Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Postthoracotomy Complications
Introduction
Thoracotomy is required to get surgical access to the thoracic cavity through the chest wall to the pleural space and the thoracic organs, such as heart, lung, thymus, and esophagus. The principles and techniques of thoracotomy are differentiated in the anterolateral (= muscle sparing) and posterolateral (= nonmuscle sparing) approach, which requires a lateral position of the patient. In addition, sternotomy, anterior or axillary thoracotomy, clamshell, or hybrid techniques are further techniques that are performed in supine positioning.
Despite extensive and aggressive perioperative management, postoperative respiratory failure or cardiac complications may still occur. Postoperative complications because of thoracotomy encompasses serious risks in general, such as bleeding or hemorrhage or mainly because of the procedure per se, such as bronchopleural fistula, atelectasis, infection, or persistent organ damage.
Postoperative cardiopulmonary complications occur in 10% to 40% of patients undergoing lung resection surgery, resulting in prolonged hospital stay and increased healthcare costs. The most common factors contributing to this high rate are postoperative respiratory complications with respiratory insufficiency. The various causes are shown in Table 27.1 .
Table27.1
Causes and Frequencies of Respiratory Insufficiency
| Atelectasis/secret retention | Nearly all patients |
|---|---|
| With the need for bronchoscopy | 3.6% |
| Pneumonia | Up to 25% |
| Therapeutic atrial arrhythmia | 10.7% |
| Bronchopleural fistula >5 d | 8% |
| Reintubation | 3.4% |
| ARDS | 1.1% |
| Phrenic/recurrent nerve paresis | 0.5% |
| Pulmonary embolism | 0.4% |
| Empyema | 0.3% |
ARDS , Acute respiratory distress syndrome.
Modified from Cao C, Louie BE, Melfi F, et al. Outcomes of major complications after robotic anatomic pulmonary resection. J Thorac Cardiovasc Surg . 2019;159(2):681–686.
Cao et al. evaluated 1264 patients who underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%) ( Fig. 27.1 ). Male sex, decreased forced expiratory volume in 1 second (FEV 1 ), reduced diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection are associated with increased likelihood of a major postoperative complication.
Morbidity and mortality further depend on the type, invasiveness, and extent of the thoracic surgical procedure. The planned admission to the intensive care unit (ICU), high dependency unit (HDU), or postanesthetic care unit depends on the clinician’s pre- and intraoperative prediction of potentially preventable major complications. In addition, adverse events may demand unplanned admission to the HDU or ICU for further diagnosis and treatment of complications. The overall risk profile for thoracic surgical patients is shown in Fig. 27.2 .
The definition of postoperative pulmonary complications (PPCs) is heterogeneous. Typically, PPCs are categorized as a composite outcome measure. The PPCs after thoracotomy are defined as need for noninvasive ventilation because of hypercapnia or hypoxia, need for tracheal intubation because of hypercapnia or hypoxia, prolonged air leak for 5 or more days after surgery, new thoracic drainage from an increased pleural effusion with respiratory compromise, and the presence of pleural empyema. Pneumonia was diagnosed according to the European Perioperative Clinical Outcome definition. This included new pulmonary infiltrate with associated leukocytosis, fever, new purulent sputum, need for antibiotic therapy, and increased oxygen demand via face mask. PPCs are ranked as the leading causes of early mortality after lung surgery, whereas sepsis and cardiac events are ranked second and third, respectively. Thoracotomy by itself was defined as a risk factor for PPCs. There is more compelling evidence that the thoracoscopic approach reduces the incidence of PPCs. Chen et al. performed a metaanalysis of 20 studies with 3457 patients comparing video-assisted thoracoscopic surgery (VATS) lobectomy with open lobectomy. There was no difference in operation time between the two groups ( P = .14), but distinct advantages in terms of intraoperative blood loss, chest drainage time, hospital stay, and complication incidence were found in the VATS group ( P < .01). Moreover, the 5-year survival rate of VATS group was significantly higher than the thoracotomy group.
Prediction of Postoperative Pulmonary Complications
The preoperative identification of risk factors and the prediction of PPCs has the potential to optimize the perioperative care of patients and could help to reduce PPC. Canet et al. assessed the incidence and characteristics of PPCs in a large sample of 2464 patients and built a scoring system with a reduced number of significant variables that would identify PPC risk in most clinical settings (Assess Respiratory Risk in Surgical Patients in Catalonia [ARISCAT]) ( Tables 27.2 and 27.3 ). ,
Table 27.2
ARISCAT Score for Postoperative Pulmonary Complications
| Age, years | ≤50 (0) | 51 – 80 (+3) | >80 (+16) | |||
| Preoperative SpO 2 | ≥96% (0) | 91 – 95% (+8) | ≤90% (+24) | |||
| Respiratory infection in the last month | No (0) | Yes (+17) | ||||
| Preoperative anemia (Hb <10 g*dL −1 ) (6.2 mmol*L −1 ) |
No (0) | Yes (+11) | ||||
| Surgical incision | Peripheral (0) | Upper abdominal (+15) | Intrathoracic (+24) | |||
| Duration of surgery | <2 hours (0) | 2 – 3 hours (+16) |
|
|||
| Emergency procedure | No (0) | Yes (+8) | ||||
Table27.3
Postoperative Pulmonary Complications Risk Score
| Risk Score Intervals | |||
|---|---|---|---|
| Low Risk <26 Points | Intermediate Risk 26–44 Points | High Risk >45 Points | |
| Postoperative pulmonary complication rate in % | 1.6 | 13.3 | 42.1 |
From Chen FF, Zhang D, Wang YL, Xiong B. Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage non-small cell lung cancer: a meta-analysis. Eur J Surg Oncol . 2013;39(9):957–963.
Postthoracotomy Complications in General and/or Specific to the Thoracic Procedure
Postthoracotomy complications may be categorized in general and/or specific to the thoracic procedure and may be related to patient- and procedure-specific risk factors.
Risk Factors
Patient-specific risk factors for the occurrence of PPCs include continued nicotine abuse, the male sex, the presence of chronic obstructive pulmonary disease (COPD), increased comorbidity (American Society of Anesthesiologists [ASA] ≥3), cachexia, increased age, obesity, preoperative impaired lung function, and preexisting hypoxia. , , ,
With regard to surgical risk factors, the extent of parenchymal resection, thoracotomy compared with thoracoscopy, as well as an extended duration of surgery, contribute to an increase in risk factors for the occurrence of PPCs. , , As previously mentioned, thoracoscopy as an alternative procedure to thoracotomy is the most important surgical factor in reducing PPCs. During the intraoperative management, a liberal intraoperative volume therapy, a high tidal volumes >8 mL/kg body weight) to the dependent lung were identified as the main risk factors for the occurrence of PPCs. , , Serpa Neto et al. evaluated 15 randomized controlled trials (2127 patients). There were 97 cases of PPC in 1118 patients (8.7%) assigned to protective ventilation and 148 cases in 1009 patients (14.7%) assigned to conventional ventilation. Patients who developed postthoracotomy complications were older, presented higher ASA scores, had a higher prevalence of sepsis or pneumonia, received more frequent blood transfusions, and were ventilated with higher tidal volumes, lower positive end-expiratory pressure (PEEP) levels, or both. , These factors increase postoperative respiratory failure after thoracic procedures. Additional patient-specific risk factors are expiratory peak flow limitations during COPD, which result in increased work of breathing and muscle fatigue and ultimately respiratory failure. The frequent presence of postoperative atelectasis formed intraoperatively often persists postoperatively and may increase intrapulmonary shunt and predisposes acute lung injury. The incidence of postoperative lung injury after thoracotomy and thoracic surgery may be as high as 4.3%.
Postthoracotomy Complications
Despite the developments and improvements in surgical technique, examples of general complications after thoracic surgical procedures are extra- or intrathoracic bleeding after hemorrhage, hemothorax, pleural effusion, nerve injuries, chylothorax, acute, and postthoracotomy pain, pneumonia without/with septic condition. More specific complications particularly during thoracic procedures are: air leakage and/or bronchopleural fistula, pneumothorax, subcutaneous emphysema, lung torsion, lung infarction after pulmonary resection, anastomotic insufficiency after esophagectomy, and airway complications: aspiration of gastric contents and retained secretions.
Postoperative Thoracic Complications
Bleeding
Postoperative bleeding after thoracic surgery is a rare but life-threatening complication. A national database with over 33,000 patients found an incidence of intraoperative bleeding of 1.9% for open, 1.3% for VATS, and 1.7% for robotic-assisted lobectomy resections. Not all postoperative bleedings are subject to immediate exploration in the operating room (OR). A chest tube drainage of 1000 mL of bloody secretion within the first hour after lung resection must be considered for immediate exploration in the OR. Furthermore, a serial drainage rate of more than 200 mL/h over 2 to 4 hours postoperatively indicates an intrathoracic hemorrhage and requires surgical revision as well.
Lobe Torsion
The torsion of a pulmonary lobe after previous lung resection leads to a circulatory disorder and bronchial stenosis because of rotation around the supplying vessels and bronchial structures. The incidence is stated to be about 0.1% to 0.3%. Lobar torsion was frequently reported after upper lobectomy (74.4%) and the middle lobe was the most vulnerable to torsion (29.4%). The main clinical presentations were dyspnea (38.4%), fever (23.3%), and chest pain (17.4%). Radiologic findings (computed tomography [CT] scan) included worsening consolidation and abrupt truncation/tapering of the pulmonary artery. The overall mortality was 8.3%. Lobe torsion is a life-threatening situation; if a pulmonary lobe torsion was detected after clinical and CT diagnostics, an immediate surgical revision must be performed ( Figs. 27.3 and 27.4 ).
A chest x-ray and a CT scan were taken of a 50-year-old woman who presented with a 2-month cough and mild symptoms of hemoptysis. On routine examination, the patient was found to have a mass measuring around 3.5 cm in right upper lung field. The patient underwent right upper lobectomy through a standard right posterolateral thoracotomy. The chest radiographs on postoperative day 1 and 2 showed adequate lung expansion with no obvious abnormality. Five days postoperatively, the patient presented fever and mild dyspnea. Follow-up chest radiograph showed a wedge-shaped opacity of large area in the middle lung field. Bedside bronchoscopy showed tight orifice of right middle lobe. CT scan showed collapse and hemorrhagic consolidation from right middle lobe torsion (see Fig. 27.4 ).
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here