Postlobectomy Early Complications

Abstract

INTRODUCTIONThe most effective management of postoperative crises is prevention. This starts with preoperative preparation and patient screening. There are many factors that can be controlled and improved by the patient, including but not limited to, smoking cessation, cardiopulmonary rehab and teaching/setting peri-operative expectations. Equally as important is patient selection, which is influenced by pulmonary function tests, cardiopulmonary reserve, and pre-existing comorbidities. After the operation, the care team can also greatly improve outcomes with aggressive cardiopulmonary therapies, ambulation, vigilant monitoring and frequent assessments of the patient. Even when all of these guidelines are followed not all early complications can be avoided.A recent review of the National Cancer Database by Rosen et al found a 2.6% mortality from lobectomy [1]. Morbidity associated with lobectomy is 10% to 50%, and increases in the elderly [2]. The population being treated by thoracic surgeons continues to age and the complexity of the operations is increasing as neoadjuvant therapies become more prevalent. Early postoperative crises after lobectomy will occur, necessitating prompt and effective management strategies. The most common complications after pulmonary resection are listed below in Table 1, in this chapter we will focus on the early complications after lobectomy [3].For the purposes of this chapter we will define early post-operative crisis as those that develop within 48 hours of the operation. AIR LEAKProlonged air leak is the most common complication after pulmonary resection, with a reported incidence of 15-18% [4]. Prolonged air leak is defined as a leak lasted more than 7 days after pulmonary resection. Cerfolio et al reported an incidence of 25% on postoperative day 1 and 20% on postoperative day 2 [5,6] U.S. Department of Veterans AffairsPublic Access Author manuscript VA Author ManuscriptVA Author Manuscript VA Author Manuscript parenchymal air leaks post-operatively and a variety of factors that influence any given patients propensity for developing an air leak. Patient factors that increase risk of developing an air leak include emphysematous lungs, larger parenchymal resection and therefore less parenchymal apposition to chest wall, and inadequate drainage of air by thoracostomy tube(s). PREVENTION STRATEGIES1. Bronchial stump buttressing with a muscle flap. In patients with an infected pleural space or who are on chronic immunosuppression, coverage of the stump with vascularized muscle may prevent bronchial stump breakdown [7]. The intercostal muscle is an excellent coverage option and is harvested from the intercostal space upon entry into the chest at the level of the thoracotomy. It is important to plan ahead, as this muscle needs to be harvested prior to placing the rib spreader in an open operation to prevent crushing the vascular supply. Dissection is begun on the inferior rib and the muscle is mobilized using a periosteal elevator posteriorly to the paraspinous muscle. Attention is...

Morphology and morphometry of pulmonary veins and the left atrium in multi-slice computed tomography

“…It is well known that age and morphometry of LA are risk factor of AF [ 15 , 20 , 33 ]. LA dimension that is the most important to assess normal morphology is LA sagittal dimension; the mean value in our study (35.00 mm) is consistent with the literature data (28.1–43 mm) [ 18 , 28 , 35 ]. LA sag significantly increases in patients with AF: based upon a sum of 731 literature cases of patients with AF LA sag in AF+ was 39.61 mm, so the proposed arbitrary value of 40.00 mm to predict AF by computed tomography seems reasonable and is also similar with echocardiographic range of normal values of LA sag which is 23–40 mm proposed by Tracz et al [ 30 ].…”

“…The atypical venous anatomy during lung resection was acknowledged in 3.12% of 642 analyzed cases by Polaczek et al [ 27 ]. With VATS the vison is limited, thus it can lead to misinterpreting the vascular structures [ 35 ] and cause potential surgical complications [ 25 ]. This is why it is so important to establish vascular anatomy prior to surgical treatment [ 11 ].…”

Sugammadex is associated with shorter hospital length of stay after open lobectomy for lung cancer: A retrospective observational study

“…Lung resection surgery is associated with a high prevalence of postoperative pulmonary complications (PPCs), including prolonged air leak, atelectasis, pneumonia, empyema, and acute respiratory distress syndrome [1]. PPCs are associated with prolonged hospitalizations, admissions to the intensive care unit (ICU), and hospital re-admissions, as well as increased morbidity, mortality, and healthcare expenditure [2][3][4][5][6].…”

Use of lung expansion techniques on drained and non-drained pleural effusion: survey with 232 physiotherapists

“…Regarding the use of positive pressure, despite many studies having been testing the benefits of its application in surgical patients [28][29][30][31], the results are still controversial [32]. We believe that, besides the weak evidence of the positive pressure use in patients with pleural effusion [19], the little familiarity with the use of this technique and the risk of Broncho pleural fistula might have restricted the choice for this lung expansion technique [33,34].…”