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J Thorac Cardiovasc Surg 1995;110:1125-1129
© 1995 Mosby, Inc.

GENERAL THORACIC SURGERY

COMPLETION PNEUMONECTOMY: INDICATIONS AND OUTCOME

London, United Kingdom

From Royal Brompton Hospital, London, United Kingdom.

Received for publication July 20, 1994. Accepted for publication Dec. 29, 1994. Address for reprints: Peter Goldstraw, FRCS, Royal Brompton Hospital, Sydney St., London SW3 6NP, England.

Abstract

Completion pneumonectomy has been associated with higher rates of morbidity and mortality and this is reflected in the selection of cases and the indications for the procedure. During a period of 14 years from January 1980 to November 1993, 38 completion pneumonectomies were done by our surgical team, representing 5.1% of all pneumonectomies. There were 24 right and 14 left completion pneumonectomies done in 26 male and 12 female patients with an average age of 61 years (range from 29 to 77 years). Lung malignancy accounted for 26 of these cases in which the indication included local recurrence in 10, second primary tumor in 9, malignancy that developed after resection for bening disease in 2, and pulmonary metastasectomy in 5 cases. Bening diseases were the indication in 12 cases: tuberculosis in 4, bronchiectasis in 4, aspergillosis in 1, and postoperative complications in 3. Additional surgical procedures were necessary in 7 cases: chest wall resection with insertion of prosthesis in 3, thoracoplasty in 2, and omental flap in 2. There was 1 early postoperative death after 5 weeks from adult respiratory distress syndrome. There was no occurrence of bronchopleural fistula, and the 18% associated morbidity rate was a result of bleeding necessitating reexploration in 3 cases, prolonged ventilation in 2, and chronic empyema in 2. Six of these complications (86%) occurred in the group with benign disease. Completion pneumonectomy can be done with an acceptable morbidity in selected patients. Careful technique is important to secure hemostasis and to avoid fistulas. The complication rate is higher when infective disease is involved. (J THORAC CARDIOVASC SURG 1995;110:1125-29)

The indications for completion pneumonectomy that is, resection of the remaining lung tissue after partial pulmonary resection, have greatly increased with the wider use of bronchoplastic techniques, the management of early lung cancer with limited resection, and the increasing demand for pulmonary metastasectomy. The concept that completion pneumonectomy carries a higher mortality and morbidity than standard pneumonectomy should be reevaluated in light of the increasing number of cases in which completion pneumonectomy is indicated. In this paper we review our experience with this operation to study the different indications for it and to evaluate the outcome when it is done.

PATIENTS AND METHODS

During a period of 14 years between January 1980 and December 1993, 38 completion pneumonectomies were done by our surgical team at the Royal Brompton Hospital, Middlesex Hospital, and University College Hospital in London. This represented 5.1% of the 745 pneumonectomies done during the same period. There were 26 male and 12 female patients with an average age of 61 years (range 29 to 77 years). Right completion pneumonectomy was done in 24 cases and left completion pneumonectomy in 14. The indication for CP was malignant disease in 26 and benign disease in 12 cases.

In the group with malignant disease the indication for completion pneumonectomy included local recurrence in 10 cases, a second primary tumor in 9, malignancy that developed after resection for benign disease in 2, and pulmonary metastasectomy in 5. Local recurrence was defined as a second lung malignancy with the same cell type, same anatomic site, and occurring within 2 years of the first operation. When there was residual tumor at the resected margin (bronchial stump) at the time of the operation or when the bronchoscopic examination showed recurrence at the stump and the tumor was of the same cell type, the case was considered as local recurrence regardless of the time interval between the two operations. In this group of cases of local recurrence (n = 10) there were four squamous cell carcinomas, three adenocarcinomas, two bronchoalveolar carcinomas, and one large-cell carcinoma. Eight of the completion pneumonectomy procedures were done on the right side and two on the left after six upper lobectomies (4 right and 2 left), one right lower lobectomy, one middle and lower bilobectomy, and one wedge excision of the right upper lobe. The disease stage at the first operation was T2 N2 in three patients, T2 N1 in three, T1 N1 in three, and T1 N0 in one. The completion pneumonectomy was done after a mean interval of 18 months (range from 3 weeks to 4 years). At operation the stage of the cancer was T2 N2 in three patients, T2 N1 in two, T2 N0 in two, T1 N0 in one, and stump recurrence in two.

A second primary tumor was defined as a second malignancy with a different cell type, different anatomic site, and occurrence after more than 2 years from the first malignancy in the absence of residual tumor at the first operation. In this group there were nine completion pneumonectomy operations (5 left and 4 right) after six upper lobectomies (3 right and 3 left), two left upper lobectomies, and 1 right basal segmentectomy. The mean disease-free interval for this group was 4.8 years (range from 2 to 8 years). The cell type of the tumor at completion pneumonectomy changed from adenocarcinoma in five, squamous cell carcinoma in three, and invasive carcinoid disease in one to squamous cell carcinoma in five, adenocarcinoma in three, and undifferentiated lung cancer in one at the second operation.

Two patients underwent completion pneumonectomy after lung resection for benign disease. One patient had a lung abscess 12 years before for which a left upper lobectomy was done and returned with T2 N0 squamous cell carcinoma involving the left lower lobe. The second patient had tuberculosis involving the left upper lobe and required lobectomy; after 12 years T2 N1 squamous cell carcinoma necessitated completion pneumonectomy.

In the group with metastatic disease, the criteria for completion pneumonectomy included (1) reliable control of the primary tumor, (2) absence of other sites of distant metastasis, (3) no contralateral pulmonary metastases, and (4) preferably a reasonable disease-free interval between the most recent pulmonary metastasectomy and the completion pneumonectomy. In this group there were five male patients with an average age of 39 years (range 28 to 51 years). There were three right and two left completion pneumonectomy procedures and the operation was done as a second-phase operation in three patients, after median sternotomy in two and after posterolateral thoracotomy in 1. The completion pneumonectomy was a third-phase operation in one patient, after median sternotomy and posterolateral thoracotomy, and a fourth-phase operation in one after median sternotomy and two posterolateral thoracotomies. The time interval between the most recent operation and the completion pneumonectomy was 6 to 24 months with an average of 10 months. The primary malignancy was soft tissue sarcoma in three, osteosarcoma in one, and transitional cell carcinoma of the bladder in one.

In the group with benign disease (n = 12) the indication for completion pneumonectomy was operative complications after resection for lung malignancy in three patients. Two of these patients had narrowing of the bronchus intermedius after right upper lobectomy for T2 N0 large-cell carcinoma in one and sleeve right upper lobectomy for small-cell carcinoma in the other. The narrowing was symptomatic and resistant to simple dilation and necessitated completion pneumonectomy 7 and 9 months later, respectively. The third patient had middle and lower bilobectomy for T2 N2 squamous cell carcinoma but an intrapulmonary abscess developed in the remaining lobe and completion pneumonectomy was done 3 weeks after the first operation. In the remaining nine patients in the benign group the completion pneumonectomy was done to deal with recurrence of the primary disease: four patients had tuberculosis, four had bronchiectasis, and one had aspergillosis. There were five male and four female patients with an average age of 61 years (range 54 to 69 years). The time interval between the first and second operation ranged from 5 to 30 years with an average of 16 years. Surgical intervention in these patients was required because of hemoptysis in four, recurrent productive cough with chest infection in three, and infection associated with empyema in two.

Operative technique
In all 38 patients the selection criteria for completion pneumonectomy were the same as those for standard pneumonectomy. Although these patients tend to have lower respiratory reserve the forced expiratory volume in 1 second in all patients was more than 1.5 L. Preoperative evaluation included assessment of cardiac and renal function. In the group with malignant disease preoperative assessment of the mediastinal lymph nodes by computed tomographic (CT) scans with or without mediastinal lymph node biopsy were done to exclude gross N2 disease. All resections in this group were potentially curative and distant metastasis was excluded. Preoperative bronchoscopic examination was done for all patients and if the diagnosis was not confirmed an intraoperative frozen section was arranged.

All 38 completion pneumonectomy operations were done by a uniform surgical technique. Prophylactic antibiotics were given to all patients and posterolateral thoracotomy was the standard surgical access. Extra time was spent to ensure complete hemostasis during lung mobilization.

In cases with malignant disease routine meticulous lymph node dissection was done as part of our intraoperative restaging before the decision to perform resection was made.

The bronchus was clamped with a crushing bronchial clamp in all cases and a hand suture technique with three layers of continuous Prolene suture (Ethicon, Inc., Somerville, N.J.) was used to ensure a short bronchial stump. This technique has been described before. ¹ In cases of stump recurrence or when the tumor was near the main bronchus, the open technique was applied. The stump was buried beneath the mediastinal structures. After hemostasis was secured the chest was closed. It is our routine not to drain the pneumonectomy space in standard pneumonectomy or elective completion pneumonectomy, but if there was a risk of excessive bleeding as when completion pneumonectomy was done because of inflammatory disease or as emergency procedure, a basal drain was used, and that was the case in 13 patients. Additional surgical procedures were required in seven cases. Three patients in whom completion pneumonectomy was done for metastasectomy required chest wall resection and the insertion of a chest wall prosthesis. In two patients who underwent completion pneumonectomy because of tuberculosis with an associated empyema, a limited thoracoplasty was added. In two patients who received completion pneumonectomy for tuberculosis and aspergilloma, an omental flap was used to cover the bronchial stump at the time of the operation. Elective mechanical ventilation and intensive care unit management after operation were not our routine practice. Eighteen of our patients were cared for after operation in the intensive care unit for an average of 30 (±6) hours. Mechanical ventilation for an average of 8 (±2) hours was required in six patients.

RESULTS

There was one in-hospital death for an operative mortality rate of 2.6%. This occurred in a 65-year-old man who had had a right upper lobectomy for tuberculosis complicated by bronchiectasis; 5 years after this he had massive hemoptysis and emergency completion pneumonectomy was done. The patient required ventilation of the lungs for 5 days after operation and the adult respiratory distress syndrome developed, which led to his death 5 weeks later.

Completion pneumonectomy was associated with considerable morbidity: seven patients (18%) had postoperative complications. Postoperative bleeding that necessitated reexploration occurred in three patients. Prolonged ventilation of the lungs for five and seven days, respectively, necessitated a tracheostomy in two patients. In two patients, chronic empyema occurred after completion pneumonectomy and an associated fistula was excluded in both cases. There were no cases of bronchopleural fistula (BPF) in the 38 completion pneumonectomy cases. Minor complications included a raised hemidiaphragm in two patients and a right Horner's syndrome in one.

All patients were followed up for a mean period of 36 months (range 5 months to 14 years). In the group of patients who had metastasectomy (n = 5), over a mean follow-up period of 24 months (range 12 to 48 months), three patients are alive with no residual tumor; the remaining two died at 7 and 14 months after operation, respectively. The initial pulmonary metastasis developed in these patients 3 and 4 years before death, respectively. In the lung cancer group (n = 21), the mean follow-up period was 6 years (range 8 months to 12 years). The overall actuarial 3- and 5-year survivals were 40% and 23%, respectively.

DISCUSSION

Completion pneumonectomy has become a more frequent therapeutic option in the field of thoracic surgery. In 1988, McGovern and colleagues ² reported from Mayo Clinic 113 cases of completion pneumonectomy with a mortality rate of 12.4% and an associated morbidity rate of 38.1%. Others reported an operative mortality rate of 10% and morbidity rate of 27% with actuarial 5-year survivals of 88% and 33% when completion pneumonectomy was done for benign and malignant diseases, respectively. ³

The indications for completion pneumonectomy have increased with the increasing demand for pulmonary metastasectomy and the longer survival of patients with early-stage lung cancer who have been previously treated with limited resection. Those patients showed a tendency for the development of a second primary lung cancer after a 5-year disease-free period. ⁴ The good results achieved in patients with several primary lung cancers may make completion pneumonectomy a more frequent option. ⁵ The complications of sleeve resection include strictures and dehiscence, which can occur in up to 13.1% of cases requiring completion pneumonectomy. ⁶ In these cases endobronchial stents can salvage the remaining lung parenchyma. ⁷

In our series we had only one operative death caused by respiratory failure in a patient with tuberculosis. This was comparable to the risk of standard pneumonectomy. We have previously studied the hospital mortality after pulmonary resection. ⁸ In that study the pneumonectomy rate was 41.3% of all pulmonary resections with an in-hospital mortality rate of 6.7%. ⁸

The associated morbidity occurred mainly in those patients who underwent completion pneumonectomy for benign disease (6 of 7 patients). Dense inflammatory adhesions and the consequences of the longstanding benign disease add greatly to the technical problems of completion pneumonectomy in these cases. Bleeding is a major postoperative complication and every effort should be made to secure hemostasis before closure. Extrapleural dissection, in comparison with intrapleural dissection, increases this risk especially when inflammatory conditions are involved. Empyema in a pneumonectomy space is a life-threatening complication and prevention is the best treatment. In cases in which empyema carries a higher risk, such as in elderly patients with infective pathologic conditions, additional surgical procedures might be advisable. Limited thoracoplasty or the use of omental or muscle flaps to fill the hemithorax at the time of the operation can reduce this risk. The most common complication after completion pneumonectomy is respiratory failure: preoperative selection of the patients and good postoperative care are essential. Respiratory failure was responsible for our postoperative death and for two cases of prolonged ventilation and the insertion of postoperative tracheostomy.

We did not have any occurrences of BPF in the 38 cases: the use of a uniform suture technique and burying the bronchial stump are our routine practices in all pneumonectomies. In our institution, the rate of BPF after pneumonectomy has been 1.6% for the past 14 years (7 of 746) and the most recent fistula occurred in 1986. ¹

Although completion pneumonectomy for pulmonary metastasectomy was done as a third- or fourth-phase operation, it was not associated with any morbidity. This can be explained by the facts that those patients had a younger average age and that there was minimal risk of infection. ⁹

The definition of a second primary tumor or recurrence of the original tumor is not yet universally accepted. ¹⁰ The consideration of 2 years as the time limit after which a similar cell type tumor will be considered a second primary tumor is controversial. ¹¹ We had a case in which the bronchial stump was involved with the first tumor and the patient was in a program of routine bronchoscopic examinations for 4 years when he had evidence of stump recurrence. This makes the treatment of patients who show positive tumor at the resected bronchial margin more difficult: the choices are either reexploration and performance of completion pneumonectomy or close follow-up by periodic examination. Our practice is to send the bronchial stump as a separate specimen for histologic examination, and if the tumor is found to be close to the resected margin the bronchial stump is sent for frozen section to obtain an intraoperative histologic diagnosis. No cases of positive findings from the stump were reported in our hospital and the two cases of stump recurrence were referred from another hospital. There were more local recurrences in the patients with adenocarcinoma and with mediastinal lymph node involvement compared with those in the other patients, but the number was too small to show statistical significance. On the other hand when completion pneumonectomy was done because of a second primary tumor there were more cases of squamous cell carcinoma with nodal negative pathologic findings at the first operation. In all cases done at our hospital either as the first pulmonary resection or when completion pneumonectomy was done for malignancy careful preoperative staging was undertaken with CT scanning and selective use of mediastinal exploration. ¹² In cases of completion pneumonectomy we tend to rely on the CT scan inasmuch as repeat mediastinoscopy is not reliable in our experience. The prevalence of local recurrence is variable and the value of routine extensive mediastinal lymph node sampling in accurate staging and in improving survival or reducing the prevalence of local recurrence is not yet clear. Curative resection should be aimed for in all cases of completion pneumonectomy and this may necessitate further resection: in our series chest wall resection with insertion of a prosthesis was necessary in two cases. Preoperative assessment and planning in these cases reduces the postoperative complications. ^13,14

The surgeon should be aware that patients who had previous pulmonary resection for benign disease are still at risk for the development of lung malignancy. Although some benign and malignant diseases share common symptoms, careful clinical and radiologic examination should be done to exclude malignancy especially in elderly patients with a history of smoking.

The time interval between the first operation and the need for completion pneumonectomy varies according to the underlying pathologic condition: it is shorter with local recurrence and longer when benign diseases or second primary tumors are involved.

The value of completion pneumonectomy is also related to the long-term results, especially when malignant diseases are involved. In the patients having metastasectomy our previous experience showed that in selected patients with the criteria described previously good long-term results can be achieved. Three of the five patients are alive and tumor-free more than 4 years from the initial pulmonary involvement. In the cancer group survival is related to the stage of the disease and although the number of patients in each stage was small the overall 5-year survival after completion pneumonectomy was similar to the survival after the first operation.

We conclude that with careful selection of patients undergoing completion pneumonectomy an operative mortality similar to that of standard pneumonectomy can be achieved. Completion pneumonectomy for benign infective problems is associated with higher morbidity and a greater level of preoperative fitness and careful preparation are necessary to keep the operative risk acceptable. Additional procedures such as thoracoplasty or omental flaps have proved useful. In dealing with malignancy as a recurrence or as a second primary tumor, an aggressive approach with completion pneumonectomy in selected patients as a curative procedure can offer good long-term survival. Completion pneumonectomy can also be done safely even as a third- or fourth-phase operation in patients with pulmonary metastasis.

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