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J Thorac Cardiovasc Surg 1995;110:1118-1124
© 1995 Mosby, Inc.

GENERAL THORACIC SURGERY

ELECTIVE PNEUMONECTOMY FOR BENIGN LUNG DISEASE: MODERN-DAY MORTALITY AND MORBIDITY

Kingston, Ontario, Canada, and Johannesburg, South Africa

From the Divisions of Cardiothoracic Surgery, Queens University, Kingston, Ontario, Canada, and the University of Witwatersrand, Johannesburg, South Africa.

Received for publication Nov. 17, 1994. Accepted for publication March 27, 1995. Address for reprints: A. A. Conlan, MD, University of Massachusetts Medical Center, 55 Lake Ave., North, Worcester, MA 01655-0304.

Abstract

This retrospective study of elective pneumonectomy for complicated inflammatory lung disease was done to define modern-day mortality and morbidity. One hundred twenty-four patients received elective pneumonectomy. Patient ages ranged from 6 months to 71 years. Past, recurrent, or new pulmonary tuberculosis was present in 107 patients (86.3%). Clinical presentation involved recurrent infections or severe suppurative sequelae (abscess, empyema). Forty-seven patients had chronic hemoptysis and 25 patients had past or recent massive hemoptysis (>600 ml of hemoptysis fluid within 24 hours). Nutritional deficiencies were common. One hundred six patients (85.5%) had end-stage destroyed lungs. Evaluative bronchoscopy showed inflammatory endobronchial changes in 106 patients (85.5%), bronchial strictures in 4, and indolent endobronchial tumor in 2. Lung separation was by double-lumen tube in 96 patients, single lung–single tube in 6, bronchus blocker in 6, and prone posture in 9. Extrapleural pneumonectomy was done in 83 patients (66.9%). Fifty-seven of these procedures were left sided and 26 were right sided. Standard transpleural pneumonectomy was done in 41 patients (33.1%): 30 left sided and 11 right sided. Nine pneumonectomies were conducted with the patient in the prone position. Four patients had completion pneumonectomy. Hospital mortality was three deaths (2.4%). Morbidity included postpneumonectomy empyema in 19 patients (15.3%). Seven postoperative bronchopleural fistulas occurred. Empyema in most patients was managed by open pleural drainage (thoracostoma) and later space closure. Pneumonectomy proved effective therapy with low mortality but postpneumonectomy empyema posed serious morbidity. (J THORACCARDIOVASCSURG1995;110:1118-24)

Pneumonectomy for the serious complications of benign lung disease is uncommon in contemporary North American surgical practice. Benign lung disease is most often caused by pulmonary tuberculosis. Other important causes include whole-lung bronchiectasis, extensive postaspiration necrotizing pneumonia, multiple or extensive lung abscesses, and spreading opportunistic fungal infection in patients with immunosuppressed conditions. Less common causes are complicated pulmonary trauma, extensive lung infarction and necrosis, multiple arteriovenous malformations, and, occasionally, congenital abnormalities.

Extensive parenchymal destruction of the lung by inflammatory disease gives rise to chronically morbid and sometimes acute life-threatening complications. These include recurrent infection, acute suppurative complications including lung abscess and empyema, septicemia, and often chronic, intermittent, or massive hemoptysis.

This two-center study was done to define and report the modern-day mortality and morbidity of elective pneumonectomy for complicated benign lung disease in university thoracic surgery units. The study comes from the Divisions of Cardiothoracic Surgery at Queen's University, Kingston, Ontario, Canada, and the University of Witwatersrand, Johannesburg, South Africa. Patients in this study underwent investigation, care, and operation at the Leratong, Baragwanath, JG Strydom, and Johannesburg Academic Hospitals in Transvaal, South Africa, between 1980 and 1987. Further patients were cared for at the Kingston General and Hotel Dieu Hospitals, Kingston, Ontario, Canada, during the period 1987 to 1994.

PATIENTS AND METHODS

This retrospective study is based on the hospital charts, investigations, operative findings, and pathologic findings of 171 patients who underwent pneumonectomy because of the serious complications of benign lung disease. One hundred twenty-four patients had elective operations, whereas 47 patients required emergency pneumonectomy. This study concerns itself with the 124 patients who underwent elective procedures.

The patient group comprised 67 men (54%), 38 women (30.6%), and 19 children (15.3%). One hundred eighteen patients (95.2%) were from the indigenous black and mixed-race peoples of South Africa. The remaining six patients (4.8%) were white. Patient ages ranged from 6 months to 71 years. Most patients, however, were in the third, fourth, or fifth decade of life. Previous, recurrent, or new pulmonary tuberculosis was documented in 107 patients (86.3%). Previous respiratory disease and other causes for destroyed lungs are presented in Table I. Forty-four patients (35.5%) were regular smokers and finger clubbing was recorded in 65 patients.

Three patients (2.4%) with destroyed lung had sputum evidence of cancer when first seen. Two patients (1.6%) had sputum positive for squamous cell carcinoma, and the remaining patient had sputum positive for adenocarcinoma.

Eighteen patients (14.5%) had sputum positive for tuberculosis on admission to the hospital and triple-drug tuberculosis chemotherapy was instituted for 3 to 6 months before the patient was considered for operation provided serious surgical complications did not intervene.

All patients were examined by standard chest roentgenography. Special radiologic studies included bronchography (44.4%), and a minority of patients underwent tomography or computed tomographic scanning, or both. All had routine lung function studies with arterial blood gas measurements done while they were breathing room air. Patients identified as having marginal lung function were additionally studied by ventilation-perfusion scan.

The most characteristic clinical and roentgenographic finding in this patient group was end-stage destroyed lung, which was found in 106 patients (85.5%). The roentgenographic features of this terminal postinflammatory condition are shown in Fig. 1.

View larger version (173K): [in this window] [in a new window]   Fig. 1. Marked contraction and scarring of right destroyed lung. Large apical cavity with marked pleural thickening.

Bronchography was generally done to document and define the structural abnormality in both the involved lung and the contralateral lung in selected patients. The bronchographic appearance of destroyed lung is shown in Fig. 2 and the bronchographic appearance of whole-lung bronchiectasis is demonstrated in Fig. 3.

View larger version (337K): [in this window] [in a new window]   Fig. 2. A, Left destroyed lung showing extreme volume loss with shift of heart into left hemithorax. B, Bronchogram of destroyed lung shown in A. Gross bronchiectatic change with dilation, tortuosity, and destruction of bronchial anatomy.

View larger version (170K): [in this window] [in a new window]   Fig. 3. Left whole lung bronchiectasis with destruction and dilation of bronchi and marked cystic changes.

Indications for elective pneumonectomy included a documented history of recurrent infection and hospitalizations or chronic infection and associated long-term ill health based on severe irreversible postinflammatory lung destruction. Additionally, chronic destroyed lungs with acute suppurative complications (lung abscess, empyema, multiple brain abscesses, and episodes of septicemia) were further indications for resective therapy. Chronic and repeated hemoptysis or past or recent massive hemoptysis were further strong indications for operation. Irreversible bronchial obstruction and distal suppurative pneumonitis mandated operation in six patients (4.8%) and three patients (2.4%) underwent pneumonectomy because of a destroyed lung complicated by cancer. Four patients (3.2%) required completion pneumonectomy after previous lobectomy for inflammatory disease. Many patients had multiple indications for operations from the named choices.

All patients underwent careful preoperative assessment and preparations for pneumonectomy. Bacterial infections were cultured and treated with appropriate antibiotics. The volume of purulent sputum was reduced by programmed postural drainage and active physiotherapy. Nutritional supplementation was given as high-calorie, high-protein, and vitamin-supplemented diet. Associated suppurative complications such as lung abscess and empyema were cleared by antibiotics, physiotherapy, and by either open or closed surgical pleural drainage before operation.

Surgical therapy and lung separation
Bronchoscopy was done at the induction of general anesthesia to clear the airways of mobile secretions. A double-lumen tube was then inserted before the patient was turned to the thoracotomy position. Endobronchial separation is vital to prevent contralateral spillage of purulent secretions mobilized during operation. Separation was by double-lumen tube in 96 patients (77.4%), single tube–single lung ventilation in 6 patients (4.8%), bronchial blocker in 6 patients (4.8%), and prone posture for operation in 9 (7.3%). The method of separation was unrecorded in 7 patients (5.6%).

Extrapleural pneumonectomy was done in 83 patients (66.9%) (57 left and 26 right). Standard or simple pneumonectomy was completed in the remaining 41 patients (33.1%) (30 left and 11 right). Nine pneumonectomies within the simple pneumonectomy group were completed with the patient in the prone position and three were completion pneumonectomies. A further patient had a completion pneumonectomy by the extrapleural route.

The patients who received prone pneumonectomy were children. Standard methods of endobronchial separation are inapplicable to their small airways. Although endobronchial catheters and blockers (Fogerty embolectomy catheter) can be used, we have found the prone position effective and safe. ¹

Bronchial stump management
Before operation endobronchial inflammatory changes and purulent secretions were treated and cleared with antibiotics, physical therapy, and postural drainage. If tuberculosis was identified operation was postponed for 6 months to allow three-drug chemotherapy to be given.

At operation, bronchial stumps were kept short and excessive peribronchial dissection was avoided to preserve vascularity. As outlined there is marked neovascularity of the bronchial arterial system and rich blood vessel formation in the peribronchial tissues. ^2-4 Healing of the bronchial stump is much enhanced.

Two standard techniques of bronchial closure were used: hand suture with interrupted sutures (absorbable Vicryl or Dexon sutures) or stapler closure. The line of bronchial closure was always covered with adjacent fascial, pleural, or mediastinal tissues as available. Pedicled pleural flaps were used in patients receiving transpleural pneumonectomy. Of 124 bronchial closures, 72 were stapled and 52 were hand sewn.

Pleural space management
All patients had tube drainage of the pleural space after operation. In most, a single 28F or 32F tube was retained for 24 hours and kept clamped unless mediastinal adjustment of space decompression was required.

Twenty-eight patients (22.6%) sustained septic intrapleural spillage during operation. Spillage occurred in 9 of 41 patients who received transpleural resection and in 19 of 83 patients who received extrapleural resection. Spillage was suctioned clear and copiously irrigated with saline solution. Samples for Gram's staining and cultures were sent. If the spillage volume was small to moderate, intravenous and intrapleural antibiotics were given for 7 days. In 4 of 18 patients treated in this manner postoperative empyema ultimately developed.

Patients with gross intrapleural spillage were treated by extensive irrigation with saline solution and two tubes were placed for continuous postoperative irrigation and drainage with 1% povidone-iodine. Of these patients seven had a relapse of empyema and three had sterile conditions after antibiotic instillation and tube removal. Established empyema and empyema with bronchopleural fistula were managed by open pleural drainage (thoracostoma).

RESULTS

Hospital mortality (death occurring in the hospital however long after operation) occurred in three patients (2.4%). Mortality and major morbidity by pneumonectomy type are presented in Table III. p Values were determined by Fisher's exact test with Systat for Windows 5.0 on an IBM-compatible personal computer. One death was a result of intraoperative cardiac arrest related to blood loss and air embolism. Another patient died of massive contralateral aspiration as a result of an endobronchial tube balloon failure. A third patient died of postpneumonectomy bronchopleural fistula and empyema. Seven patients (5.6%) had documented bronchopleural fistula after operation with one hospital death. Three fistulas occurred in patients who had hand-sewn bronchial closure (N = 52). Four fistulas occurred in patients who had stapler closure (N = 72).

Postpneumonectomy pleural space infection occurred in 19 patients (15.3%). Fifteen patients had open pleural drainage (7 irrigation failures, 5 bronchopleural fistulas, 3 late empyemas). Three patients were cured of infection by pleural irrigation and antibiotic instillation as described. One patient refused all therapy except open tube thoracostomy drainage. After thoracostoma drainage three fistulas closed or diminished beyond clinical recognition. Pneumonectomy space closure after thoracostoma was delayed to allow clearance of sepsis and nutritional recovery. Ultimately closure was by thoracoplasty (6 patients), muscle transposition (2), and classic Clagett closure (2). One Clagett procedure failed. Five patients had thoracostoma drainage only.

Specimen pathologic findings
The pathologic findings in the resected pneumonectomy specimens were reviewed. The final diagnosis in 97 patients (78.2%) was end-stage destroyed lung as a result of tuberculosis. This postinflammatory residual is essentially a cavitated fibrous contracted mass. A vertical cut section of such a lung is demonstrated in Fig. 4. The cavities are often lined by granulation tissue and there is associated marked destruction of lung with bronchiectasis. Areas of acute suppuration and obvious lung abscess superimposed on the chronic destructive changes are observed in many patients.

View larger version (115K): [in this window] [in a new window]   Fig. 4. Vertical whole lung slices of fresh extrapleural pneumonectomy specimen. Marked scarring and fibrous replacement of parenchyma. There is large upper lobe cavity.

Two patients with bronchial strictures and distal destroyed lung showed chronic foreign bodies. Three patients had destroyed lung and associated carcinoma. Two had adenocarcinoma, two had squamous cell carcinoma, and one had a peripheral adenocarcinoma. All three patients had positive findings in intrapulmonary nodes and thus had stage II lesions. Two patients had long-standing indolent endobronchial tumors. These were a mucoepidermoid carcinoma and a carcinoid tumor, respectively. Whole-lung bronchiectasis was the primary diagnosis in 26 patients in the series.

DISCUSSION

Pneumonectomy proved expeditious and effective management for the serious complications of benign lung disease in this study. The hospital mortality rate of 2.4% compares favorably with modern-day cancer pneumonectomy rates. ^5-7 Ginsberg and associates ⁵ report an average 5% mortality rate for left-sided pneumonectomy, and the mortality rate may vary up to 15% for right-sided resections. Past series of pneumonectomy for both inflammatory and malignant disease indicates mortality rates ranging from 6% through 25%. ^5-9 More recently Stevens and associates ¹⁰ reported a 3.1% mortality rate for elective pneumonectomy for inflammatory lung disease.

Present-day preoperative evaluation, preparation, and precise anesthesia techniques, particularly airway separation, are important factors. ^1,10,11 The ablation of active infection, especially active tuberculosis, before operation is critical. ^2,8 Clinical lung abscess and empyema associated with destroyed lung should be managed by either closed or open drainage before operation is done. Important intraoperative surgical measures include the use of surgical staplers for both proximal and distal bronchial control. The plan is to terminate the risk of contralateral spillage of mobilized endobronchial debris and of course to minimize the risk of ipsilateral pleural spillage during the handling of these lungs. The use of the extrapleural approach in many of these patients allowed expeditious mobilization of the lung and early bronchial access and control. ^2,12

The persistence of major inflammatory lung disease, especially pulmonary tuberculosis, presents an evolving global problem. ^2,3,13 In North America, Europe, and Scandinavia pulmonary tuberculosis persists only in certain well-defined patient groups. These include recent third-world immigrants and their extended families and the modern-day remnants of the aboriginal and native peoples. Likewise, the indigent and undernourished poor often ravaged by alcohol and drugs present pockets of tuberculosis. The rising prevalence of tuberculosis in persons infected with human immunodeficiency virus suggests the need for heightened surveillance and awareness of a vast new potential epidemic.

Destroyed lung caused by tuberculosis is an end-stage phenomenon prone to serious complications. The involved lung is nonfunctional with demonstrable absent perfusion and ventilation. It is nonetheless richly vascularized by systemic arterial connections. ^2-4 This neovascularization is effected by the bronchial arterial system and includes the adjacent intercostal arteries, branches of the subclavian, axillary, pericardial, diaphragmatic, and esophageal arteries. Thin-walled new vessels bleed readily as evidenced by the commonness of chronic, recurrent, and often massive hemoptysis. ^2-4

The cavitated and bronchiectatic areas of these destroyed lungs are prone to recurrent bacterial infection and occasionally to the acute suppurative complications of infection such as lung abscess and associated empyema. A further complication is fungus infestation (aspergillus) of chronic posttuberculous cavities. The increased likelihood of massive hemoptysis is a result of this. ^2,3 Reactivated or undiagnosed and thus untreated tuberculosis is a further major problem and should be actively investigated and treated before operation.

The occurrence of three bronchogenic carcinomas associated with chronic destroyed lungs reminds us of the small, but definite, risk of cancer in these patients. ⁹ Lung cancer is 20 times more frequent in the scarred lungs of persons with tuberculosis than in the general population. ⁹

The surgical technique for handling these complicated infected lungs is crucial. Because of the extensive revascularization hemostasis has to be meticulous and done concurrently with blunt and sharp dissection as mobilization of inflammatory lungs and early hilar access. ^2,12 The bronchus is approached posteriorly and taken first. It should be stapled both proximally and distally. This terminates the risk of endobronchial spillage and intrapleural spillage on the same side. Unfortunately, intrapleural spillage may occur from a peripheral ruptured or breached abscess cavity or other loculus during operation. Such peripheral loculi of infection or associated empyema preoperatively almost guarantee pleural contamination. ^10,11

Postpneumonectomy pleural space infection rates can be as high as 40% when operation is done through an empyema. ¹¹ It is a feared and ever-present threat when operation is done for lung disease of inflammatory origin. However, it was not a cause of major hospital mortality in this series (1 early death and 1 late death). It was, however, a major cause of morbidity necessitating sequential surgical procedures for both drainage and ultimate space closure.

There have been few publications of large pneumonectomy series for benign postinflammatory lung disease in recent decades. Stevens and associates ¹⁰ report on 64 patients with two perioperative deaths caused by massive endobronchial spillage. Odell and Henderson ¹¹ reported a mixed pneumonectomy series of 251 cases (67.3% tuberculosis, 24% bronchiectasis and necrotizing pneumonia, 7.9% cancer). This series achieved a credible 6.8% mortality rate.

This present series of 124 patients undergoing elective pneumonectomy for the severe complications of benign disease would indicate that in modern-day thoracic surgery units resection can have a low and acceptable mortality. It is clear that careful preoperative assessment and preparation are crucial to management. Modern-day anesthesia and surgical techniques are complementary. The use of a double-lumen tube was effective in almost all patients and we continue to recommend the use of the prone posture position in children. ¹

The presence of a destroyed postinflammatory lung in a patient who is free of symptoms has not been in the past an immediate indication for operation. This was largely because of the expected excess mortality and morbidity. ⁸ Because of the documented serious complications that will inevitably arise from these postinflammatory residuals, we recommend elective pneumonectomy for these patients. ^1-3,8,10,11 Elective pneumonectomy done in the absence of serious infective complications or active hemoptysis, and when nutritional status is good, promises further improvements in the mortality and morbidity of this patient group. The prophylaxis and prevention of postpneumonectomy empyema after pneumonectomy for inflammatory disease deserves the highest treatment prioritization.

References

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Conlan, A. A. Articles by Hurwitz, S. S. Search for Related Content PubMed PubMed Citation Articles by Conlan, A. A. Articles by Hurwitz, S. S.