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Ann Thorac Surg 2007;83:2258
© 2007 The Society of Thoracic Surgeons
Department of Thoracic Surgery, University Hospital of Strasbourg, 1 place de l’Hopital, Strasbourg, F-67091 France
(Email: gilbert.massard{at}chru-strasbourg.fr).
Herrera and colleagues [1] address the prevalence of pulmonary complications after lung resection in patients with previous head and neck cancer. This study is remarkable because we believe it is the first to compare 76 of these patients with the remaining cohort of 1,557 patients operated on during the same timeframe. It highlights an increased risk for aspiration pneumonia (9.2% vs 0.6%), pneumonia (17.1% vs 10%), and bronchopleural fistula (3.9% vs 0.8%). Aspiration pneumonia led to an increased 30-day mortality (5.9% vs 2.2%). Univariate analysis identified five risk factors for aspiration pneumonitis: preoperative aspiration, preoperative vocal cord paralysis, surgery of the mandible, surgery of the hypopharynx, and tongue resections; only vocal cord paralysis remained a significant risk factor in the multivariate setting.
These results may be compared with a series of 114 patients we published in 1996 [2]. We included only patients with squamous cell carcinoma of the tongue, oral cavity, pharynx, or larynx, which share common risk factors with lung cancer, and we did not consider thyroid carcinoma.
Head and neck cancer was treated by exclusive radiation therapy in 22 patients, resection preserving the larynx in 65, and total laryngectomy in 27. Our pulmonary resections were more aggressive with 22% of pneumonectomies and a single wedge resection. Operative mortality rate was 3.5%. Postoperative pneumonia defined on the basis of purulent sputum with fever and infiltrate on chest roentgenograms occurred in 17 patients (15%), 3 of whom died (17.6%). Pneumonia occurred in 4% after total laryngectomy, 13% after exclusive radiation therapy, and 23% after conservative resection. After resection preserving the larynx, the incidence of pneumonia was nil after limited excision, 20% after glossectomy, 26% after partial laryngectomy, and 54% after mandibular resection.
Pathogenesis of postoperative pneumonia is probably not only related to gross or "silent" aspiration favored by impaired swallowing. There are at least two additional factors. Incomplete closure of the glottis impedes effective cough by reducing the generation of high intrabronchial pressure. Radiation therapy and repeated aspiration bronchitis may alter viscosity of bronchial secretions. These three factors play together in favor of retention of secretions and bacterial colonization.
Comprehensive management should decrease the incidence of pulmonary infections. In opposition to Herrera and colleagues [1], we consider that patients who have total laryngectomy are easy to manage with aggressive physiotherapy, aerosol therapy against drying of the mucosa, and repeated endotracheal suction. Patients with obviously disabled swallowing (in particular after mandibular resection) should be set to NPO and intravenous diet or tube feeding; reopening of a tracheostomy should be discussed on individual basis. Patients with minor swallowing disability or with previous radiation therapy may be initially managed with interdiction of fluids (use of gelified water) and aggressive physiotherapy; NPO is to be applied at the first signs of infection.
We compliment Herrera and colleagues [1] for a nice study focusing on a particular patient population with increased operative risk.
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