Extrapleural Pneumonectomy After Induction Chemotherapy: Perioperative Outcome in 251 Mesothelioma Patients From Three High-Volume Institutions

Management of Complications After Pneumonectomy

“…Despite decreasing rates of operative mortality, rates of morbidity after standard pneumonectomy (25%-60%) 2,[22][23][24]33,37,38 and EPP (30%-60%) 29 /chronic obstructive pulmonary disease (COPD), 2 (long) operating room time, 2 acute blood loss anemia, 2,37 and right pneumonectomy. 37 There has been debate in the literature regarding whether patients who smoke up to the time of surgery do 2,40 or do not 33,41,42 have an increased risk of postoperative complications.…”

“…29 Pericardial patch complications include an overly constrictive patch that can result in restrictive/tamponade physiology or a poorly secured patch (sewn to the weaker adjacent pericardial tissues rather than the cut edge of the pericardium) that can result in cardiac herniation. Technical errors in diaphragm reconstruction can also result in cardiovascular complications; constriction of the inferior vena cava will impair diastolic filling of the ventricle, and a patch that is constructed too loosely will allow the liver to impinge on the heart and impair venous return when the patient is lying supine.…”

“…2,29,33 Bleeding can be minimized by meticulous hemostasis, avoiding hypothermia, and correction of any coagulopathy. In addition, the chest should be irrigated at the end of the operation to eliminate the endogenous thrombolytic factors (eg, plasmin) that are innately a component of clotted blood.…”

“…Several contemporary series have reported mortalities to be 3% to 5.8% after standard pneumonectomy 3,4,21-24 and 5% to 8.5% after EPP. 22,[25][26][27][28][29] Several studies have identified various independent risk factors for 30-day hospital mortality, including American Society of Anesthesiologists classification, 30,31 congestive heart failure (CHF), 32 coronary artery disease, 31,33,34 prior acute myocardial infarction, 32 diabetes, 34 cerebrovascular disease, 32 chronic renal insufficiency, 32 lower FEV 1 , 29,30 malnutrition, 2 high preoperative C-reactive protein levels, 29 intraoperative blood loss (>4 units), 2 intravenous fluid volume, 35 right-sided pneumonectomy, 36 and low-volume centers. 34 Although increasing age has been identified by several studies as a risk factor for 30-day hospital mortality, 2,33,34,36 it is unclear from these studies whether associated comorbidities (which tend to occur at a greater frequency in older patients) are confounding this finding.…”

Invited Commentary

“…The article by Lauk and colleagues [1] presents a multiinstitution, retrospective study of perioperative outcomes after extrapleural pneumonectomy following induction chemotherapy for mesothelioma. The authors demonstrated excellent results despite the challenges of operating on patients who have undergone induction chemotherapy.…”