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Complications of Surgery

Introduction

Surgical resection remains a mainstay of therapy for patients with carcinoma of the lung.
Unfortunately, any surgical intervention carries with it the potential of morbidity and mortality.
Although many advances have occurred in the preoperative, intraoperative, and postoperative
care of these patients to minimize the risk of surgery, complications still occur.1 Complications
after surgery can never be totally eliminated, but they can be minimized by careful attention to
the many details of prevention. When complications do occur, proper management usually
yields a satisfactory result. Prevention includes accurate preoperative assessment,
meticulous surgical technique, and a knowledge of surgical maneuvers to minimize potential
problems.

Preoperative Assessment

Traditional attempts to assess surgical morbidity and mortality after pulmonary resection have
primarily focused on clinical assessment and static pulmonary function testing, such as
spirometry, radionuclide scans, and temporary unilateral pulmonary artery balloon occlusion.
Nagasaki and associates2 studied 961 patients undergoing surgical treatment for carcinoma
of the lung. Variables including age, gender, cell type, extent of resection, cardiopulmonary
status, and stage of disease were evaluated. The authors found that certain high-risk groups
could be identified:

1. patients older than 70 years of age in whom a major resection is necessary;
2. patients with a positive cardiac history;
3. patients with severely restricted pulmonary reserve, regardless of age.

Gender, stage of disease, and cell type were found to have little influence on the frequency of
postoperative complications. Kohman and colleagues3 studied 476 patients undergoing
thoracotomy more thoroughly by analyzing 37 preoperative risk factors, including the forced-
expiratory volume at 1 second (FEV1) and arterial blood gases, and their effects on morbidity
and mortality. Only three of these factors were found to have a significant association with
mortality. These consisted of age 60 years or older, need for pneumonectomy, and premature
ventricular contractions on admission electrocardiogram. However, all these preoperative risk
factors together were found to account for only 12% of the risk of mortality observed. The
authors speculated that most deaths after pulmonary resection might therefore be random,
unpredictable events. Clearly then, increased accuracy in preoperative assessment
necessitates measure of more physiologic parameters.

Boysen and colleagues4 studied the predictive value of simple spirometric testing with and
without more specific testing, and concluded that additional testing over spirometry did not
appear to add any predictive value. In contrast, most investigators believe that static
pulmonary function tests lack the specificity and sensitivity to predict postoperative
cardiopulmonary complications accurately.5,6 The dilemmas are to define which additional
patient parameters will add to the predictive value and to accomplish this task in a minimally
invasive, cost-effective manner. Keagy and associates7 sought to increase the predictive
value of preoperative spirometry in 90 patients undergoing pneumonectomy. All patients had
forced vital capacity (FVC), FEV1, and FEV1/FVC ratio measured. The results demonstrated
no correlation between postoperative morbidity and mortality with FVC, FEV1, and FEV1/FVC
ratio. A further limitation of standard spirometric measurements is that they do not
compensate for variations in body surface area. This reduces the usefulness of such
measures when applied to either very large or very small patients.

The diffusing capacity of the lung for carbon monoxide (DLCO) was included in the
preoperative assessment of 165 pulmonary resection patients by Ferguson and colleagues.6
Using logistic regression analysis, the authors found that the most important single predictor

of postoperative complications or death was the preoperative DLCO. The DLCO estimates
pulmonary capillary surface area and can reveal diffusion defects and emphysematous
changes even with acceptable spirometric values. This increase in sensitivity and predictive
value appears to justify measurement of diffusion capacity as part of the preoperative
assessment. In a retrospective review of 376 patients, Ferguson8 noted that the most reliable
predictor of postoperative complications was the percent predicted postoperative diffusing
capacity. Predicted postoperative FEV1 percent was also analyzed in this review, and
statistical analysis determined that there was no correlation between PPO FEV1 percent and
PPO DLCO percent in predicting morbidity or mortality after major lung resection. Each value
should be analyzed separately and correlated with the planned amount of lung tissue to be
removed. Ferguson9 concludes that a preoperative diffusing capacity under 60% of predicted
indicates an increased risk for complications following pneumonectomy. This increase in
sensitivity and predicted value appears to justify measurement of diffusion capacity as part of
the preoperative assessment.

Several investigators have sought a more accurate measurement of functional
cardiopulmonary reserve. The measurement of maximum oxygen consumption during
exercise (VO2max) has been used to predict postoperative complications. A postulate is that
oxygen consumption is directly related to cardiac output and that a reduced peak oxygen
consumption may correlate with increased postoperative complications. Bechard and
Wetstein10 reported minimal risk of postoperative complications in 50 consecutive patients in
whom the VO2max was greater than 20 mL per kg per minute. Patients with a VO2max of less
than 50 mL per kg per minute accounted for 75% of all postoperative complications observed.
Bolliger11 concluded that a VO2max under 10 mL per kg per min is predictive of a high risk of
complications following any pulmonary resection and could even be considered prohibitive. A
value greater than 20 mL per kg per min or greater than 75% of predicted normal is safe for
major pulmonary resection, including pneumonectomy.

Recent studies have evaluated exercise oximetry to predict operative risk. Rao12 carried out a
retrospective analysis of 299 patients who underwent both exercise oximetry and spirometry.
Sensitivity of oximetry was low, but compared with spirometry it more reliably predicted
prolonged hospital stay and respiratory failure. Ninin and colleagues13 evaluated 46
consecutive patients undergoing pneumonectomy with exercise oximetry and concluded that
exercise oximetry was predictive of morbidity and prolonged intensive care stay following
pneumonectomy. Prospective randomized trials are needed to confirm the reliability of this
test.

Although much effort has been expended to define high-risk patient populations for pulmonary
resection, the dilemma of choosing appropriate therapy for such patients remains.
Postoperative deaths are dreaded by all involved. However, a more conservative approach
might deny a patient a potentially curative resection. Vigorous preoperative respiratory
therapy, cessation of smoking, bronchodilator therapy, and even short-term corticose steroid
therapy have been shown to improve the operability of lung cancer patients with marginal
pulmonary reserve.14 Finally, tailoring the procedure to the patient, such as a segmentectomy
versus a lobectomy or sleeve lobectomy versus a pneumonectomy, might also offer an
otherwise marginal patient the chance of a curative procedure. For more discussion of
preoperative risks see Chapter 36.

Arrhythmias

Atrial and ventricular arrhythmias can occur after pulmonary resection. Many factors may
contribute to the development of arrhythmias postoperatively (Table 41.1), with potentially
serious complications. As early as the 1940s, several investigators noted the increased
incidence of arrhythmias after pulmonary resection.15,16 The incidence of arrhythmias after
pulmonary resection has been cited as 3.4% to 30%. Atrial arrhythmias are far more common,
consisting of fibrillation, flutter, and supraventricular tachycardia.17–19 Loss of sinus rhythm
adversely affects cardiac output, with resultant decrease in coronary, renal, and cerebral
blood flow. When arrhythmias do occur, it is usually during the first few days after surgery and
most commonly on the second or third postoperative day. Shields and Ujiki18 studied 125

consecutive patients and reported a 22% mortality in those patients who developed a
postoperative arrhythmia, as compared with a 7% mortality in patients who remained in
normal sinus rhythm. These findings are consistent with a series of 236 pneumonectomy
patients studied retrospectively by the Mayo Clinic.15 In this study, the authors observed a
25% 30-day mortality in patients developing tachyarrhythmias after surgery.

Table 41.1: Potential Factors Relating to Postoperative Arrhythmias
Pericardial irritation
Increased sympathetic discharge
Atrial damage
Electrolyte disturbance
Atrial distention
Underlying coronary or valvular heart disease
Postoperative myocardial ischemia
Hypoxia
Preoperative theophylline use

The relation of age to the development of postoperative arrhythmias is somewhat conflicting
in the literature. Although some authors17 have reported a near linear relationship between
the incidence of arrhythmias with increasing age, Krowka and associates20 studied 236
pneumonectomy patients and failed to demonstrate any significant association between the
patient age and development of arrhythmias. It seems intuitive, however, that age should be a
strong predictor of postoperative arrhythmias, because the conduction system also ages, as
reflected by a decreasing number of functional sinus node pacemaker cells.21 In addition,
patients of advanced age are more likely to also have coexisting predisposing factors. This is
consistent with the findings of Wheat and Burford19 of a 50% incidence of postoperative
arrhythmias in patients 70 years and older who underwent pulmonary resection.

Several series have confirmed a direct relationship between the magnitude of resection and
the incidence of postoperative arrhythmias. Mowry and Reynolds17 reported an overall
incidence of 19.4% after pneumonectomy as opposed to 3.1% after lobectomy in their series
of 301 patients. Other series18,19 have observed a less dramatic disparity and have suggested
that the relationship between the incidence of arrhythmias and the magnitude of resection is
less pronounced in the older population. Krowka and associates20 studied the relationship
between preoperative pulmonary function and the incidence of postoperative arrhythmias.
Although they did not demonstrate a firm correlation, they did report an increased incidence in
patients with radiographic evidence of fluid overload after a pneumonectomy. This would
follow, because right heart distention is felt to be an important factor in the development of
postoperative arrhythmias. Wittnich and associates22 pointed out that Swan-Ganz
measurements of pulmonary artery pressures may not be accurate after pneumonectomy. In
this situation, the inflation of the balloon tip catheter to measure pulmonary wedge pressure
may in fact increase right ventricular afterload, with resultant decreased cardiac output and
therefore decreased left atrial pressure. The authors suggest that in this situation, central
venous pressure measurements may in fact be a more accurate measure of true cardiac
output.

Although many known factors contribute to postoperative arrhythmias, we still cannot
accurately identify patients that are of the greatest risk of developing them. In addition, while
may studies have used preoperative digoxin or low-dose beta-blockage in the prevention of
postoperative arrhythmias, the data are conflicting. Digoxin has long been the drug of choice
for the prevention of arrhythmias following thoracic surgery. However, potential side effects
and the development of newer pharmacologic agents have diminished its popularity. Digoxin's
predominant action is thought to be a slowing of conduction through the AV node, mediated
by enhanced vagal tone. This is consistent with the known effect of digoxin in slowing the
ventricular response to a rapid supraventricular rate while at the same time being relatively

ineffective in converting to a sinus rhythm. This mechanism is also consistent with the
observation of a reduced efficacy of digoxin in the immediate postoperative period, when
andrologic influences are more pronounced.

There is some evidence that low-dose beta-blockage may have a beneficial prophylactic
effect. However, many of the patients presenting for pulmonary resection have underlying
pulmonary disease or reduced ventricular function and are therefore not ideal candidates for
the administration of beta-blocking agents.23,24

The prophylactic administration of the calcium-channel-blocking agent verapamil has been
shown to reduced significantly the occurrence of postoperative arrhythmias following
thoracotomy.25 In addition, verapamil was found to lower right ventricular systolic and diastolic
pressures, an important action because elevated right-sided pressures are felt to predispose
to atrial arrhythmias.26 A recent study by Van Mieghem and associates27 demonstrated that a
relatively large dose of intravenous verapamil (10 mg bolus) following pulmonary resection
effectively reduced the incidence of atrial arrhythmias by 50%. However, side effects such as
bradycardia and hypotension seen with this dosage led to discontinuation of the drug in many
patients.

Diltiazem, also a calcium-channel-blocking agent, has been shown to be equally efficacious to
verapamil in treating atrial arrhythmias, but with fewer side effects. This has led to the greater
acceptance of this agent in the postthoracotomy patient.28,29 Amar30 recently reported on a
comparison of diltiazem and digoxin for the prevention of postoperative atrial arrhythmias in
pneumonectomy patients. They found that when compared to digoxin, diltiazem was safe and
more effective in preventing atrial arrhythmias in these patients. In addition, the observed
incidence of postoperative arrhythmias in digoxin treated patients was similar to that observed
in the untreated controls. Amiodarone has also been used in the treatment of postoperative
atrial arrhythmias; however, its association with the development of pulmonary infiltrates and
dysfunction has prevented its widespread acceptance in pulmonary resection patients.

Once postoperative arrhythmias such as atrial fibrillation occur, there are several therapeutic
guidelines that should be followed. First, the heart rate should be acutely controlled. Rapid
atrial fibrillation results in poor cardiac filling and therefore reduced cardiac output. Digoxin
can be administered intravenously over several hours to a total loading dose of 1 mg in the
adult patient. However, digoxin does not slow the ventricular rate acutely and often requires
several hours to produce an effect. In addition, digoxin does not reliably convert the patient to
a sinus rhythm nor maintain the sinus rhythm. Postoperative atrial fibrillation with a rapid
ventricular response requires prompt intervention and generally responds to intravenous
calcium-channel-blocking agents such as diltiazem, as previously discussed. In addition,
underlying predisposing conditions such as metabolic derangements or hypoxia should be
accurately sought and corrected. Digoxin may be used as an initial drug in patients with
compromised ventricular function and in patients not hemodynamically compromised by the
increased ventricular rate, which would require a more rapidly acting agent. Conversion to
normal sinus rhythm in patients with refractory atrial fibrillation or flutter generally requires
administration of other pharmacologic agents such as quinidine or procainamide. Rarely do
patients become so refractory that they require electrocardioversion unless they have a long
history of preoperative atrial fibrillation. Patients who require pharmacologic conversion
should generally be kept on these medications for at least three months after surgery.

Patients undergoing lobectomy are generally not prophylactically digitalized. If postoperative
atrial arrhythmias occur, the patient is treated pharmacologically. In contrast, pneumonectomy
patients are generally prophylactically digitalized and maintained on a daily dose
postoperatively. As previously mentioned, there are no data indicating that this prevents the
patient from experiencing atrial fibrillation, but it should prevent a rapid ventricular response
should atrial fibrillation occur. Occasionally a planned lesser resection results in a
pneumonectomy secondary to intraoperative findings. In these situations, the patient is
loaded with digoxin postoperatively and maintained on a daily dose. All pulmonary resection
patients should have cardiac monitoring for at least 24 hours postoperatively. We generally

several more recent studies have confirmed and expanded upon this earlier work. Interestingly. these authors did not observe a correlation between perioperative fluid administration and postresection pulmonary edema.extend the observation period in pneumonectomy patients and in older patients with other comorbid conditions that might predispose them to arrhythmias.39 current understanding of factors associated with the development of postresection pulmonary edema was presented and summarized in Table 41. Patel and associates35 retrospectively studied 197 pneumonectomy patients in England and found a 15% incidence of postoperative pulmonary edema and a mortality rate of 43%. 4. and 1% of all lobectomies. A larger series involving 402 lung resection patients from Leeds. Verheijen-Breemhaar34 and associates reviewed 243 pneumonectomy patients in the Netherlands and found that postoperative pulmonary edema occurred in 4. no significant difference was found between the affected patients and age. Affected patients had a 100% mortality rate and histologic evidence of adult respiratory distress syndrome (ARDS) at autopsy. with a mortality rate of 27% in affected patients. right pneumonectomy. the etiology was still uncertain.2: Postpneumonectomy Edema Incidence of 2% to 5% after pneumonectomy Appears two to three days after otherwise uncomplicated postoperative period Radiologic onset may precede symptoms by 12 to 24 hours Radiologic image of interstitial pulmonary edema Unresponsive to conventional therapies Mortality of 50% to 100% Histology compatible with ARDS Occurs despite a normal pulmonary wedge pressure .2.0% of left pneumonectomies.6%) who experienced postresection pulmonary edema. Table 41. Finally. They further concluded that several factors were involved in the pathogenesis of interstitial pulmonary edema. Shapira and Shahian38 reviewed the literature in their report and confirmed that pulmonary edema developed in approximately 4% of patients following a major lung resection. and high urine output as a sign of relative overhydration.36 In this series. At that time. England. Postresection Pulmonary Edema Noncardiogenic pulmonary edema following lung resection was first discussed by Gibbon and Gibbon31.1% of right pneumonectomies.32 in 1942. increased administration of perioperative fluid. they reported on two patients who had undergone bilateral lobectomies and succumbed within 12 hours of surgery. the authors found an increased incidence of PPE in right versus left pneumonectomy patients and in those who had a more positive fluid balance as well as in patients who required reoperation for bleeding. As in Zeldin's33 report." Since then. was reported by Waller and associates. it was recommended that "the anesthesiologist must not boldly load the patients up with fluids prior to induction. Patients who had a right-sided resection had a threefold higher incidence of PPE as compared to left pneumonectomy patients. This clinical experience as well as experimental studies conducted in a feline model led the authors to conclude that edema occurs because of increased capillary blood pressure following acute reduction of the pulmonary vascular bed. Turnage and Lunn37 retrospectively reviewed charts on 806 pneumonectomy patients at the Mayo Clinic and found 21 cases (2. In conclusion. The mortality rate was 55% in patients who developed this complication. which prompted discussion regarding other possible mechanisms. After comparison. Interestingly.and sex-matched control groups with regard to administration of perioperative fluids. in a recent review by Deslauriers and colleagues. The authors concluded that while postresection pulmonary edema is more common following right pneumonectomy. More recently Zeldin and associates33 compiled ten cases from several institutions and retrospectively compared them with controls.5% of patients. the authors identified three significant risk factors for postresection pulmonary edema (PPE). PPE occurred in 5.

Aucoin A. Increased cardiac output from catecholamine release secondary to pain or from excessive fluid administration will exacerbate this situation. Perioperative fluid management for thoracic surgery: the puzzle of postpneumonectomy pulmonary edema. Their findings suggested that following pneumonectomy. Forty years later.From Deslauriers J. Preventative Maneuvers . with permission. Zeldin and associates33 confirmed the role of overhydration in the canine model. Other possible factors implicated in the formation of PPE include increased capillary pressure and endothelial cell damage producing a "leaky capillary" situation. This is consistent with an ARDS histology previously described in these patients. Table 41. Postpneumonectomy pulmonary edema.31. possible or of questionable influence (Table 41.to tenfold without leading to pulmonary edema. In addition. mediastinal and subcarinal dissection can effectively compromise the lymphatic drainage from the remaining lung. dogs were randomized to receive lactated Ringers at 100 mL per kg before or during a right pneumonectomy. a proportional amount of lymphatic channels is removed with the specimen. with permission.05]. The authors concluded that following pneumonectomy. Fluid overload has been implicated in the pathogenesis of PPE since the early work of Gibbon and Gibbon.8(3):611. and compared to a control group that received lactated Ringers but no resection. it has been estimated that lymph flow can increase seven.32 and almost certainly plays a major role. J Cardiothorac Vasc Anesth 1995.9:442. Following pneumonectomy. He further characterized the causes of PPE into probable. Pathogenesis Slinger 40 pointed out in his review that the cause of PPE was probably multifactorial since no single factor could adequately explain the clinical experience. Nohl-Oser42 has further described the lymphatic drainage of the lung and mediastinum and reported that the lymphatics from the right and left lungs are notably different. Chest Surg Clin N Am 1998. Six of the 12 pneumonectomy dogs developed PPE. which predisposes to edema formation. Interruption of mediastinal lymphatics probably also plays a role in the formation of PPE.3: Causes of the Postpneumonectomy Pulmonary Edema Probable: Fluid overload Interrupted lung lymphatics Increased pulmonary capillary pressure Pulmonary endothelial damage Possible: Hyperinflation Right ventricular dysfunction Cytokine release Oxygen toxicity From Slinger PD. Therefore a right pneumonectomy is more likely also to disrupt lymphatic drainage from the remaining left lung. while none of the controls did [p = less than 0.3). the contralateral lung was more prone to extravascular fluid development secondary to the loss of parenchymal and hilar lymphatic drainage routes. In their study. possibly contributing to edema formation. the entire cardiac output is directed to the remaining lung with resultant increase in the intracapillary pressure. Gregoire J. Little and colleagues41 studied the effect of pneumonectomy and mediastinal lymphatic interruption in a canine model. In normal lungs. The majority of lymphatic channels from the left lung cross the midline.

and jugular venous distention. but left-sided . about 30 additional cases of cardiac herniation have been reported after both left and right pneumonectomies. Placement of a central venous pressure monitoring line is often useful in assessing intravascular volume and will aid in the decision to administer diuretic or inotropic therapy. Patients who develop cardiac herniation typically experience cardiovascular collapse. which results in entrapment of the heart. This results in elevation of central venous pressure and resultant diminished cardiac output. Beyond that time.47. Most patients will require intubation and mechanical ventilation. This complication usually occurs either during the procedure or in the immediate postoperative period. and maintenance of adequate oxygenation and nutritional support. A chest radiograph often diagnoses right-sided herniation (Figure 41. efforts should be made to restrict fluid administration during the intraoperative and early postoperative periods. These changes were reflected by an increase in the alveolar-arterial gradient. Because of this.1). Inspired oxygen concentrations of 80% to 100% may be required to maintain adequate arterial saturation. Total positive fluid balance in the first 24 hours perioperatively should not exceed 20 mL per kg. The precipitating event is often a change in the patient's position. Peak inspiratory pressures greater than 30 mm of mercury should be avoided if possible. Current therapy advocated is supportive and essentially the same as for ARDS. hypotension. and if not promptly reoperated to reposition the heart within the pericardial space.As previously described. thereby preventing gross displacement of the heart. less than 2 liters intraoperatively followed by less than 50 mL per hour postoperatively for an average adult. Most series in the literature have reported about a 50% mortality rate with this complication. diuretic therapy. in refractory cases. Cardiac Herniation Cardiac herniation is a rare but potentially lethal complication that can occur after pulmonary resection when a pericardial defect is created.5 mL per kg is unnecessary in the early postoperative period unless renal insufficiency exists. with resultant elevation in pulmonary capillary pressure.48 Physical findings include cardiovascular collapse with tachycardia. Urine output greater than 0. Adequate pain control is essential to minimize catecholamine release with resultant increase in cardiac output. typically. Recently. In their series affected patients were treated with standard supportive measures plus inhaled nitric oxide at 10 to 20 parts per million. following pneumonectomy the entire cardiac output is directed to the remaining lung. It is now believed that acute hyperinflation of the remaining lung is probably a significant factor in the development of PPE. positive pressure ventilation. Overall mortality for this limited series was 30%.45 This complication was first reported in 1948 after a left intrapericardial pneumonectomy with resultant pericardial defect. intrapericardial adhesions usually form. extracorporeal membrane oxygenation (ECMO) may improve survival.46 Since then. Experimental work by Raffensperger and colleagues43 in dogs confirmed that overdistention of the contralateral lung following pneumonectomy led to deterioration in lung function. coughing. but its role is not yet fully defined. or excessive negative pressure in a pneumonectomy space. Avoidance of mediastinal shift and overdistention of the remaining lung is also essential. The mechanism is simply anatomic displacement of the heart through the pericardial defect. This generally consists of fluid restriction. prolonged ventilation may increase barotrauma and bronchial stump dehiscence. Empiric administration of antibiotics is probably of little benefit because the underlying process is not infectious in nature. Treatment As previously stated. Finally. the development of PPE is associated with a mortality rate in excess of 50%. death ensues. Unfortunately. thereby effectively obstructing both venous inflow and arterial outflow. Mathisen and colleagues44 have recently reported on the use of inhaled nitric oxide in a series of ten PPE patients with reasonable success. lumbar or thoracic epidural anesthesia has proved extremely useful in this situation by providing adequate pain control without oversedation of the patient.

Fluoroscopy has also been suggested as a diagnostic aid in this condition. Any patient suspected of having cardiac herniation should undergo prompt reexploration and repositioning of the heart into the pericardial space. . A lateral chest radiograph may help to demonstrate posterior displacement of the heart. The pericardial defect should then be closed to prevent reoccurrence.herniation can be somewhat more difficult to appreciate on a standard posteroanterior film. but this may needlessly postpone timely reexploration to reduce the herniation.

.

which is durable and easy to suture.49 Closure of the pericardial defect after a resection is the more widely held method of prevention. large pericardial defects must be closed. and further displacement will not result in hemodynamic compromise unless the heart is strangulated through a small defect. owing to the fact that right-sided displacement of the heart. even without entrapment.1: A: Cardiac herniation after radical right pneumonectomy. including pleura. We generally do not attempt primary closure of pericardial defects but rather place a material such as Gore-Tex. B: Chest radiograph after repair with prosthetic patch to close the defect in the pericardium.48 Dippel and Ehrenhaft50 have advocated a technique of suturing the pericardial defect edge to the adjacent atrial and ventricular myocardium.51 Lobar Torsion . In contrast.Figure 41. Suturing of the edge of the pericardial defect directly to the myocardium should be discouraged because of unwarranted risk to the coronary vessels. and even a latticework of catgut. Vicryl mesh. Others have documented the inability of partial pericardiectomy to prevent hemodynamic embarrassment when cardiac displacement does occur. large left- sided defects do not necessarily have to be patched because the heart normally resides in the left thorax. We believe that all small pericardial defects should be closed. Many authors have advocated closure of pericardial defects with a variety of materials.24 fascia. some authors have advocated wide excision of the pericardium to prevent entrapment and strangulation of the heart through a small defect. causes hemodynamic compromise. On the right side. To prevent cardiac herniation.

the middle lobe can rotate on its bronchovascular pedicle. and intraoperative damage to the bronchial circulation have all been implicated in postoperative pulmonary infarction. with resultant infarction and eventual gangrene of the parenchyma involved.57 . either in the left upper lobe after lower lobectomy (Figure 41. Schuler53 reviewed this complication and reported a 16% mortality rate in a series of 31 patients.52 If the middle lobe is not secured by either an incomplete transverse fissure or by direct suturing to the remaining lower lobe.55.Postresection lobar torsion has been most commonly described involving the right middle lobe after a right upper lobectomy.2) or in the lower lobe after upper lobectomy.54. lobar torsion can occur on the left side. This results in occlusion of the pulmonary veins. Pulmonary vein thrombosis. Pulmonary infarction can also occur postoperatively in the absence of lobar torsion.56 Pulmonary lobar torsion involves rotation of the lung parenchyma on its bronchovascular pedicle. Less commonly. Angulation of the bronchus also compromises the bronchial circulation. pulmonary artery occlusion. which further endangers remaining lung parenchyma. with resultant circulatory embarrassment of the involved lung parenchyma.

2: A: Torsion of the left upper lobe after left lower lobectomy.Figure 41. B: Chest radiograph after repositioning of the left upper lobe and fixation with a pleural flap. .

Clinically.3). and malodorous chest drainage. Accidental ligation of the middle lobe vein requires middle lobectomy. Complete interlobar fissures permit rotation of a remaining lobe and should be prevented by placement of sutures to the adjacent lobe. This is done to ascertain that all remaining lung tissue is fully expanded. When recognized intraoperatively. which is a diagnostic finding. Radiographic findings consistent with torsion include hilar displacement.Early recognition of this complication is essential to prevent irreversible damage to the involved lobe. only to have the bronchus reobstruct after removal of the bronchoscope. .59 If left untreated. thereby facilitating reexpansion of the pulmonary parenchyma. pulmonary artery blood flow is also decreased in patients with large areas of atelectasis or postoperative parenchymal hematomas. bronchial cutoff. resection is mandatory. A bronchus with a "fish-mouth" occlusion generally indicates that torsion has taken place. Nuclear perfusion scans and pulmonary angiography can support the diagnosis by demonstrating lack of arterial blood flow to the affected lobe.58. the affected lobe should be resected if the venous injury is not easily repaired. A baseline chest radiograph should be obtained shortly after the completion of any pulmonary resection. Finally. However. Prevention of lobar torsion is essential and begins in the operating room after pulmonary resection. Treatment consists of early recognition of this condition in the postoperative period and a low threshold for performing flexible bronchoscopy in any patient suspected of having this condition. patients commonly develop foul- smelling or blood-tinged sputum. and lobar consolidation. securing it to the adjacent lobe to prevent recurrence. The bronchoscope can be manipulated through the narrowed area. fever. these patients can progress to frank sepsis with hemodynamic instability and even death. once the parenchyma has infarcted with ensuing gangrene. Careful inspection of the remaining lung tissue should be performed while the lung is carefully reexpanded. Reexploration is required with repositioning of the affected lobe. any inadvertent compromise of lobar venous drainage results in pulmonary infarction (Figure 41. If the affected lobe is clearly infarcted at the time of reexploration. with proper positioning of chest tubes. Urgent flexible bronchoscopy should be considered to examine the bronchus and remove any retained secretions. However. Avoidance of unnecessary dissection of a fissure also minimizes this complication. the patient may lack any significant symptoms early in the postoperative period.

62 Although airway occlusion from retained secretions. Other causes of atelectasis include prolonged shallow breathing or splinting secondary to pain.Figure 41.60. with resultant distal gas absorption and alveolar collapse. foreign bodies. pneumothorax.63.64 . blood. the etiology is far more complex. The first is a periodic sigh breath. but other large series of patients generally agree on an overall incidence of 20% to 30% after thoracotomy. An incidence as high as 70% has been reported.3: Pulmonary infarction caused by obstructive venous drainage of the right upper lobe. which is generally twice the usual resting tidal volume and serves to recruit collapsed alveolar. Atelectasis Atelectasis after thoracotomy is probably the most common postoperative complication. The reported incidence varies widely in the literature as a result of an inability adequately to define significant atelectasis. At least two mechanisms normally prevent alveolar collapse. or other space- occupying lesions.2. absorption atelectasis with high inspired oxygen concentration. and parenchymal compression from retraction. hemothorax.61 Atelectasis was previously believed to result from mucus plugging of small airways. Patients who have shallow breathing secondary to pain and ventilated patients with inadequate tidal volumes may experience progressive alveolar closure with resultant atelectasis. or bronchospasm can lead to atelectasis.

. It follows that. and this can progress to collapse of an entire lobe. Linear horizontal densities in the basilar segments are typical of small areas of atelectasis and usually occur near the diaphragm. however.65. distal gases in the alveoli are absorbed. LaPlace's theorem states that the surface tension of a distensible sphere increases proportionately as the radius decreases. and impaired gas exchange. effective cough. Conditions such as malnutrition. sepsis. This results clinically in increased work of breathing and impaired gas exchange. Patients must refrain from smoking for as long as possible before thoracotomy. Several maneuvers can be extremely valuable in the prevention of postoperative atelectasis. Epidural analgesia is an effective means of obtaining adequate analgesia without significant sedation. indicating involvement of entire segments or lobes. Physiologically significant atelectasis results in decreased lung compliance. In addition. Local analgesics or opiates are injected into the epidural space continuously to achieve the proper level of analgesia. along with increased cost. and vital capacity. Normally. acts to reduce the surface tension within alveoli and thereby prevent preferential collapse of smaller alveoli. thereby hastening the process. tachycardia. We routinely leave epidural catheters in place for 72 hours postoperatively but have maintained selected patients for up to five days. Larger areas can usually be visualized if entire segments are involved. Contraindications to placement of an epidural catheter include bleeding diathesis. Airways must remain free of retained secretions. Intermittent positive-pressure breathing may be of some benefit in selected patients but has generally not been effective in treating postoperative atelectasis. and collapsed lung tissue must be reexpanded.65 These results. Surfactant. urinary retention.67 Physical findings usually include crackles over the affected area. parenchymal injury. Sudden stoppage of an air leak frequently occurs with atelectasis. a higher concentration of oxygen in the trapped or anesthetic gases is more readily absorbed. spinal deformity. Patients are best trained in this technique preoperatively. Atelectasis may also render the lung more susceptible to infection.68 Treatment of postoperative atelectasis involves many of the principles used in its prevention. neurologic deficit. and hypotension secondary to peripheral vasodilatation. any bronchospasm detected either clinically or on preoperative pulmonary function testing should be minimized with medical therapy. and prolonged collapse can adversely affect production of surfactant and predispose to alveolar collapse. Side effects and symptoms of overdosing include respiratory depression. nausea.The second preventive physiologic mechanism involves surfactant. Adequate analgesia is essential to prevent splinting and to allow adequate pulmonary hygiene. the sum of the partial pressures of gases in the alveoli exceeds the partial pressure in mixed venous blood. The radiologic appearance of atelectasis varies depending on the extent of involvement. This relation alone would favor collapse of smaller alveoli into larger units. A condition known as absorption atelectasis merits comment. pruritus. Patient training and use of incentive spirometry should be initiated in the preoperative period and continued postoperatively. or local infection in the area of catheter placement. with proximal airway occlusion. Patient positioning in the early postoperative period is also important. In addition. functional residual capacity. More extensive atelectasis results in tubular breath sounds. resulting in alveolar collapse. and therapeutic physiotherapy. have persuaded many to abandon this technique. tachypnea. We continue to use epidural analgesics routinely for three to five days postoperatively because they provide excellent pain relief with minimal adverse effects. Incentive spirometry is inexpensive and effective in preventing atelectasis.66 Patients typically manifest with varying degrees of fever.60. Adequate postoperative analgesia is essential to allow for deep breathing. Functional residual capacity declines by about 40% in the supine position as compared with upright. a normally occurring wetting agent in the alveoli. Routine elevation of the head of the bed to 45 degrees and early ambulation promote effective inspiration.

Nasotracheal aspiration is effective when performed by personnel experienced in passing the catheter into the trachea.Patients with thick or copious secretions require a more aggressive approach.77 .76 Treatment of postoperative atelectasis should be graded according to the patient's clinical status and risk factors as described by Massard. Au and colleagues69 reported using this technique in 144 postthoracotomy patients.4). in the setting of significant pulmonary collapse or after bronchoplastic procedures. if necessary. prolonged suctioning can precipitate hypoxia and should therefore be performed only intermittently for short periods following administration of supplemental oxygen.71.72 have confirmed the efficacy of this technique for pulmonary hygiene and treatment of atelectasis secondary to retained secretions. or "minitracheostomy.73. Routine use of flexible bronchoscopy for the prevention of postoperative atelectasis has been studied prospectively and found to offer no advantage over other less invasive techniques. can be repeated often.74 Patients who require more aggressive treatment of secretions should undergo flexible bronchoscopy (Figure 41.75 However. A 20F tracheostomy tube is inserted into the trachea through the cricothyroid membrane under local anesthesia." has been developed. Passing a catheter through a nasal trumpet may facilitate the process while decreasing patient discomfort. Also. The minitracheostomy tract was found to be a relatively safe and effective means to prevent postoperative sputum retention. Bronchoscopy can be easily performed at the bedside using local analgesia and. Complications with this technique are uncommon and consist mostly of bleeding at the insertion site. A technique of percutaneous cricothyroidotomy. Others70. Caution should be exercised when passing the catheter blindly into a patient's airway after pneumonectomy or a bronchoplastic procedure. fiber-optic bronchoscopy is a safe and effective method to aspirate secretions under direct vision. and vocal cord dysfunction from hematoma have also been reported.63. Catheter aspiration. pneumothorax.

4: A: Atelectasis of the residual right middle and lower lobes after right upper lobectomy and chest wall resection. Bronchial Fistula . B: Full expansion after aspiration of retained secretions by flexible fiberoptic bronchoscopy.Figure 41.

The lymphadenectomy between the vena cava and trachea is done carefully to minimize damage to the blood supply to the lateral walls of the trachea. Preoperative bronchoscopy is an important step in evaluating the status of the bronchial mucosa at the site of the planned resection. and is associated with an increased incidence of bronchial fistula.7%) after staple closure of the bronchus.6% in the staple group. and the other half had bronchial closure with nonabsorbable suture or stainless steel. There were 23 fistulas in 506 pneumonectomy patients (4.78. Bronchial closure was carried out by using stapling techniques in half of the patients. and its distal margin has a limited blood supply. The bronchus should always be divided as proximally as possible. Radiation destroys small blood vessels. and many patients with an obstructive endobronchial neoplasm have distal pneumonitis producing chronic low-grade infection. It is mandatory that special care be given to the bronchial stump in all patients who have received neoadjuvant therapy.82 The avoidance of the complication of a bronchial fistula implies prevention. In 1980. The right mainstem bronchus receives its blood supply from vessels posterior to the trachea and bronchus. and a lung cancer patient may be particularly prone to this complication. It is important for the surgeon to have knowledge of the anatomic location of the bronchial arteries and to preserve as many as possible despite the necessity for a radical procedure. and there were seven fistulas (1. and several technical factors can minimize this complication. specific attention is made to the stump closure along with coverage by flaps of tissue for reinforcement and added blood supply. If inflammation is present. residual bronchial disease. Systemic factors include the patient's general nutrition status and the presence of sepsis. Forrester-Wood83 reported results of 450 pneumonectomies. on occasion. poor approximation of the mucosa. The subcarinal area is traversed by feeding bronchial arteries. If surgery for the cancer is semielective. Effects of chemotherapy can be debilitating to the patient. and depleted nutritional status can be a significant factor in the development of a bronchial fistula. This is particularly true when carrying out mediastinal lymphadenectomy in the lung cancer patient. and it is appropriate to not dissect this area if at all possible. An excessively long bronchial stump accumulates excessive secretions. The method of bronchial stump closure is generally the surgeon's preference. Numerous studies indicate that the causes of bronchial fistula include devitalization and devascularization by excessive dissection. the bronchial tissues must be cleared with care and precise sharp dissection. and the ability of tissues to heal is decreased. The surgeon must be aware of contraindications to close the bronchus by stapling techniques.3%). Al-Kattan and associates84 reviewed the incidence of bronchopleural fistula in 530 consecutive pneumonectomies after hand-suture closure of the bronchus. a large bronchial artery has its origin from the distal transverse aorta and. parabronchial infection related to nonabsorbable suture. of 33 patients who developed a bronchopleural fistula after resection for bronchogenic carcinoma. and the surgeon's lack of experience.80 Both systemic and local factors are associated with the development of a bronchopleural fistula. Sepsis can also retard bronchial healing. but closure must not compromise the adjacent trachea or bronchial lumen. Polypropylene suture was used for the closure. the length of the stump. can be preserved despite removal of lymph nodes in the aorticopulmonary window. In 1982. Lung cancer patients frequently lose weight. The incidence of fistula formation was 11% in the suture group and 2.81 Vester and colleagues78 reported that.5%). and this dissection must be done as carefully as possible to preserve some of these nutrient vessels. Neoadjuvant protocols for the treatment of clinically advanced lung cancer include chemotherapy and radiation. then it can be delayed for additional supportive therapy and antibiotics. If the cancer is close to the . 20 had received radiation or chemoradiation. Vester and colleagues78 reported on 30 bronchial fistulas in 1773 pulmonary resections (1.79.The incidence of bronchopleural fistula after pulmonary resection is reported to be under 5%. both factors predisposing to poor healing. creates fibrous tissue. Lawrence and colleagues79 studied 378 patients undergoing pulmonary resection and found no significant difference between the hand-sewn and stapled bronchial closure. On the left side. In a patient with lung cancer.

The rib spreader can traumatize the intercostal muscle.86. Azygos vein. It has also been demonstrated to deliver increased blood supply to the bronchial tissue. ensuring its viability and blood supply. In this instance. However. All right pneumonectomy stumps should be covered with some form of tissue. Tissue coverage of the pneumonectomy stump can minimize the complication of a small bronchial fistula and can also bring additional blood supply to the bronchus to promote healing. careful judgment is required to determine the appropriate type of bronchial closure. The left pneumonectomy stump. and there were nine fistulas after bilobectomy for primary cancer of the lung (right upper lobe and right middle lobe. and excessive tension permits edges of the bronchus to separate. the bronchus is transected by a knife. the bronchus is transected by knife dissection. and every attempt is made to avoid placing the needle through the entire thickness of the bronchial wall. If the tissues are too thick or the cancer is too close to the margin of resection. and the decision for tissue coverage requires careful judgment. Whenever there is a question about the proximal extent of the cancer. it is not as suitable. Only the parabronchial tissues are sutured to the pleura. other tissue coverage is generally recommended. it is recommended that the hand-suture technique be carried out with either nonabsorbable or absorbable monofilament suture (see also Chapter 38). and its insertion is detached from the . When the flap is used after completion of the resection. Special attention must be given to the bronchial stump of a bilobectomy. In this instance. stapling techniques are not used. It was noted that this maneuver is important to decrease the incidence of bronchial fistula in patients older than 60 years and in those who underwent resection for lung cancer. This flap is best created through a posterolateral thoracotomy. It is important to consider tissue coverage of the bronchial stump after bilobectomy to minimize this complication. the pleura contains few blood vessels and does not enhance the healing process with additional blood supply. The increased incidence of fistula after a bilobectomy undoubtedly relates to the extensive dissection of the bronchus. This only distorts the bronchus and decreases its blood supply. four. Al-Kattan and colleagues84 recommend burying the bronchial stump beneath the mediastinal tissues. The serratus anterior muscle provides excellent coverage to the bronchial stump and is the muscle flap of choice for some thoracic surgeons.85 It is helpful to have made the decision to use the intercostal muscle flap before opening the chest. right middle lobe and right lower lobe. and esophageal wall can all be used for this technique. We prefer to use a 4. adjacent pleura. the stapling techniques should not be used. The same principles used in dissecting and closing the bronchus for a pneumonectomy apply to the bronchus after lobectomy.8-leg-length staple for the lobar bronchus because there is less compression of the tissue and distal blood supply is preserved through the B shape of the staple. The intercostal muscle pedicle flap provides good reinforcement of a bronchial closure. It was used in 59 patients. Rendina and associates85 clearly described the construction of the intercostal pedicle flap. the bronchial tissues can be particularly thick and fibrotic. and suture closure of the bronchus is carried out. A broad-based pleural flap can also be used to cover the bronchial stump. with a probable decrease in blood supply to the surrounding tissues. The pleura is tacked to both sides of the bronchus with a 4–0 absorbable suture. and both the proximal and distal margins are inspected. In this instance. Several methods are available for tissue coverage of a pneumonectomy stump. After neoadjuvant therapy. This is particularly true if the patient has received neoadjuvant therapy.87 The serratus anterior muscle is mobilized at the time of the posterolateral thoracotomy. if done correctly. retracts deeply into the mediastinum. A thickened bronchus does not hold the staples. All pneumonectomy patients who have received neoadjuvant therapy should have both the right and left pneumonectomy stumps covered with tissue.bronchial orifice. five). For this reason. Vester and colleagues78 reported ten bronchial fistulas in 965 patients receiving either bilobectomy or lobectomy. as observed by bronchoscopy or identified during hilar dissection. and postoperative angiographic studies of the intercostal artery in 14 patients demonstrated full patency of this vessel. because the flap can be developed with a portion of parietal pleura. and the vessel can be damaged by retraction or extension of the thoracotomy incision posteriorly. pericardium.

If this muscle flap is not used to cover the bronchus. Its blood supply is not as generous as that of a serratus anterior muscle or intercostal muscle flap. We use a broad-based mediastinal fat pad for coverage of both the right and left pneumonectomy stumps (Figure 41. the serratus anterior muscle can be preserved during a posterolateral thoracotomy. it is important to place fixation sutures in the peribronchial wall. In patients who have received neoadjuvant therapy.5). both anteriorly and posteriorly. One problem associated with the serratus flap is that the patient may complain of a winged scapula due to detachment of the fibers from the inferior portion of the scapula. If the surgeon decides to use this muscle flap to cover the bronchus. to secure the coverage. because this does not provide an adequate seal. The muscle is then sutured in place with 4–0 absorbable sutures and amply covers the stump and areas of mediastinal dissection. and the muscle is not separated from its scapular attachments until a final decision is made to use it as a tissue flap. Muscle is easily brought through the incised third intercostal space or through a defect made by a subperiosteal excision of a small portion of the third rib. which was successfully treated by antibiotics and additional tissue placed into the pneumonectomy space. The fat pad is sharply dissected from the pericardium and freed to the upper mediastinum. the construction of the flap can be completed at the end of the procedure. then it can be resutured to the tissue adjacent to the ribs. Again. it is easily brought over to the bronchial stump. The lateral thoracic artery is preserved. with the incision closed in the standard fashion. but only one recurrent fistula. Most patients have an adequate amount of fat that extends down to the cardiophrenic angle. There were four empyemas in this group of patients.5). but secure tissue coverage is obtained (see Figure 41. It is not appropriate just to place the fat pad over the bronchus and suture to the adjacent pleura. The use of this flap for bronchial coverage is reserved for patients who have received an excessive amount of radiation or when there is concern about the viability of the bronchial stump closure. and dissection frequently encompasses the lateral wall of the thymus gland. Regnard and colleagues87 used this technique in seven patients who underwent pneumonectomy after 6.500 cGy of radiation.ribs with a cautery technique. Added exposure is obtained by detaching it from several ribs.000 to 6. Care must be taken that the muscle flap is not under tension and that its vascularity is not compromised by compression of tissues in the intercostal space. .

the space is filled with the antibiotic solution. it is treated by adequate dependent drainage. If the patient undergoes reoperation. Serum levels of the antibiotics are obtained to be certain that toxic blood levels are not present.000 mL of sterile saline. and the pleural space is filled twice daily with an appropriate concentration of antibiotics and 1. Balanced pleural drainage is preferable. but it can be difficult to position in the presence of a mainstem bronchial fistula. and the space eventually closed by thoracoplasty or myoplasty or both. Use of the omentum is not recommended for routine coverage of pneumonectomy stump. but their blood supply is not as generous as the previously mentioned flaps. The first stage consists of opening of the thoracotomy incision with debridement and closure of the bronchial fistula and coverage with viable tissue. it is also an excellent flap to provide coverage for the bronchial fistula.88 If the serratus anterior muscle was preserved at the time of the original thoracotomy. new antibiotics. and the chest is emptied every ten hours.5: Large mediastinal fat pad covers the right pneumonectomy stump.Figure 41. Precise placement of the endotracheal tube is achieved under direct bronchoscopic visualization and eliminates any possibility of contamination of the dependent lung during positioning of the patient. Flexible fiber-optic bronchoscopy should be done to evaluate the status of the pneumonectomy stump and clear the airway of any secretions or fluid. may become dyspneic. The tube is clamped.90 for fistula closure and sterilization of the empyema space. and the stump is closed with an interrupted suture technique using nonabsorbable monofilament suture. and when healthy . and the success of antibiotic irrigation in combating empyema. With the development of vascular tissue flaps for stump coverage. A double-lumen catheter can be used. The antibiotic sterilization can again be attempted if a fistula is not present. Chest radiograph illustrates a decreasing amount of fluid in the pneumonectomy space and the presence of subcutaneous air. a long single-lumen endotracheal tube is placed into the contralateral bronchus with the aid of the flexible fiber-optic bronchoscope under local anesthesia. and the chest tube is then removed. and the pedicle would have been prepared before opening the chest. Proper position of the double-lumen tube must be documented with the small-diameter flexible bronchoscope. cultures of the draining fluid are obtained to be certain that the effluent fluid is sterile.89 A two-stage procedure is advocated by Deschamps et al. After ten days of antibiotic irrigation. Arrows depict the superior vena cava. the patient should be positioned with the operated side down to prevent spillage of the pleural fluid into the contralateral lung. a chest tube is inserted into the pleural space to remove all of the fluid. The omentum is reserved for closure of a bronchial fistula if the complication does develop. and excessive manipulation of the tube may only make the fistula larger. It requires the placement of additional incision in the abdomen and a longer operating time than the flaps described earlier. In the hospital. Before removal. Without delay or diagnostic studies. but a standard underwater-seal drainage system can also be adequate. as described by Claggett and Gerace. and frequently develop subcutaneous emphysema. because detrimental physiologic mediastinal shift can occur. The pleural space is cultured to determine whether infection is present and also to obtain antibiotic sensitivities for postoperative antibiotic irrigation. Antibiotic irrigations are begun in the first postoperative 48 hours through a previously placed intercostal catheter. The empyema cavity is thoroughly debrided and the cavity is packed open with gauze soaked in povidone-iodine solution diluted 20 to 1. The drainage system must not be connected to suction.88 Patients who develop a bronchial fistula three to four weeks after pneumonectomy expectorate varying amounts of serosanguineous fluid. reoperation and bronchial stump reclosure can be considered up to 14 days after the initial operation. The packing is changed daily. Intercostal muscle and mediastinal fat can also be used. Omentum provides excellent coverage and blood supply to a dehisced bronchial stump. and the head of the patient is to the left. If an empyema develops at a later date. The necrotic edges of the bronchial stump are carefully debrided back to viable tissue.

are now the accepted standard of therapy for treatment of the chronic bronchopleural fistula and empyema. along with the omentum.93 After successful transsternal closure of the fistula. and rectus abdominis. the cavity is filled with antibiotic solution and a watertight chest wall closure is obtained. consideration can be given to the transsternal approach for reamputation of the stump. Closure of small fistulas in both pneumonectomy and lobar stumps has been achieved. a new chest tube must be inserted into the developing space as soon as the diagnosis of a lobar stump fistula is made. A to-and-fro motion of secretions at the stump. and bronchial blood supply is jeopardized. and its use should be considered when a small fistula has been identified. and the surgeon must thoroughly review the literature before embarking on this repair. along with omentum. Tissue glue in the United States can be made from cryoprecipitate and thrombin. These techniques have significantly decreased the need for a disfiguring thoracoplasty. At the time of the bronchial fistula closure. necrotic tissue. and granulations are all indicators of a fistula. Failure of sterilization of the residual space can be successfully managed with packing and daily dressing change. or the development of a space after chest tubes have been removed. the empyema cavity can be obliterated using myoplasty and thoracoplasty techniques. acute debridement of a dehisced lobar stump may result in little . or pleura. latissimus dorsi. Fibrin glue can successfully close a small fistula up to 4 mm in size. The cryoprecipitate and thrombin are instilled through catheters passed through the channel of a fiber-optic bronchoscope.95 Bronchial fistula after lobectomy is a rare occurrence. Other symptoms include fever and a cough productive of serosanguineous fluid or purulent material from a developing empyema. and the pneumonectomy space cannot be closed or sterilized until the fistula has healed. If the chest tubes have been removed. Complete separation of a bronchial closure is obvious. and achieved an 88% success rate in closing fistulas and controlling intrathoracic sepsis. This is a technically demanding procedure. The management of a bronchopleural fistula that occurs several weeks or months after pneumonectomy requires that the space be clean and dependently drained. and the European version with a stronger tensile strength is now available. for several reasons. A cancer resection requires an extensive dissection when carrying out a bilobectomy. which is the alternative method of treating postpneumonectomy empyema and fistula. antibiotic sterilization of the pneumonectomy space is done. In general. Any residual cavity that remains can be successfully sterilized using the Claggett89 technique. The surgeon must pay particular attention to closure and coverage of bilobectomy stumps. All of these closures were buttressed with vascularized pedicle flaps of omentum. bronchoscopy should be carried out.94. Pairolero and colleagues86 used muscle grafts of pectoralis. This technique is associated with low morbidity and can be the initial therapeutic maneuver if the fistula is small.granulation tissue appears in the pleural space. If a fistula is suspected. serratus anterior. Puskas and colleagues91 described successful closure of chronic bronchopleural fistulas in 40 of 47 patients (85%) using direct suture closure of the bronchial stump in 37 patients and suturing of omental or tissue flaps over the fistula in ten patients. Early dehiscence of a bronchial stump after lobectomy is evidenced by a persistent and moderate air leak. it is better to treat lobar bronchial fistula in a long-term conservative manner. muscle. If a pneumonectomy fistula occurs in a long bronchial stump. but small defects in a lobar bronchus may be difficult to identify. with expected obliteration of the space by granulation tissue over several months. a sudden increase in the size of an air leak. Extrathoracic muscle transpositions. First. and it is more common for a lobar bronchial fistula to occur after a bilobectomy than a standard lobectomy.91 The presence of a chronic bronchopleural fistula requires direct closure because it will not heal on its own. This is best accomplished with the open-window thoracostomy or Eloesser flap. A decision is then made about appropriate therapy.

incomplete lung fissures. but most remain open. the surgeon has several options. The use of the stapler can minimize air leaks from a divided minor or major fissure and helps to separate the upper lobe from the middle lobe. a successful long-term result can usually be achieved. A small fistula may eventually close with fibrotic resolution of the space. Tube drainage is maintained until the residual lung tissue is adherent to the parietal pleura. depending on the surgeon's technique. but the surgeon must be aware of possible anastomotic failure along with probable difficulty in reexpansion of the residual lung tissue. resulting in an increase in morbidity and mortality. Myoplasty or thoracoplasty. lung cancer patients have had neoadjuvant irradiation and chemotherapy. but they are accomplished at less risk when the patient's condition is able to withstand a second operation. dependently drained space. If the bronchial tissues are necrotic. Air leaks from staple lines and disrupted parenchyma are closed with fine. the amputation of the bronchus at a higher level must be considered. may be necessary to close the fistula and obliterate the associated space. . The lung tissue. and there is fibrosis in the mediastinum that limits its ability to shift its position. This technique is applicable when a right lower lobectomy stump has developed a fistula. These leaks can be minimized at the time of resection by careful attention to technical detail. Third. Sleeve lobectomy can be considered after an upper-lobe bronchial fistula. Frequently. nonabsorbable. the raw surface of a segmentectomy. and the bronchial stump and lung parenchyma are carefully observed. but some require special maneuvers in an attempt to stop the leak. the probable infected space may predispose the fistula closure to failure. The elderly lung cancer patient is prone to prolonged air leaks from emphysematous lung tissue. and parenchymal air leaks fail to heal. Alveolo-pleural fistulas originate from lung tissue that has been denuded of its visceral pleura. and the middle lobe can be resected with bronchial closure at the proximal bronchus intermedius. The bronchus can be resected to obtain more healthy tissue. Basic criteria to be carried out include control of the underlying disease process and a clean. and the stump is reapproximated with a fine. the anesthetist fully expands the lung to 20 to 25 cm of airway pressure with the lung and bronchus submerged in saline. (b) mediastinal shift. or both. Most persistent air leaks originate from small bronchi or disrupted alveoli and can be termed alveolo-pleural fistulas. monofilament suture. Small air leaks near the hilum can be approximated with carefully placed sutures to avoid damage to major arteries or veins. The stapling device can also minimize air leaks when carrying out wedge resection or segmental resection. does not fully expand.remaining bronchus to reapproximate. The staple line should be reinforced with a bovine pericardium or Gore-Tex when the lung tissue is emphysematous. a completion pneumonectomy may be required. All reoperative bronchial closures must be covered by a viable tissue flap. and the fistula is then treated as a chronic problem. Second. A defect in the bronchial stump is repaired. If reoperation for a lobar fistula is decided on. and nonanatomic resections for neoplasms. The normal mechanisms of compensation for the loss of lung tissue are (a) expansion of the residual lung. The lung cancer patient is particularly prone to the development of these complications. and prevention is the best method of treatment. Most air leaks close within seven days of the operative procedure. if fibrotic from irradiation. with increased morbidity and mortality. Despite the fact that adequate tube drainage after lobar bronchial fistula may result in a more protracted course. interrupted absorbable sutures. At the close of the operation. to achieve closure of viable bronchial tissue. (c) narrowing of the intercostal spaces. and closure would compromise a mainstem bronchus.96 Spaces and Air Leaks A decrease in the incidence of the development of the postoperative space and prolonged air leak directly results in a decreased incidence of postoperative complications. and (d) elevation of the diaphragm.

and only 6% become infected. there are several therapeutic maneuvers that can be attempted. Suction is maintained until the air leak stops or the patient is discharged with a Heimlich valve attached to the leaking chest tube. The leak usually stops by the time of the first office visit. and incomplete decortication from prior pleural effusion or infection. the emphysematous nature of the remaining lung. the suction is restarted. and the leaking lung surface adheres to the parietal pleura. and if a space is developing. Despite the relatively low incidence of major complications associated with a persistent space. reexpansion can be difficult. repositioning the tube allows the lung to expand. with a resultant residual space. 7% are persistently sterile. It may be necessary to leave the tube in place for an additional two to three weeks until the air leak stops. Suction is never increased if the residual lung is fully expanded because increased suction may potentiate the air leak. A chest-tube hole may be directly adjacent to a small air leak. . Factors that play a role in this decision include the general condition of the patient.A pedicle flap of pleura can be used to cover air leaks from tissue just as well as it can cover a bronchial stump. superior. A second maneuver is to withdraw the anterior chest tube by 1 or 2 inches. and discontinuing the suction will cause the leak to close. The development of a postoperative space is commonly related to a persistent and large air leak. and the presence and magnitude of an intrapleural space. There are no specific guidelines for the indications of reoperation of a patient with a persistent air leak at seven to 14 days. because it is possible that the increased negative intrapleural pressure is maintaining the air leak. The patient is seen at weekly intervals in the office. 13% require temporary drainage. despite the presence of a small air leak. Reoperation and necessary decortication can create new air leaks. This technique can be successful. If the lung remains expanded after discontinuation of suction. a chest tube must be reinserted. If the air leak persists four weeks after hospital discharge. Kirsch and colleagues97 reported on the natural history of the pleural space and noted that 74% undergo spontaneous resolution. fibrosis in the remaining lung that limits expansion. If a segmentectomy has not been done by the stapling technique. and the tube is then removed. the thoracic surgeon must make every attempt to minimize it because an infected space is a problem for both the patient and the thoracic surgeon. a free graft of pleura can be used to reinforce sutures. This method of tube management is predicated on the fact that the patient does not have an infected space and the lung is expanded. The tube is then shortened by 1 or 2 inches at weekly intervals until it is removed. The management of a persistent air leak is noted in Figure 41. consideration can be given to removing the chest tubes. Chest-tube suction is maintained for the initial postoperative seven days because it has been our experience that if the lung collapses in the early postoperative period. and open drainage is instituted. but other causes include resection of two lobes on the right side. Postoperative atelectasis and a fixed mediastinum due to irradiation or prior inflammation also contribute to the development of a space. A chest radiograph is obtained in 24 hours. and medial basal and lingular segmentectomies. All of these factors are seen in patients undergoing resection for lung cancer. the patient is considered to have an empyema.6. Suction can be discontinued. Absorbable sutures can be placed through the pleura and then through the lung tissue to anchor the pleura flap securely over the leaking area of lung. but if a space does develop. the residual segmental lung surface can be approximated to the adjacent lobe. This technique is particularly applicable to posterior. the speculated cause of the persistent air leak. only the basal segments of either lobe remaining. On occasion. anterior. If an air leak persists at seven days. and careful judgment is required to reoperate for a persistent air leak. A large and increasing air leak may make reoperation necessary.

6: Suggested management of prolonged air leak. which effectively eliminates a space problem.) Practical steps can be carried out in the management of a postoperative space. Evacuation of the air permits the raw lung surface to reach the parietal pleura. (From Piccione W Jr. but have not been used in .Figure 41. We routinely start with 20 cm of water suction immediately after the operation and recommend increasing suction to 30 or 40 cm of water pressure if there is a space in association with an air leak. Transplantation of the diaphragm and crushing of the phrenic nerve have been advocated to minimize the postoperative space. We do not use suction set at more than 40 cm of water pressure because of patient discomfort. eds. Early postoperative consideration must be given to increasing the amount of chest-tube suction. Complications in cardiothoracic surgery. Suction should be increased in increments of only 10 cm of water to evaluate the patient's ability to tolerate it. The patient can be dyspneic owing to a decrease in tidal volume as inspired air is removed by increasing suction. If an extrapleural dissection was required to resect an upper-lobe lesion. then a pleural tent is obviously not available. and small air leaks close. Management of complications related to pulmonary resection. Even if a constructed pleural tent is not airtight.7). St. with permission. In: Waldhausen JA. Orringer MB. the large pleural flap can cover residual lung tissue and expedite the closure of parenchymal air leaks. Significant pleural pain can also be troublesome. Certain intraoperaive maneuvers can also minimize the possible complications of the postoperative space. Louis: Mosby Year Book. One method is to use a pleural tent (Figure 41. Faber LP. 1991:336. The first is to be certain that the residual lung tissue is clear of all secretions and that postoperative atelectasis is aggressively treated.

4. with wire fixation of these ribs to the posterior sixth rib. The most extensive intraoperative procedure is to bring the chest wall to the lung tissue. . This is accomplished by either a tailoring or an osteoplastic thoracoplasty.our experience. An osteoplastic thoracoplasty is a subperiosteal resection of the posterior portions of ribs 2. Disadvantages include the time involved to transplant the diaphragm and the loss of diaphragmatic motion. A tailoring thoracoplasty entails subperiosteal resection of the first and second ribs along with a portion of the third rib to decrease the size of the apex. 3. and 5. A standard five.or seven-rib thoracoplasty in association with an extended pulmonary resection is not recommended. which decreases the patient's ability to cough as well as long- term pulmonary function. because it will result in inadequate postoperative ventilation owing to paradoxical chest wall motion.

.

One chest tube drains the space above the pleural tent.8). If the air leak stops and there is a persistent space. and two chest tubes drain the normal pleural space.7: A: Pleural tent constructed to minimize air leak and pleural space after left upper lobectomy and resection of a portion of the superior segment of the left lower lobe. The sterile space obliterates with fibrous tissue over time.Figure 41. and the space is treated as if it were sterile. the chest tube is removed. . Arrows depict the location of the pleural tent. The patient can be safely discharged without antibiotic therapy and is followed with periodic chest radiographs (Figure 41. B: Chest radiograph six months later in the same patient.

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8: Frontal (A) and lateral (B) views of a sterile space after left upper lobectomy. or if the space is large. Other tissues that can be used include the omentum. and the tube is slowly backed out as the space obliterates. . there remain two surgical options. and the muscle can be used to close any residual bronchial fistula. Space management is detailed in Figure 41. it is managed with open-tube drainage.Figure 41. serratus anterior muscle. and latissimus dorsi muscle if it has not been transected by the previous thoracotomy. A large space necessitates a standard posterior seven-rib thoracoplasty. If the space is small.9. Space will obliterate in several weeks with no postoperative sequela. If closure of an infected space does not occur after several weeks. tube drainage is mandatory. Careful attention to all the preoperative and postoperative details in managing the lung cancer patient minimizes the complications of the postoperative space. The pedicle muscle flap is the most effective method of obliterating almost any infected residual space.98 The pectoralis major is particularly well suited for placement into the apex of the chest and avoids the deformity of a thoracoplasty. and the space must be located so that the appropriate type of thoracoplasty obliterates it. If an empyema does develop in a postoperative space. The first is thoracoplasty.

Faber LP. St. it is appropriate to obtain provisional control of the more proximal pulmonary artery. and there are various technical maneuvers that can be undertaken to minimize its occurrence. and meticulous sharp dissection is necessary to remove the cancer from these structures. Neoadjuvant therapy. Right Hilum The primary cancer or involved regional lymph nodes may render approach to the pulmonary artery or its branches technically difficult. 1991:336. and the avoidance of damage to these vessels is difficult. and other maneuvers must be undertaken to ligate it more proximally.99 . (From Piccione W Jr. Also.) Intraoperative Hemorrhage Hilar dissection can be extremely difficult when central lung cancers are removed. in many instances. Neoadjuvant therapy for a clinically advanced lung cancer frequently obliterates tissue planes and makes the hilar dissection extremely difficult. The thoracic surgeon must be prepared to handle intraoperative hemorrhage. Louis: Mosby Year Book. Management of complications related to pulmonary resection. because they often invade major vascular structures. In this instance. the cancer obliterates the standard approach to the main pulmonary artery. In: Waldhausen JA.9: Suggested management of the postoperative space. Orringer MB. also renders the paratracheal tissues fibrotic and further complicates mediastinal lymphadenectomy. coupled with prior mediastinoscopy. The normal tissue plane of the pulmonary artery and its branches can be totally obliterated.Figure 41. eds. with permission. Complications in cardiothoracic surgery.

A second approach to the right pulmonary artery is more medial. Transection of the main artery is then done on the other side of the superior vena cava. and provisional proximal control can usually be obtained by this technique. This approach can also be used to transect the pulmonary artery either by using the stapling technique with vascular staples or by placing a vascular clamp proximal and then suturing the transected pulmonary artery stump. If a pneumonectomy is being done.10).10: The right main pulmonary artery is isolated medial to the superior vena cava after the pericardium is widely opened. If the azygos vein can be encircled. and it is necessary to open the pericardium widely to provide exposure to the pulmonary artery between the ascending aorta and superior vena cava (Figure 41.11). The . it is ligated proximally and distally and transected to provide added exposure. the artery is usually ligated at this level with a heavy permanent suture. and care must taken not to disrupt the main artery with this maneuver. It is rare that a tumor extends to this level of the main pulmonary artery.An approach to the right main pulmonary artery is to open the pericardium at the level of the superior pulmonary vein and extend this opening to a level onto the superior vena cava above the azygos vein. Figure 41. a provisional Rumel tourniquet can be applied to control the main pulmonary artery if bleeding does occur during the dissection. The right main pulmonary artery can then be isolated medial to the superior vena cava (Figure 41. If a difficult lobectomy is to be attempted. A significant portion of this dissection must be done by blunt finger dissection.

and the technique of isolation is by both sharp and blunt finger dissection. or vascular clamps can be placed on both the superior and inferior pulmonary veins to minimize blood loss while the arterial defect is closed. After transection of the bronchus. but the instrument can be difficult to position. To avoid contamination of the space during continued aspects of the dissection. the posterior aspect of the pulmonary artery is readily accessible and it can be isolated by initially dissecting the right mainstem bronchus so that it can be transected. and a more proximal dissection with ligation and transection of the right main pulmonary artery can be carried out. Figure 41. but the mainstem bronchus remains free of cancer involvement.11: The proximal right main pulmonary artery is isolated between the aortic arch to the right and the superior vena cava.12). In this instance. The pneumonectomy stump is closed by the staple technique (Figure 41. distal control of the pulmonary artery must be obtained. This approach is predicated on the finding that the proximal right mainstem bronchus can be freed for transection and closure. the posterior aspect of the pulmonary artery becomes readily available. The pericardium has been widely opened. In this instance. the stapler can also be used to close the distal bronchus. . Despite proximal control of the main pulmonary artery. a defect in a large lobar branch can bleed profusely from atrial back bleeding and large bronchial arteries supplying the tumor. An upper-lobe tumor may totally occlude the anterior approach to the pulmonary artery.vascular stapling technique can also be used to divide the main artery.

The defect is closed with a running monofilament suture. and provisional ligatures are placed. In other instances.12: The right main pulmonary artery is approached posteriorly after transection and closure of the right mainstem bronchus. Involvement of either the superior or inferior pulmonary vein by the cancer necessitates opening of the pericardium to obtain more proximal control. On occasion. If the invasion is minimal. and it is transected. The vena cava can be bypassed by a catheter technique. and proximal control is achieved. The atrial tissues are then reapproximated by a running monofilament suture. The vascular stapling device can be placed on the atrium to obtain an adequate margin of resection beyond the tumor. a large vascular clamp is placed to occlude the atrium. The primary tumor or involved lymph nodes may invade the superior vena cava. The vena cava can also be replaced or bypassed by Gore-Tex grafts. Tumor obliterates the customary anterior approach to the right main pulmonary artery. see Chapter 62. as described by Dartevelle and associates.101 For more on these techniques. In this situation.Figure 41.100 and the defect in the vena cava is repaired by a patch graft of pericardium. a portion of the wall of the vena cava may require resection to remove all of the tumor. as described by Piccione and colleagues. a partially occluding vascular clamp can be placed. The pericardium is opened. and a portion of the vena cava wall is transected. both the superior and inferior pulmonary veins are involved by the tumor. Left Hilum . The right and left innominate veins must be isolated. and a provisional tourniquet is placed at the level of the caval-atrial junction. and the stapling instrument is not long enough to close a single atrial cuff.

Figure 41.Left-sided lung cancer frequently invades the aorticopulmonary window. The pericardium is then opened medial or lateral to the phrenic nerve. It is also necessary to identify the proximal portion of the right pulmonary artery to ensure that the main pulmonary artery is not ligated or compromised. and this opening is extended up above the aortic arch. The atrium is handled in similar fashion as described for the right side. Staple closure of the artery with the vascular stapling technique is effective in this instance. intrapericardial approach is particularly difficult. and the proximal left main pulmonary artery is dissected free (Figure 41. and the pulmonary artery cannot be dissected safely outside the pericardium. This is particularly true when a large hilar tumor has been treated with . The left main pulmonary artery can also be approached posteriorly after dissection and transection of the left mainstem bronchus. Provisional proximal left pulmonary artery control can also be obtained with a Rumel tourniquet after the pericardium is opened during a difficult lobar dissection.13: The left main pulmonary artery is isolated after the pericardium is opened. The primary tumor or involved lymph nodes frequently are densely adherent to the transverse aortic arch. The right main pulmonary artery must be clearly identified before transection. The main pulmonary artery is identified.13). This approach provides additional exposure if the anterior. It is usually necessary to isolate and transect the ligamentum arteriosum to provide exposure for proximal transection and closure.

This is particularly true in patients who have had either transient ischemic attacks or coronary bypass surgery for atherosclerotic heart disease. In this situation. Others may take aspirin for chest pain. the patient's physiologic status. and blood vessels. chest wall. Prevention is the key to the avoidance of the postoperative complication of bleeding. arthritis. they are corrected. In this instance. continued observation can be carried out if the surgeon thinks that the trend of blood loss is slowing and the patient's condition is stable. A ligature can roll off a previously tied branch of the pulmonary artery or pulmonary vein. because the quantity of chest-tube drainage is not a reliable indicator. Symptoms of postoperative hemorrhage include tachycardia and hypotension. careful sharp dissection is necessary to free the tumor from the aorta. It is important to obtain the chest radiograph in the upright position to quantitate better the amount of retained blood in the chest cavity. cryoprecipitate. This information should be obtained in the patient's history. The second major cause of postoperative bleeding is a coagulation defect related to transfusion of several units of stored bank blood during the operative procedure. A portable chest radiograph should be obtained to ensure that blood is not accumulating in the thorax. or platelets as indicated. Aspirin affects platelet function. It is appropriate to stop aspirin two weeks before the operation. and if generalized oozing persists during an extended difficult dissection for lung cancer. Agents used include fresh frozen plasma. Postoperative Hemorrhage Postoperative bleeding usually occurs from the site of the pulmonary resection or from an intercostal vessel in the thoracic incision. Frequently. Coagulation studies are obtained. Meticulous hemostasis is carried out during and after the resection.neoadjuvant therapy and the fibrotic tissues are difficult to dissect. are transected during the resection. The main pulmonary artery and veins are . The mediastinum is carefully explored for a large bronchial artery that may have clotted off but that will start bleeding after the clot moves or the patient has an episode of postoperative hypertension. and when defects are identified. Cautery is used generously on the chest wall or pleural surface to stop the ooze from the many disrupted small vessels after pleurectomy. both large and small. This type of invasion usually precludes long-term survival of the patient. A ligature may have slipped from a large vessel. or prophylaxis to avoid a stroke because of a prior family history. It is rarely indicated to resect a portion of the transverse or descending thoracic aorta en bloc with a primary lung cancer. and the persistent oozing of blood from the chest wall can be difficult to control. Blood replacement is carried out dependent on measured blood loss during the operative procedure. and aortic graft replacement with its attendant morbidity is not indicated. it is necessary to carry out an extrapleural dissection. It is important to avoid development of a plane of dissection between the adventitia of the aorta. and all aspirin- related products must be stopped before the surgical procedure. A sudden rush of blood into the chest drainage system approximating several hundred milliliters mandates immediate reexploration. The usual evidence of significant postoperative bleeding is the drainage of about 200 mL or more of blood per hour through the chest tubes into the drainage system. Many elderly patients who undergo resection for lung cancer take aspirin as a prophylactic measure to avoid vascular problems. Continued blood loss at a rate of 200 mL per hour for four hours is generally an indication for reoperation to identify and control the source of bleeding. and blood loss in the recovery unit can be sudden and precipitous. and diaphragm. because this defect can rupture during the dissection or in the postoperative course. Lung cancers invade the mediastinum. and the measured blood loss through the chest tubes. or a vascular repair may have partially separated. then platelets can be administered to the patient who did not stop aspirin before the thoracotomy. This decision must be carefully correlated with the operative findings and the speculative cause for the postoperative bleeding.

Frequently. and this is a clue to the fact that a defect has been created. The anterior and posterior portions of a thoracotomy are always carefully inspected to ensure that there is no bleeding from a traumatized intercostal artery. and mass ligation of this tissue is carried out with a heavy silk suture. reoperation was required. the area of the fistula is edematous. and meticulous observation of the amount of daily drainage is recorded. Further dissection to visualize the fistula better can result in bleeding. supradiaphragmatic ligation of the main duct should be carried out. the chyle can appear more golden- yellow than milky. Whenever a small flow of milky fluid is identified. and in four.104 Just above the diaphragm. Analysis of the pleural fluid shows chylomicrons with lipoprotein electrophoresis. Large vessels require suture ligation. It remains on the right side of the vertebral bodies until it crosses to the left at the level of the fifth or sixth thoracic vertebra. If the patient has not eaten for several hours before the surgical procedure. The pneumonectomy space must be drained by tube thoracostomy. in five patients. the tissue between the aorta and the azygos vein is bluntly freed with an angled clamp. the development of a chylothorax is indicated by rapid filling of the pneumonectomy space with deviation of the mediastinum away from the operated side. and the triglyceride level is more than 100 mg per dL if the fluid is chyle.carefully inspected for any defects in the closure. and secure closure of the boggy tissues is not obtained. and central hyperalimentation is carried out. Lobar branches from the pulmonary artery must be securely tied. and persistent bleeding is controlled with fine interrupted sutures. and total parental nutrition is carried out. We recommend that in reoperation for a thoracic duct fistula after pulmonary resection. Often. After pneumonectomy. The thoracic duct enters the chest through the aortic hiatus at the level of T-12 and is adjacent to the aorta. it is mandatory that the defect in the main duct or one of its branches be closed with interrupted permanent sutures. as reported by Lampson. but if fluid loss is persistent at seven days. The duct can be multichanneled and have many tributaries in the area of the subcarinal space. The maximal amount of time for observation is two weeks. The patient can be given cream or olive oil two to three hours before the thoracotomy. Subcarinal lymphadenectomy requires exposure of the esophagus. and this will enhance recognition of the site of the fistula. Sarsam and colleagues102 reported postpneumonectomy chylothorax in nine patients. Frequently. However. and the removal of these lymph nodes may result in unrecognized thoracic duct injury. and the chest-tube drainage is not the characteristic milky color. It then passes behind the aortic arch to an area adjacent to the esophagus and exits the mediastinum to drain into the left subclavian vein. the chest should be opened on the side of the fistula. and tissues do not hold sutures well. As soon as the patient begins to eat solid food. the continued drainage of serous fluid measuring more than 1. operation for closure of the fistula is undertaken. and the operator can feel a break in the intima as the initial knot is placed. Postoperative Chylothorax Chylothorax after pulmonary resection is a rare complication and occurs more frequently after pneumonectomy than after lobectomy or segmentectomy. All oral feedings are discontinued. Damage to the main duct or tributaries can occur anywhere along the mediastinum.000 mL in 24 hours alerts the surgeon to the possibility of a thoracic duct fistula. Damage can also occur on the left side when the proximal left mainstem bronchus is freed for transection. Miller103 reported that spontaneous closure after an operative injury may be expected in only about half of patients. including the more proximal ligature. patients do not eat solid food after a major pulmonary resection.102 The initial treatment of a postresection chylothorax is conservative. and lymph nodes involved by a tumor are removed along the descending thoracic esophagus. damage to the duct or its tributaries is clearly identified during the dissection. a persistent loss of fluid at seven days indicates the need for reoperation in our experience. Clips should be avoided because . conservative therapy managed the problem. to prevent slippage. At reoperation. Although two weeks can again be used as a time limit for conservative management. Chest-tube drainage is maintained to provide expansion of the remaining lung or mediastinum stabilization. the classic milky appearance of the fluid appears.

However. and during this aspect of the dissection. Long-term conservative management of the postoperative chylous fistula is to be avoided. Bronchoscopy is usually carried out to detect the presence of a bronchial fistula. application of fibrin glue. This ligation can be accomplished through either a right or left thoracotomy. The placement of a chest tube may reveal food particles. vigorous cautery should be avoided because unrecognized damage and subsequent necrosis of the esophageal wall can occur. The esophagus is also directly posterior to the subcarinal space. A careful review of the preoperative computed tomographic scan usually reveals the presence of the tumor in close proximity to the esophageal wall. bleeding can be significant if the vessels are not seen and cut. and it can be damaged during subcarinal lymphadenectomy from either the right or left side. However. on occasion. this approach has been used despite a left-sided chylous fistula. In this instance. and the placement of a nasogastric tube before the procedure assists in early definition of the entire thoracic esophagus. Massard and associates105 recommend the routine use of a barium swallow whenever a postpneumonectomy empyema develops.14). Esophagopleural Fistula The anatomic pathway of the esophagus is in close proximity to the lower trachea and right mainstem bronchus. These arteries can be large because they have nourished the cancer or involved subcarinal lymph nodes. An adjacent pleural flap is easily constructed to buttress the repair. Cautious use of cautery in the subcarinal space is directly applicable to subcarinal lymphadenectomy from both the right and left sides. with a resultant esophagopleural fistula. and the appearance of an air fluid level in a previously opacified hemithorax. This finding alerts the surgeon to the need for clear anatomic definition of the esophageal wall during the dissection. The signs and symptoms are those of an empyema.they damage the duct and a new fistula will occur where the duct is clipped. and thorascopic ligation of the thoracic duct. loss of appetite. a falling air fluid level in the pneumonectomy space. a two-layer repair is accomplished with a fine absorbable monofilament suture. Damage to the esophagus can also occur during this phase of the dissection. placement of a pleural peritoneal shunt. Interrupted sutures are evenly placed to achieve a watertight seal. Other surgical options include pleurectomy. with fever. chest discomfort. and its muscular wall can be directly invaded by a large hilar cancer. but a diagnosis of empyema is obvious. Several bronchial arteries traverse the subcarinal space and are in close proximity to the esophageal wall because they originate from the aorta. the muscularis is reapproximated with similar suture material. the esophagus must be freed from the adjacent tissues to permit a high amputation of the left mainstem bronchus. If a defect is made in both the muscular and mucosal layers of the esophagus. the gold standard to which all other techniques must be compared is direct ligation of the duct. it is more easily accomplished through a limited lower right thoracotomy. and an immediate esophagogram confirms the presence of the clinically suspected esophageal fistula (Figure 41. . and on occasion. An esophagopleural fistula after a pulmonary resection can occur either in the early or late postoperative period. because the patient's condition will only deteriorate and nutritional depletion will cause further complications and possible mortality. Pneumonectomy and resection of the neoplasm may result in an unrecognized defect in the wall of the esophagus. These vessels should be individually ligated as they are encountered. If it is determined during the resection that only the muscularis of the esophagus has been removed and that the mucosa is intact. The performance of a left pneumonectomy requires exposure of the carina and the medial aspect of the proximal right mainstem bronchus. This diagnostic study is particularly important after the development of a late empyema.

and it may be necessary to provide long-term open drainage with attempted later sterilization by the Claggett technique. Gastrostomy and jejunostomy are required for alimentation and drainage of gastric contents. and careful debridement of the pneumonectomy space is carried out. omentum is an excellent choice because of its vascularity and adhesive qualities. therapy is directed toward direct repair of the fistula. thoracotomy and direct repair of the esophageal defect are carried out. this is a difficult empyema to sterilize. The previous thoracotomy space is opened. this is accomplished by thoracoplasty in . The pneumonectomy space must be obliterated. The esophageal fistula is identified and repaired in two layers. and an immediate esophagogram confirms the presence of the clinically suspected esophageal fistula. the chest tube can be removed. In the early postoperative period. The pneumonectomy space is lavaged with antibiotic solution. A gastrostomy for drainage and jejunostomy for feeding and postoperative alimentation are also recommended.106 The development of an esophagopleural fistula in the late postoperative period requires rib resection and adequate drainage of the pleural space. When the patient's condition is stabilized and the pleural space is clean. serratus anterior muscle. and omentum. and in this instance. the one-stage repair is generally recommended. However.Figure 41. and if sterilized.14: Bronchoscopy is usually carried out to detect the presence of a bronchial fistula. However. It must be buttressed with a vascularized tissue flap that includes intercostal muscle. The fistula must be buttressed with tissue. An alternative approach is to exclude the esophagus by a proximal cutaneous fistula and perform a distal ligation with a second-stage reconstruction.

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