. The patient went into cardiogenic shock during dialysis and died 1 month postoperatively. Although he was our oldest patient, we do not regard age itself as a contraindication for surgery. Two of 3 patients suffering pulmonary complications had poor lung function: in patient 2, vital capacity was 1.76 L (52.9%), and in patient 3, forced expiratory volume in 1 second was 1.09 L (55.1%). One patient died as a result of intracranial bleeding during hemodialysis at an outpatient clinic 2 months postoperatively. As regards the long-term outcome of the 3 patients, 1 patient died from brain metastasis 6 months after surgery, 1 patient died from pulmonary metastasis 1 year 2 months after surgery, and 1 patient died of bone metastasis 4 years 1 month after surgery. Thus, operative morbidity and mortality were 100% and 14%, respectively.
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Comment
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Two major underlying problematic factors may be associated with dialysis patients requiring pulmonary resection. One factor is the preoperative underlying disease or condition, such as poor nutrition, anemia, electrolyte abnormalities, bleeding tendency, and immunocompromised state [5–9]. Such conditions should be corrected preoperatively as far as possible. For general surgery, the recommended preoperative values of hematocrit, serum creatinine, blood urea nitrogen, and potassium should be maintained at approximately 30%, 6 mg/mL, 60 mg/mL, and below 4.0 mEq/L, respectively [9]. In our series, to correct any water and metabolic imbalances, in addition to any electrolyte abnormalities, hemodialysis was performed on 3 consecutive days immediately before surgery. Anemia was corrected by blood transfusions whenever necessary.
Another important issue is operative conditions that may directly affect a patient’s short-term outcome. One special trend associated with pulmonary resection, but not with general surgery, is a decrease in lung volume that may cause cardiopulmonary complications. To avoid pulmonary edema due to excessive hydration, postoperative fluid replacement should be carefully managed based on the hemodynamic values, such as central venous pressure and pulmonary artery pressure. In our opinion, a pulmonary artery catheter should be placed in patients with poor lung function in case the patient’s cardiopulmonary status deteriorates postoperatively, but this is not necessary for all patients. Patients should be returned to a regular dialysis schedule as quickly as possible to correct physiologic conditions. However, bleeding complications may represent an obstacle to this quick dialysis return. Nafamostat mesilate is an ultra–short-acting multienzymatic inhibitor. In contrast to heparin, nafamostat mesilate prolonged clotting times only in the extracorporeal circuit; therefore, it is a useful anticoagulant in patients needing hemodialysis who are at high risk for bleeding [10]. We applied nafamostat mesilate as a hemodialysis anticoagulant (20 to 40 mg/h) by continuous infusion during hemodialysis in all patients except patient 1. Celite-activated coagulation time at the plasma separator inlet and outlet was adequately prolonged during dialysis, but celite-activated coagulation time in systemic blood showed no prolongation throughout the procedure, because nafamostat mesilate was rapidly inactivated. There was no observable blood coagulation in the extracorporeal circuit including the plasma separator.
In our limited experience, anticoagulation for dialysis did not increase the frequency of early postoperative bleeding complications such as massive bleeding from the thoracic cavity. However, 1 patient in our series died as a result of intracranial bleeding 2 months after surgery under regular heparin usage as an anticoagulant, and thus this should not be considered a surgery-related complication.
In the present 7 patients, operative morbidity and mortality were higher than previously reported rates, most of which involved general surgery and not pulmonary resection. Other investigators have reported relatively low mortality rates of 0% to 6% in patients undergoing several different operative procedures [5]. The causes of early death in the above series were of a cardiac origin, including hemorrhage, sepsis, hepatic failure, pneumonia, and hyperkalemia. In general, the importance of such complications as hyperkalemia, sepsis, hemorrhage, cardiac dysfunction, and hemodynamic instability has been suggested [5–8]. In patients undergoing pulmonary resection, we would like to emphasize the importance of monitoring pulmonary complications associated with difficulties in water homeostasis and decreases in lung volume, especially in patients with poor lung function. In this regard, the preoperative value of vital capacity may be one important predictor of postoperative pulmonary complications. Pulmonary edema triggers hypoxisemia and pneumonia, both of which are fatal. However, such complications may be managed by appropriately timed dialysis. If a patient presents with hemodynamic instability, continuous hemodiafiltration is one relatively safe dialysis option.
Regarding the poor prognosis of the patients in this series and the frequent pathologic upgrading, preoperative accurate staging is important. When mediastinal lymph node swelling is observed on computed tomographic scan, biopsy by cervical mediastinoscopy should be performed to avoid unnecessary surgery for patients with pathologically proven mediastinal lymph node metastasis (N2).
In conclusion, we reported on our series of 7 cases of pulmonary resection, because the number of reported cases to date is low [11, 12]. Although the risk of pulmonary resection for patients on dialysis is high, and treatment is difficult, morbidity and mortality can be reduced through careful management. To establish the efficacy of this surgical procedure and to improve long-term outcome, further research on aggressive treatments for dialysis patients is needed.
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References
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Abstract
Introduction
