Pneumonectomy

Last updated
Pneumonectomy
Lung cancer.jpg
Appearance of the cut surface of a pneumonectomy specimen containing lung cancer, here a squamous cell carcinoma (the whitish tumor near the bronchi).
ICD-9-CM 32.5
MeSH D011013

A pneumonectomy (or pneumectomy) is a surgical procedure to remove a lung. It was first successfully performed in 1933 by Dr. Evarts Graham. This is not to be confused with a lobectomy or segmentectomy, which only removes one part of the lung.

Contents

There are two types of pneumonectomy: simple and extrapleural. A simple pneumonectomy removes just the lung. An extrapleural pneumonectomy also takes away part of the diaphragm, the parietal pleura, and the pericardium on that side. [1]

Indications

The most common reason for a pneumonectomy is to remove tumorous tissue arising from lung cancer. Other reasons can arise are a traumatic lung injury, bronchiectasis, tuberculosis, a congenital defect, and fungal infections. [2]

Contraindications

Tests

The operation will reduce the respiratory capacity of the patient, and before conducting a pneumonectomy, survivability after the removal has to be assessed. If at all possible, a pulmonary function test (PFT) should be done. It has been found that forced expiratory volume in one second (FEV1) and diffusion capacity of the lungs (DLCO) provides the best indicator of survival. [3] Other tools can be used to assess effectiveness as well, such as cardiopulmonary exercise testing to measure maximal oxygen consumption (VO2 max), stair climbing, shuttle walk test, and a 6-minute walk test. [4]

Pathologies

If someone has severe valvular disease, severe pulmonary hypertension, or poor ventricular function or if cancer has spread from the lungs into the other intra-abdominal structures, ribs, or contralateral hemithorax, it is contraindicated. [5]

Surgical approach

Posterolateral thoracotomy using the fourth or fifth intercostal space is the most common approach used for pneumonectomy. In case of inflammatory and infectious indications, excision of the fifth rib may be necessary to achieve adequate surgical exposure if there is rib crowding. [6]

Video-assisted thoracoscopic surgery (VATS) approach: VATS pneumonectomy is a safe and feasible treatment for advanced malignant and benign diseases and has lower morbidity. [7]

Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With a sound technique most procedures can be completed robotically without any major complications. [8]

Anatomical changes

After a pneumonectomy is performed, changes in the thoracic cavity occur to compensate for the altered anatomy. The remaining lung hyperinflates as well as shifting over along with the heart towards the now empty space. This space is full of air initially after surgery, but then it is absorbed, and fluid eventually takes its place. [9] The fluid which fills the residual space in the chest cavity slowly gelatinizes into a proteinaceous material, and the chest scaffold collapses slightly.[ citation needed ]

X-ray of a person who has had their right lung removed. Note how fluid has replaced the lung PneumonectomyXray.PNG
X-ray of a person who has had their right lung removed. Note how fluid has replaced the lung

Living with one lung

As with the kidneys, it is often possible for a person to live with just one lung. Although it is not possible for the lung to re-grow like the liver, the body is able to compensate for the reduced lung capacity by slow and gradual expansion of the other remaining lung. Post-pneumonectomy patients in due time reach about 70–80 percent of their pre-surgery lung function. [10] People have been able to return to near-normal lives, including running marathons after a pneumonectomy, provided there has been adequate cardio-pulmonary conditioning. [11]

Complications

Most common complications after a pneumonectomy are:

History

Diagram showing the parts removed in a pneumonectomy Diagram showing the removal of a whole lung (pneumonectomy) CRUK 365.svg
Diagram showing the parts removed in a pneumonectomy

Pioneering dates

See also

Related Research Articles

<span class="mw-page-title-main">Pulmonology</span> Study of respiratory diseases

Pulmonology, pneumology or pneumonology is a medical specialty that deals with diseases involving the respiratory tract. It is also known as respirology, respiratory medicine, or chest medicine in some countries and areas.

<span class="mw-page-title-main">Cardiothoracic surgery</span> Medical specialty involved in surgical treatment of organs inside the thorax

Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart, lungs, and other pleural or mediastinal structures.

<span class="mw-page-title-main">Fontan procedure</span> Surgical procedure used in children with univentricular hearts

The Fontan procedure or Fontan–Kreutzer procedure is a palliative surgical procedure used in children with univentricular hearts. It involves diverting the venous blood from the inferior vena cava (IVC) and superior vena cava (SVC) to the pulmonary arteries. The procedure varies for differing congenital heart pathologies. For example in tricuspid atresia, the procedure can be done where the blood does not pass through the morphologic right ventricle; i.e., the systemic and pulmonary circulations are placed in series with the functional single ventricle. Whereas in hypoplastic left heart syndrome, the heart is more reliant on the more functional right ventricle to provide blood flow to the systemic circulation. The procedure was initially performed in 1968 by Francis Fontan and Eugene Baudet from Bordeaux, France, published in 1971, simultaneously described in 1971 by Guillermo Kreutzer from Buenos Aires, Argentina, and finally published in 1973.

<span class="mw-page-title-main">Chest tube</span> Type of surgical drain

A chest tube is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substances such as air (pneumothorax), excess fluid, blood (hemothorax), chyle (chylothorax) or pus (empyema) from the intrathoracic space. An intrapleural chest tube is also known as a Bülau drain or an intercostal catheter (ICC), and can either be a thin, flexible silicone tube, or a larger, semi-rigid, fenestrated plastic tube, which often involves a flutter valve or underwater seal.

<span class="mw-page-title-main">Thoracotomy</span> Surgical procedure

A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. A thoracotomy is the first step in thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.

Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:

<span class="mw-page-title-main">Pulmonary sequestration</span> Medical condition

A pulmonary sequestration is a medical condition wherein a piece of tissue that ultimately develops into lung tissue is not attached to the pulmonary arterial blood supply, as is the case in normally developing lung. This sequestered tissue is therefore not connected to the normal bronchial airway architecture, and fails to function in, and contribute to, respiration of the organism.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Lobectomy</span> Surgical excision of a lobe

Lobectomy means surgical excision of a lobe. This may refer to a lobe of the lung, a lobe of the thyroid (hemithyroidectomy), a lobe of the brain, or a lobe of the liver (hepatectomy).

Lobectomy of the lung is a surgical operation where a lobe of the lung is removed. It is done to remove a portion of diseased lung, such as early stage lung cancer.

<span class="mw-page-title-main">Pulmonary laceration</span> Medical condition

A pulmonary laceration is a chest injury in which lung tissue is torn or cut. An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, while pulmonary contusion does not. Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.

<span class="mw-page-title-main">Video-assisted thoracoscopic surgery</span>

Video-assisted thoracoscopic surgery (VATS) is a type of minimally invasive thoracic surgery performed using a small video camera mounted to a fiberoptic thoracoscope, with or without angulated visualization, which allows the surgeon to see inside the chest by viewing the video images relayed onto a television screen, and perform procedures using elongated surgical instruments. The camera and instruments are inserted into the patient's chest cavity through small incisions in the chest wall, usually via specially designed guiding tubes known as "ports".

Pulmonary rehabilitation, also known as respiratory rehabilitation, is an important part of the management and health maintenance of people with chronic respiratory disease who remain symptomatic or continue to have decreased function despite standard medical treatment. It is a broad therapeutic concept. It is defined by the American Thoracic Society and the European Respiratory Society as an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. In general, pulmonary rehabilitation refers to a series of services that are administered to patients of respiratory disease and their families, typically to attempt to improve the quality of life for the patient. Pulmonary rehabilitation may be carried out in a variety of settings, depending on the patient's needs, and may or may not include pharmacologic intervention.

Video-assisted thoracoscopic surgery (VATS) lobectomy is an approach to lung cancer surgery.

A bronchopleural fistula (BPF) is a fistula between the pleural space and the lung. It can develop following pneumonectomy, lung ablation, post-traumatically, or with certain types of infection. It may also develop when large airways are in communication with the pleural space following a large pneumothorax or other loss of pleural negative pressure, especially during positive pressure mechanical ventilation. On imaging, the diagnosis is suspected indirectly on radiograph. Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Infectious causes include tuberculosis, Actinomyces israelii, Nocardia, and Blastomyces dermatitidis. Malignancy and trauma can also result in the abnormal communication.

Raja Michael Flores is an American thoracic surgeon and former candidate for mayor of New York City, currently Chief of the Division of Thoracic Surgery at Mount Sinai Hospital and Ames Professor of Cardiothoracic Surgery at the Icahn School of Medicine at Mount Sinai, both in New York City. On March 20, 2021, Dr. Flores announced his campaign for mayor of NYC.


The Revised Cardiac Risk Index (RCRI) is a tool used to estimate a patient's risk of perioperative cardiac complications. The RCRI and similar clinical prediction tools are derived by looking for an association between preoperative variables (e.g., patient's age, type of surgery, comorbid diagnoses, or laboratory data) and the risk for cardiac complications in a cohort of surgical patients (the "derivation cohort"). Variables that have independent predictive value in a logistic regression analysis are incorporated into the risk index. Ideally, the accuracy and validity of the risk index is then tested in a separate cohort (the "validation cohort"). In 1977 Goldman, et al., developed the first cardiac risk index, which included nine variables associated with an increased risk of perioperative cardiac complications. This became known as the Original Cardiac Risk Index (or alternatively the Goldman Index). In 1999, Lee et al. published a cardiac risk index derived from 2893 patients and validated in 1422 patients aged ≥ 50 undergoing major noncardiac surgery, which became known as the Revised Cardiac Risk Index (RCRI). Lee identified six independent variables that predicted an increased risk for cardiac complications. A patient's risk for perioperative cardiac complications increased with number of variables that were present.

<span class="mw-page-title-main">Eloesser flap</span> Surgical procedure

The Eloesser flap is a surgical procedure developed by Dr. Leo Eloesser in 1935 at the San Francisco General Hospital. It was originally intended to aid with drainage of tuberculous empyemas, since at the time there were no effective medications to treat tuberculosis. The procedure was used extensively until the development of effective chemotherapy for tuberculosis in the late 1940s and early 1950s. It is still used occasionally for chronic empyemas.

<span class="mw-page-title-main">Hazim J. Safi</span> Physician

Hazim J. Safi, MD, FACS, is a physician and surgeon who is well known for his research in the surgical treatment of aortic disease. Safi and his colleagues at Baylor College of Medicine were the first to identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. Safi now serves as professor of cardiothoracic surgery, and founding chair at McGovern Medical School at The University of Texas Health Science Center in Houston, TX.

<span class="mw-page-title-main">Lung surgery</span>

Lung surgery is a type of thoracic surgery involving the repair or removal of lung tissue, and can be used to treat a variety of conditions ranging from lung cancer to pulmonary hypertension. Common operations include anatomic and nonanatomic resections, pleurodesis and lung transplants. Though records of lung surgery date back to the Classical Age, new techniques such as VATS continue to be developed.

References

  1. Opitz I, Weder W (June 2017). "A nuanced view of extrapleural pneumonectomy for malignant pleural mesothelioma". Annals of Translational Medicine. 5 (11): 237. doi: 10.21037/atm.2017.03.88 . PMC   5497104 . PMID   28706905.
  2. "Pneumonectomy". www.hopkinsmedicine.org. 2019-11-19. Retrieved 2022-11-09.
  3. Brunelli, Alessandro; Kim, Anthony W.; Berger, Kenneth I.; Addrizzo-Harris, Doreen J. (May 2013). "Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines". Chest. 143 (5 Suppl): e166S–e190S. doi: 10.1378/chest.12-2395 . PMID   23649437.
  4. Colice, Gene L.; Shafazand, Shirin; Griffin, John P.; Keenan, Robert; Bolliger, Chris T.; American College of Chest Physicians (September 2007). "Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition)". Chest. 132 (3 Suppl): 161S–77S. doi:10.1378/chest.07-1359. PMID   17873167.
  5. Fleisher, Lee A.; Beckman, Joshua A.; Brown, Kenneth A.; Calkins, Hugh; Chaikof, Elliot L.; Chaikof, Elliott; Fleischmann, Kirsten E.; Freeman, William K.; Froehlich, James B.; Kasper, Edward K.; Kersten, Judy R.; Riegel, Barbara; Robb, John F.; Smith, Sidney C.; Jacobs, Alice K. (2007-10-23). "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery". Journal of the American College of Cardiology. 50 (17): 1707–1732. doi: 10.1016/j.jacc.2007.09.001 . PMID   17950159. S2CID   37626938.
  6. Bancewicz, J (May 2002). "Mastery of surgery. 4th ed. R. J. Baker and J. E. Fischer (eds) 285 × 215 mm. Pp. 2448. Illustrated. 2001. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins. US$359·00". British Journal of Surgery. 89 (5): 630. doi:10.1046/j.1365-2168.2002.02093_2.x. ISSN   0007-1323.
  7. Xu, Hao; Zhang, Linyou (March 2019). "The Feasibility of Thoracoscopic Left Pneumonectomy". The Thoracic and Cardiovascular Surgeon. 67 (2): 137–141. doi:10.1055/s-0038-1642618. ISSN   1439-1902. PMID   29715708. S2CID   22615029.
  8. Patton, Byron D.; Zarif, Daniel; Bahroloomi, Donna M.; Sarmiento, Iam C.; Lee, Paul C.; Lazzaro, Richard S. (2021). "Robotic Pneumonectomy for Lung Cancer: Perioperative Outcomes and Factors Leading to Conversion to Thoracotomy". Innovations (Philadelphia, Pa.). 16 (2): 136–141. doi:10.1177/1556984520978227. ISSN   1559-0879. PMID   33448886. S2CID   231612473.
  9. Beshara, Michael; Bora, Vaibhav (2022). "Pneumonectomy". StatPearls. PMID   32310429. NBK555969.
  10. Brunelli, A.; Charloux, A.; Bolliger, C. T.; Rocco, G.; Sculier, J-P.; Varela, G.; Licker, M.; Ferguson, M. K.; Faivre-Finn, C.; Huber, R. M.; Clini, E. M.; Win, T.; De Ruysscher, D.; Goldman, L.; on behalf of the European Respiratory Society and European Society of Thoracic Surgeons joint task force on fitness for radical therapy (2009-07-01). "ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)". European Respiratory Journal. 34 (1): 17–41. doi:10.1183/09031936.00184308. ISSN   0903-1936. PMID   19567600. S2CID   14118484.
  11. Ali, Kamran (2023-01-03). "Can you live with one Lung?". Dr Kamran Ali. Retrieved 2023-01-23.
  12. Keshava, Hari B.; Boffa, Daniel J. (November 2015). "Cardiovascular Complications Following Thoracic Surgery". Thoracic Surgery Clinics. 25 (4): 371–392. doi:10.1016/j.thorsurg.2015.07.001. ISSN   1558-5069. PMID   26515939.
  13. Yano, Tokujiro; Kawashima, Osamu; Takeo, Sadanori; Adachi, Hirofumi; Tagawa, Tsutomu; Fukuyama, Seiichi; Shimokawa, Mototsugu; National Hospital Organization Network Collaborative Research-Thoracic Oncology Group (2017). "A Prospective Observational Study of Pulmonary Resection for Non-small Cell Lung Cancer in Patients Older Than 75 Years". Seminars in Thoracic and Cardiovascular Surgery. 29 (4): 540–547. doi:10.1053/j.semtcvs.2017.05.004. ISSN   1532-9488. PMID   29698655.
  14. Darling, Gail E.; Abdurahman, Adel; Yi, Qi-Long; Johnston, Michael; Waddell, Thomas K.; Pierre, Andrew; Keshavjee, Shaf; Ginsberg, Robert (February 2005). "Risk of a right pneumonectomy: role of bronchopleural fistula". The Annals of Thoracic Surgery. 79 (2): 433–437. doi: 10.1016/j.athoracsur.2004.07.009 . ISSN   1552-6259. PMID   15680809.
  15. Cook, D.; Powell, E.; Gao-Smith, F. (2009). "Post-pneumonectomy Pulmonary Edema". In Vincent, Jean-Louis (ed.). Intensive Care Medicine. New York, NY: Springer. pp. 473–482. doi:10.1007/978-0-387-92278-2_45. ISBN   978-0-387-92278-2.
  16. Chambers, N.; Walton, S.; Pearce, A. (June 2005). "Cardiac herniation following pneumonectomy--an old complication revisited". Anaesthesia and Intensive Care. 33 (3): 403–409. doi: 10.1177/0310057X0503300319 . ISSN   0310-057X. PMID   15973927. S2CID   31646200.
  17. Naef, A (1993). "Hugh Morriston Davies: First Dissection Lobectomy in 1912". Annals of Thoracic Surgery. 56 (4): 988–989. doi: 10.1016/0003-4975(93)90377-t . PMID   8215687.
  18. Wilkins, Earle W. (2013). "Invited Commentary". In Rosenthal, Ronnie Ann; Zenilman, Michael E.; Katlic, Mark R. (eds.). Principles and Practice of Geriatric Surgery. Springer Science & Business Media. pp. 393–395. ISBN   978-1-4757-3432-4.
  19. Horn, L; Johnson DH (July 2008). "Evarts A. Graham and the first pneumonectomy for lung cancer". Journal of Clinical Oncology. 26 (19): 3268–3275. doi:10.1200/JCO.2008.16.8260. PMID   18591561.
  20. Churchill, E; Belsey R (1939). "Segmental Pneumonectomy in Bronchiectasis: The Lingula Segment of the Left Upper Lobe". Annals of Surgery. 109 (4): 481–499. doi:10.1097/00000658-193904000-00001. PMC   1391296 . PMID   17857340.