Ann Thorac Surg 2010;89:226-231. doi:10.1016/j.athoracsur.2009.10.007
© 2010 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Pneumonectomy in Children for Destroyed Lung: Evaluation of 18 Cases
Altug Kosar, MDa,*,
Alpay Orki, MDb,
Hakan Kiral, MDa,
Recep Demirhan, MDc,
Bulent Arman, MDb
a Sureyyapasa Chest Disease and Chest Surgery Training and Research Hospital, Istanbul, Turkey
b Medical Faculty of Maltepe University Thoracic Surgery Clinic, Istanbul, Turkey
c Kartal Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
Accepted for publication October 6, 2009.
* Address correspondence to Dr Kosar, Sureyyapasa Chest Disease and Chest Surgery Training and Research Hospital, Department of Thoracic Surgery, Ataturk cad. Murat Apt. 46/16, Erenkoy, Istanbul, 34734, Turkey (Email: altugkosar{at}yahoo.com).
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Abstract
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Background: Destroyed lung is an uncommon condition; it describes a nonfunctional lung and is most often caused by inflammatory diseases. Surgical resection is used to resolve or prevent complications and improve quality of life. We reviewed our experience in surgery for destroyed lung in children.
Methods: The records of 18 children aged 16 years and younger who had undergone pneumonectomy for destroyed lung between 1991 and 2007 were analyzed retrospectively.
Results: Eighteen children, 10 males (55.5%) and 8 females, aged 5 to 16 years, with a mean age of 12.3 underwent pneumonectomy. Cough was the major presenting symptom (n = 18, 100%). The median preoperative period for symptoms was 6 years. Radiologic diagnostic methods included chest radiograph, computed tomography, bronchoscopy, and bronchography. Bronchiectasis (n = 13), tuberculosis (n = 4), and aspergillosis (n = 1) were the main pathologies. Five patients had tuberculosis history, and tuberculosis culture was positive in 2 patients. Pneumonectomy was applied to the left side in 14 and right side in 4 patients. There was no mortality. Complication occurred in 3 patients (atelectasis [n = 1], fistula and empyema [n = 1], and wound infection [n = 1]). Atelectasis was treated with bronchoscopy and stoma was needed for another patient for empyema. The mean follow-up was 64.9 months (range, 19 to 164 months). In their follow-up period, scoliosis was found in 1 patient.
Conclusions: The morbidity and mortality rates of pneumonectomy are acceptable for selected and well prepared children. Antibiotics and antituberculosis treatment in certain cases and good timing in pneumonectomy are essential. Children grew and developed normally after pneumonectomy.
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Introduction
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Destroyed lung is an uncommon condition in children, and results in irreversible changes in the lung parenchyma. The condition is caused most often by inflammatory lung diseases such as bronchiectasis, tuberculosis, necrotizing pneumonia, lung abscesses, fungal infections, lung gangrene, bronchial stricture, congenital malformations, and mycobacterium infections other than tuberculosis [1–5].
Pneumonectomy for benign, inflammatory lung diseases is complex. The aim is to resolve complications in destroyed lung and to improve the patient's overall quality of life. Only symptomatic patients who are amenable to surgery, with ongoing features of productive cough, hemoptysis, recurrent chest infections, and chronic empyema, and those who have destroyed a lung, as evidenced with computerized tomography, undergo pneumonectomy [3, 6]. The development of effective, antituberculosis bacillus medications has improved the cure rate in pulmonary tuberculosis. However, the prevalence of pulmonary tuberculosis remains high in many regions of the world, and pneumonectomy is often necessary to treat either the active disease or its sequelae, such as destroyed lung, tuberculosis empyema, and bronchial stenosis [7]. In the present study, we reviewed our clinical data extending over 14 years in surgery for a destroyed lung in children.
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Material and Methods
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The present study was approved by the Institutional Review Board, and data from 18 children who had undergone a pneumonectomy for destroyed lung between 1991 and 2007 were analyzed retrospectively. Patients who had a completion pneumonectomy were not included in the study. Eight of the participants were girls (44.5%), and 10 of the children were boys (55.5%). The mean age of the participants was 12.3 years (range, 5 to 16 years). Six of the patients were 10 years old or younger (33.3%). While 16 of these children (88.9%) had been operated on between 1991 and 2000, only 2 children (11.1%) underwent a pneumonectomy between 2000 and 2007. The majority of the patients were from families in lower socioeconomic classes. Patients had been operated on after an extensive evaluation period. Sputum smears were obtained from all of the patients. Patients showing a growth in the culture were treated by antibiotics in accordance with the results of the antibiogram. Expectorant therapy also was administered. All of the patients had been administered a tuberculin skin test and sputum smear, and a culture test was examined for acid-fast bacilli. In cases of detection of acid-fast bacilli, appropriate therapy was started, and surgery was delayed for 6 months. All of the children, including the ones with growth retardation, received a high-protein, energy-rich diet. Postural drainage and chest physiotherapy were done on patients with bronchiectasis to decrease the amount of purulent sputum. In patients referred to our clinic with diagnosis of empyema, chest drainage was performed by a chest tube. Daily flushing of the chest tube with povidone iodine was done in patients in whom bronchopleural fistula was not detected. Patients showing a decrease in the drainage amount, and no growth in bacterial culture, were prepared for the operation. A respiration function test was administered in 13 children who were older and more cooperative. The remaining 5 patients were tested with a 6-minute walking test. Oxygen saturations were assessed by finger pulse oxymetry, before and after the test. All of the children could walk continually for 6 minutes, and none showed oxygen saturation lower than 90%. In addition, blood gas samples were taken from all patients from their femoral arteries. Radiologic diagnostic methods included chest radiograph, computed tomography (to determine the severity of disease of the affected lung), bronchoscopy (to rule out intrabronchial disease and foreign body), ventilation-perfusion scan (to determine contributing function of the affected lung), and bronchography during the first years of the study (Figs 1; 2).
The term destroyed lung (computerized tomography evidence) often covers a combination of the entities such as bronchiectasis, cavitations, and fibrosis. All of the operations done were elective. Patient demographics, medical history, symptoms, underlying diseases, preoperative assessments and treatments, surgical procedures, and postoperative complications were reviewed, and follow-up results were evaluated.
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Fig 1. Preoperative chest radiograph (A) and chest computed tomographic scan (B) of patient 15 showing cavitary lesions in the right lung, as well as left lung herniates into the right chest.
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Fig 2. Preoperative bronchography (A) and chest computed tomographic scan (B) and (C) of patient 6 showing destruction and collapse as well as thin-walled cavities in the left lung.
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Operative Technique
A classic posterolateral thoracotomy (almost always muscle-sparing) through the fifth intercostal space was given under general anesthesia in all patients. A double-lumen endotracheal tube was used in older children (n = 9). The bronchi were regularly aspirated by an anesthetist during surgery. A rib resection was not performed owing to sufficient exposure. Dissection was performed in the extrapleural plane (72.2%) to avoid contamination of the intrathoracic cavity with suppurative lung tissue, except 5 patients (27.8%). During extrapleural dissection, electrocautery was used to reduce blood loss. Intrapericardial pneumonectomy was performed in 12 patients. The main bronchus was cut as short as possible. The bronchial stump was closed by a stapler in 2 patients, and by hand suturing with polyglactin (Vicryl; Ethicon, Edinburgh, UK) suture in the other patients (n = 16). The bronchial stump was tested underwater at a pressure of 30 cm of water, and always reinforced with a mediastinal pleura, pericardial fat pad, or intercostal muscle pedicle. Hemostasis was achieved by meticulously using electrocautery. In addition, the pleural space was flushed with copious amounts of saline or antiseptic solution. Intraoperative blood loss was recorded carefully and replaced with packed red blood cells and fresh-frozen plasma. A single 32-F chest tube was routinely placed into the pleural space, and almost always removed on the first postoperative day. A careful watch was kept for signs of mediastinal shift. All patients were extubated before transfer to the intensive care unit, where postoperative monitoring was continued for 24 to 48 hours. All patients were given supplementary oxygen therapy to maintain a pulse oximeter saturation of 90% to 92%. In addition, blood gas analyses were done regularly postoperatively. Antibiotherapy was continued postoperatively for 5 to 7 days, and antituberculosis chemotherapy was continued as instructed by pulmonary physicians. Toilet bronchoscopy and nutritional support was continued postoperatively with oral supplements.
Statistical Analysis
Statistical evaluation was performed by using SPSS 11.0 for Windows (SPSS, Inc, Chicago, IL). The Mann-Whitney U test was used for comparison between groups. Differences were considered significant if p values were less than 0.05.
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Results
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Clinical findings are summarized in Table 1. Destroyed lungs were detected on the left side in 14 children (77.8%) and on the right side in 4 children (22.2%). Bronchiectasis (n = 13, 72.2%) was the most common underlying disease. Other underlying diseases were tuberculosis (n = 4, 22.2%) and aspergilloma (n = 1, 5.6%). Five patients had a history of tuberculosis, 2 of which were positive for acid-fast bacilli. Surgical intervention was delayed for 6 months in these patients. Antituberculosis chemotherapy was continued postoperatively as instructed by pulmonary physicians. The most common symptom was cough (100%). Other symptoms were expectoration of purulent sputum (77.8%), clubbing (50%), growth retardation (33.3%), hemoptysis (22.2%), and chest pain (22.2%) (Table 2). The mean duration of the symptoms during the preoperative period was 6 years (range, 2 to 12 years).
Preoperative pulmonary function tests showed that vital capacity ranged between 1.18 and 2.34 L (median, 1.96 L), and forced expiratory volume in 1 second ranged between 0.82 and 1.92 L (median, 1.56 L). Ventilation-perfusion scans demonstrated that the affected lung has a minimal contribution with a perfusion ratio of 5.8% (range, 3.2% to 7.4%).
Growth was observed in preoperative, nonspecific sputum smears in 5 children (27.8%). The pathogens detected were Streptococcus pneumonia in 3 children, Staphylococcus aureus in 1 child, and Pseudomonas aeruginosa in 1 child. Two of the 18 children (11.1%) had empyema, as assessed in the preoperative period.
The postoperative, mean amount of drainage was 277.8 mL (150 to 550 mL). There was no statistically significant difference between patients who underwent intrapleural or extrapleural pneumonectomy for postoperative amount of drainage (p = 0.320).
There was neither intraoperative nor postoperative 30-day period mortality. However, postoperative complications occurred in 3 children (16.7%). These complications were wound infection in 1 patient, atelectasis in 1 patient, and bronchopleural fistula and empyema in 1 patient. While the patient who developed atelectasis was treated by fiberoptic bronchoscopy, the patient with bronchopleural fistula and empyema was initially treated by chest tube drainage and appropriate antibiotics were continued afterward. After 24 days, an open thoracostomy with an Eloesser flap was done when the clinical condition of the patient was ameliorated. The patient was followed up by débriding the inside of the thorax from the stoma. In month 51 of the follow-up the muscle flap closure was performed after it was confirmed that the thoracic space was minimized. The mean duration of postoperative hospital stay was 14.4 days. Postoperatively, pulmonary function tests showed that vital capacity was decreased by an average of 16.6% (range, 12% to 21%), and forced expiratory volume in 1 second by an average of 18.2% (range, 14% to 22%) as compared with preoperative values.
The mean postoperative follow-up was 64.9 months (range, 19 to 164 months). During the follow-up scoliosis was examined in patient 4 (less than 10 degrees). There was a marked herniation of the remaining lung with a mediastinal shift to the opposite side, without symptoms on follow-up chest radiograph or computerized tomography, in all patients (Fig 3).
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Fig 3. Computed tomographic scans of the chest (A) and (B) for patient 4 shows the left lung goes into the right chest, with displacement of the mediastinal structures into the right hemithorax 63 months after operation.
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Comment
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Destroyed lung is an end-stage phenomenon prone to serious complications and irreversible changes in the parenchyma, and rarely observed in children. The involved lung is nonfunctional, with demonstrable absent perfusion and ventilation caused by benign inflammatory lung diseases such as bronchiectasis, tuberculosis, necrotizing pneumonia, lung abscesses, fungal infections, lung gangrene, bronchial stricture, congenital malformations, and mycobacterium infections other than tuberculosis. Bronchiectasis remains the most important cause of chronic, suppurative, pulmonary disease in the pediatric population [1–5, 8, 9]. Parallel to the findings published in the literature, a destroyed lung has been shown to develop due to bronchiectasis in 72.2% of our patients (13 of 18). Insufficient and inadequate use of medications for pulmonary infections and tuberculosis in patients, and a lack of follow-up over time, create a background for lung destruction. The prevalence of a destroyed lung has declined in our country with improved health care and the availability of suitable antibiotics in the last decade.
Pneumonectomy for a benign, inflammatory lung disease has been considered a high-risk procedure because of technical hazards and postoperative complications [10, 11]. Several authors have concluded that the procedure should be avoided whenever possible [4]. However, there are situations when pneumonectomy or pleuropneumonectomy remain the only curative treatment modality for the treatment of benign inflammatory lung disease. Those include a destroyed lung, significant hemoptysis, main bronchial stenosis, multidrug-resistant tuberculosis, or significant symptoms such as a productive cough [1, 12, 13]. Extrapleural pneumonectomy remains the most expeditious and effective management in patients having inflammatory lung disease with serious complications. When this method is used contamination of the intrathoracic cavity is avoided and postoperative complications are minimized [8, 9, 12]. Blyth [14] advocated this approach because extrapleural pneumonectomy is practical and bleeding is no worse. In line with this idea, we performed an extrapleural pneumonectomy in the majority of our patients (n = 13, 72.2%). Our results showed no difference in the amount of postoperative drainage between the extrapleural and intrapleural pneumonectomy when meticulous bleeding control could be achieved. We did not find a significant difference between the two procedures (p = 0.320).
Destroyed lung gives rise to chronically morbid and sometimes acute life-threatening complications such as massive hemoptysis, empyema, secondary fungal infections, secondary amyloidosis, septicemia, pulmonary-systemic shunting, pulmonary hypertension, and respiratory failure. Surgical resection in destroyed lung is used to resolve serious complications and improve a patient's quality of life [1, 8, 15, 16].
The persistence of major inflammatory lung disease, especially pulmonary tuberculosis, presents an evolving global problem. The destroyed posttuberculosis lung is a pathologic term describing the complication of end-stage inflammatory residues that follow gross pulmonary destruction by tuberculosis and other causes. Surgery in patients with tuberculosis infections is indicated for treatment of a destroyed posttuberculosis lung [1, 8, 13, 17].
In children, although symptoms are often denied, an abnormal chest radiograph would lead to investigation and pneumonectomy when appropriate. Whereas elective surgery in asymptomatic patients is usually in a much better clinical state, it may yield better results [1]. Children were noted to grow and develop normally after surgery. Young children (with more potential for growth) tolerated pneumonectomy well, with less functional disability than adults [18, 19]. The long-term outlook for the respiratory function of children after pneumonectomy is good. They have a better vital capacity than those who undergo the same procedure at an older age. Children can perform daily activities and exercise without difficulty, despite reduced pulmonary reserves [20].
Pneumonectomy is rarely indicated in the pediatric population. Pneumonectomy for inflammatory lung disease is frequently associated with high mortality rates, and the frequencies of postpneumonectomy space empyema and bronchopleural fistula are high [1, 8–10]. We believe that performing pneumonectomy in selected and well prepared children (ie, those given nutritional support, appropriate medical treatment, postural drainage, and pulmonary physiotherapy) is safe and worthwhile. Protection of the contralateral lung and meticulous surgical and anesthetic techniques are more important. Preoperative antibiotics, antituberculosis treatment in certain cases, and washout of the pneumonectomy space all contribute to the reduced morbidity and mortality rates. Children and adults have been evaluated together in many reports about destroyed lung. Despite that the mortality rate was demonstrated to be between 0% and 25% [1, 2, 8, 9, 14, 16] in these reports, no cases of mortality occurred in the present study. In the literature, complication rates for pneumonectomy in children have a range from 11.8% to 23.5% [2, 9]. Postoperative complications occurred in 3 children (16.7%) in our series with only 1 major complication (ie, bronchopleural fistula and empyema). In our study population, destroyed lung was more common on the left side (14 patients, 77.8%) than on the right side [1, 8, 9].
During the follow-up (mean, 64.9 months) scoliosis was examined in only 1 child (less than 10 degrees). After pneumonectomy, the mediastinum shifts to the site of the removed lung, and the lung in the contralateral hemithorax becomes overexpanded. This results in a counterclockwise rotation to the right of the heart and the tracheobronchial tree after a right pneumonectomy. The postpneumonectomy syndrome appears usually months or years after surgery with a higher prevalence in children [2, 9, 21]. Herniation of the remaining lung, with a mediastinal shift to the opposite side without symptoms, was observed on a follow-up chest radiograph or a computerized tomography of all the children.
As a result, pneumonectomy for complete resection of chronically infected lung can be accomplished with low mortality. Children can easily tolerate pneumonectomy with acceptable rates of mortality and morbidity and could achieve satisfactory long-term survival for the treatment of tuberculosis. They acquire higher lung volumes as the result of partial compensatory lung growth and better nutritional status in the long term.
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Abstract
Introduction
