Complications of general thoracic surgery

Current Problems in

Sur Volume 37

ry

Number 11 November 2000

Complications of General Thoracic Surgery A. Thomas Pezzella, MD Associate Professor of Surgery Division of Cardiothoracic Surgery Department of Surgery University of Massachusetts Medical Center Worcester, Massachusetts

Samuel A. Adebonojo, MD Professor of Surgery Wright State University School of Medicine Chief, Surgical Service Department of Veterans Affairs Medical Center Dayton, Ohio

Sandra G. Hooker, MD, PhD Senior Surgical Resident Department of Surgery Wright State University School of Medicine Dayton, Ohio

Oluwatope A. Mabogunie, MD Professor of Surgery Wright State University School of Medicine Assistant Chief, Surgical Service Department of Veterans Affairs Medical Center Dayton, Ohio

A. Alan Conlan, MD Professor of Surgery Division of Cardiothoracic Surgery Department of Surgery University of Massachusetts Medical Center Worcester, Massachusetts

~v~[ Mosby

Current Problems in

Sur Volume 37

ry ~ Number 11

November 2000

Complications of General Thoracic Surgery Foreword

738

In Brief

739

Biographic Information Introduction

741 742

Philosophical Perspective Overview of Complications

742

Incidence of Complications Preoperative Evaluation

751

History and Physical Examination Risk Factors Cardiac Risk Right Heart Function Dysrhythmias Pulmonary Function Infection Prophylaxis Pulmonary Thromboembolism Prophylaxis Renal Dysfunction Human Immunodeficiency Virus Infection Nutritional Status Preoperative Immunosuppressive Therapy Neurologic Problems Blood Transfusions Liver Disease Other Preoperative Considerations Curr Probl Surg, November 2000

745

752 752 755 756 758 760 763 771 772 773 773 774 774 775 775 776 777 735

Operative Phase Median Stemotomy Muscle-sparing Thoracotomy Thoracoplasty Anesthesia Monitoring

Postoperative Phase General Complications Fever Wound Healing Gastrointestinal Complications

Complicationsof General ThoracicSurgery Bleeding/Hemothorax Pain and Pain Control Mediastinal Shifts Atelectasis Respiratory Failure Pulmonary Edema Adult Respiratory Distress Syndrome Long-term Ventilation Multisystem Organ Failure Postresection Pulmonary Edema Aspiration Pneumonia Pneumonia Empyema Subcutaneous Emphysema Air/Space Complications Bronchial Stump Leak Bronchopleural Fistula Esophagopleural Fistula Subarachnoid Pleural Fistula Paraplegia Lung Torsion and Gangrene Chylothorax Tumor Embolus

ComplicationsSpecificto Pneumanectomy Postpneumonectomy Empyema Postpneumonectomy Bronchopleural Fistula Postpneumonectomy Syndrome Cardiac Herniation Acute Right-to-left Shunt

736

778 779 779 780 780 782 785 788 788 788 790 791 791 793 795 795 796 798 798 799 8OO 801 8O2 8O2 8O4 8O5 8O6 810 811 813 813 814 815 815 817 818 818 819 82O 82O 821

Curr Probl Surg, November 2000

Specific Procedure- or Disease-associated Complications Bronchoscopy Esophagoscopy, Esophageal Dilatation, and Esophageal Stents Scalene Lymph Node Biopsy Thoracentesis Tracheostomy Tracheal Innominate Fistula Tracheal Esophageal Fistula Chest Tube Thoracostomy Mediastinoscopy Anterior Mediastinoscopy (Chamberlain Procedure) Video-assisted Thoracoscopic Surgery Laser Surgery Bronchoplastic Procedures Surgery of the Diaphragm Thoracic Outlet Syndrome Surgical Access to the Thoracic Spine Tracheal Surgery Mediastinal Operations Advanced Techniques Lung Transplantation Lung Volume Reduction Surgery for Emphysema Pediatric Thoracic Surgical Procedures Esophageal Procedures

References

Curr Probl Surg, November 2000

822 822 822 823 823 823 825 825 825 826 826 826 829 829 830 831 831 831 832 833 833 834 834 835 844

737

Foreword As the population of industrialized society ages and as the ravages of exposure to environmental and other carcinogens become manifest, there will be a substantial increase in the incidence of pulmonary and esophageal disorders. The specialty of thoracic surgery was formerly incorporated within cardiothoracic surgery; however, as clinical medicine has progressed and medical technology has become more sophisticated, thoracic surgery is coming to be recognized as a defined clinical discipline. In this issue of Current Problems in Surgery, Dr Thomas Pezzella and his associates from the Massachusetts Medical Center and the Wright School of Medicine review the topic of complications of thoracic surgery. This monograph is well written and heavily illustrated and will prove to be a highly valuable resource to house officers and practicing clinicians in all branches of medicine.

Samuel A. Wells, Jr, MD Editor in Chief

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Curr Probl Surg, November 2000

gg.

In Brief "As a surgeon, his primary objective was not only to make the operation safe for the patient but to make the patient safe for the operation." Oliver H. Bears, MD, commenting on Dr Donald C. Balfour (Surgery 2000;127:227) Despite all the advances in thoracic surgery, complications still occur. Morbidity and mortality rates after simple and complex thoracic procedures or operations remain a significant concern for patients, families, and the health care community. Twenty-five years ago, the following complications after pulmonary resection were highlighted: pulmonary insufficiency, arrhythmias, intrapleural spaces, bronchoalveolar fistula (prolonged air leaks), postpneumonectomy empyema, bronchopleural fistula, cardiac herniation, pulmonary lobar gangrene, esophagopleural fistula, pulmonary embolism, and tumor embolism. This was a bold attempt to organize and collate the available information, both historical and contemporary. Since that time the major thoracic surgery texts have organized chapters to discuss general complications and to focus on specific, procedural complications. More than 40 million operations are performed annually in the United States, and more than 100,000 thoracotomies are performed yearly. The patient age, comorbidity, risk factors, and complexity of the operative procedures continue to rise. Nonetheless, the safety and success of the operations have also risen. Needless to say, the financial costs have risen as well. Despite all efforts, preoperatively and perioperatively, complications will occur (planned, unplanned; predicted, unpredicted; recognized, unrecognized; anticipated, unanticipated). We have made a focused attempt to highlight present-day concepts that regard approaches to complications in thoracic surgery. The preoperative assessment is the single most important area. Increasing age, obesity, chronic lung disease, cardiac disease, smoking history, and debilitation all pose added risks for general anesthesia and thoracic operations. An organized logical approach to these patients will identify those whose condition is unsuitable for surgery and better prepare those high-risk patients whose condition is suitable. Delayed operations or less invasive surgery (ie, wedge resection vs lobectomy) is better designed, with more thoughtful and thorough evaluation. Sophisticated anesthetic techniques are safer but potentially harmful. An experienced anesthesia team is necessary. Technical expertise (especially with epidural catheter placement and double-lumen endotracheal Curt Probl Surg, November 2000

739

tube management) is necessary. Sophisticated monitoring requires both subjective and objective interpretation. The operating surgeon and staff must organize and discuss the strategy of the operation. The positioning of the patient, adequate exposure, knowledge of the specific operative techniques, and availability of the instrumentation and services needed (eg, frozen section pathologic examinations) are all necessary for a smooth, efficient, and successful operation. The transition from the operating room to the recovery room, intensive care unit, nursing ward, rehabilitation center, and home requires varying degrees of attention and expertise. The first 24 hours after operation are crucial for all major thoracic procedures, because the major complications of bleeding and respiratory insufficiency usually occur during that period. Experienced staff, appropriate monitoring, and diagnostic studies are crucial. More importantly, anticipation of the potential major complications is necessary. All thoracic operations, whether major or minor, have accepted, documented complications. Most retrospective series report them openly and honestly. However, specific details about the treatment are sparse. Recently, a considerable amount of attention has focused on the recognition and treatment of specific complications. We provide an overview of the complications after noncardiac thoracic surgery. The text is by no means exhaustive. However, adequate references are provided for the reader to pursue topics of interest in greater detail. The emphasis is on the incidence, prevention, recognition, and treatment of the various complications. Operations that involve the pericardium, heart, thoracic aorta, and great vessels are not discussed. The preoperative phase stresses and focuses on the subsystem approach, whereas the postoperative phase focuses on complications common to most procedures, a specific procedure or operation, or a particular associated disease entity.

740

Curr Probl Surg, November 2000

A. Thomas Pezzella, MD, has been Associate Professor of Surgery at the ~P University of Massachusetts Medical Center in Worcester, Massachusetts, since 1986. A graduate of Holy Cross College and St Louis University School of Medicine, he obtained his general and cardiothoracic surgery training at the University of Kentucky. A Colonel in the United States Army Reserve, Dr Pezzella has a special interest in both civilian and military trauma. He has helped in establishing cardiac surgery in several developing countries. ~

~Samuel A. Adebonojo, MD, is 9 Professor of Surgery at the Wright State University School of Medicine and Chief of the Surgical Service at the Department of Veterans Affairs Medical Center in Dayton, Ohio. A graduate of the University of Pennsylvania School of Medicine, Dr Adebonojo received his general surgical training at Bryn Mawr Hospital and his cardiothoracic surgical training at the Hahnemann Medical Center, Philadelphia. He served as Chief of General Thoracic Surgery at Walter Reed Army Medical Center from 1991 to 1996. His major interests include suppurative lung disease, pulmonary tuberculosis, and thoracic oncology. ~

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Sandra G. Hooker, MD, PhD, is senior surgical resident at the Wright State University School of Medicine. She obtained her PhD in biochemistry at East Tennessee State University and her MD from East Tennessee State University JH Quillen College of Medicine. Dr Hooker is a Captain in the United States Air Force. She is presently the representative of resident education of the American College of Surgeons. ~'~f~--"~_ A/I~ J~-~~ D/ ~

Oluwatope A. Mabogunje, MD, is Professor of Surgery at the Wright State University " School of Medicine and staff surgeon at the ' Department of Veterans Affairs Medical Center in Dayton, Ohio. A graduate of Harvard Medical School, Dr Mabogunje obtained his general surgical training at New York UniversityBellevue Hospital, an oncology fellowship at Memorial-Sloan Kettering Hospital, and an additional fellowship at Children's Hospital in Los Angeles. (~)

A. Alan Conlan, MD, is Professor of Cardiac and Thoracic Surgery at the University of Massachusetts and Chief of Thoracic Surgery at University of Massachusetts Memorial Healthcare in Worcester. A graduate of the National University of Ireland (Cork), he is a Fellow of the Royal College of Surgeons of England and Canada. His primary clinical research interests include massive hemoptysis, inflammatory lung disease, video-assisted thoracic surgery, airway access procedures, and surgery for emphysema. ~. ( ~

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Curr Probl Surg, November2000

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741

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Complications of General Thoracic Surgery he 20th century witnessed significant advances in thoracic surgery as well as the recognition and management of complications (Table 1). 1-9 The "macro" or remote history described by Moore x~ encompasses 5000 years of medical history, whereas the "micro" history focuses on recent events. Airway control with endotracheal intubation and positive pressure ventilation to support the open chest cavity was a major advance. 11 The FellO'Dwyer apparatus of 1899 allowed endotracheal intubation with bellows ventilation (Fig 1). The Meltzer-Auer insuffiation technique of 1909 allowed continuous flow of gasses through small intramural tubes. This supplanted the Sauerbruch negative-pressure chamber of 1903 (Fig 2). In recent years improved technology has made video-assisted thoracoscopic surgery (VATS) a common operation, with increasing applications. This is a remarkable example of how a technique developed by Jacobaeus earlier in the century remained dormant until new technology popularized it. Better pain control has markedly reduced the early morbidity after operation, particularly atelectasis, by allowing earlier ambulation, improved pulmonary physiotherapy, and shortened hospital stay. All of these advances have helped to increase the number and scope of thoracic operations to offer more complex procedures for older patients with more comorbid conditions. Despite all of these advances, however, the underlying foundation for the growth and development of thoracic surgery, particularly in the United States, was the establishment and organization of the thoracic surgery residency programs. Sloan and colleagues 12 summarized the history of the thoracic surgery residency program at the University of Michigan, highlighting the leadership and vision of John Alexander.

Philosophical Perspective Physicians (still a better term than providers) are involved in the medical care of patients (again a better term than client or customer). This care involves both preventive (less expensive) and curative (more expensive) aspects. For surgeons this endeavor includes the simple or complex task of problem solving (Fig 3). The objective tools needed or required include a knowledge base and acquired technical skills. The knowledge base is 742

CurrProbl Surg, November2000

Fig 1. Early device (FelI-O'Dwyerapparatus) for resuscitation.(From Wastell C, Nyhus LM, Donahue PE, editors. Surgery of esophagus,stomach and small intestine.5th ed. Boston:LittleBrown; 1995. p 6. With permission.) TABLE 1. Significant advances in thoracic surgery during the 20th century

Aseptic surgery (Halsted) Intratracheal anesthesia (Meltzer SJ, Auer J) Open pneumothorax (Graham EA, Bell RD) Antibiotics (Fleming) (decrease of resection for tuberculosis from 45% to less than 5%) Blood banks (increase since World War II) Anesthetic agents/techniques Thoracic residency- 1928 (Alexander) Surgical experience (World War II) American Board of Thoracic Surgery (1948) Advanced techniques (pneumonectomy, lung transplantation, VATS, robotic surgery)

enhanced today by the ready availability of knowledge and information on the Internet (eg, http://www.ctsnet.org) and the many society meetings, specific courses, and workshops. Local, national, and international consultation (both specific and general) is readily available, given the ready Curr Probl Surg, November 2000

743

Fig 2. Negative-pressure room constructed for clinical use by Sauerbruch and Von Mikulicz at the University Hospital, Breslau. (From Wastell C, Nyhus LM, Donahue PE, editors. Surgery of esophagus, stomach and small intestine. 5th ed. Boston: Little Brown; 1995. p Z With permission.)

accesses to telephone, facsimile, electronic mail, and telemedicine by way of satellite transmission. The subjective tools include judgment and experience. This is not a static equation, but rather a dynamic one that evolves over a surgical career. The solution to a particular problem many times may not involve an operation or procedure (commission). Oftentimes nonoperative or delayed treatment (omission) is mandated or warranted. If the problem cannot be solved, at least it can be managed (ie, controlled, delayed, or temporized). When a technical, operative approach is selected (be it major or minor), certain criteria should be considered (Table 2). The indications and contraindications should be known, documented, and discussed openly with all parties involved (ie, patients, family, referring doctor/consultants). The timing of operation is crucial (ie, emergency, urgent, elective, delayed, or expectant). There are a variety of approaches, all of which should be evaluated and discussed. Precise knowledge and experience with the specific procedure are crucial. The risks and complications (ie, expected, unexpected, predicted, and unpredicted) are the subject of this monograph. These complications and risks should be discussed openly with the patient and appropriate parties both before and after operation. 744

Curr Probl Surg, November 2000

Knowledge Objective Technique

Problem

--)

Solution/Management

Judgement )

Subjective

Experience Fig 3. Problem-solvingequation.

Overview of Complications An appreciation of the incidence and causes of postoperative complications is essential. A constructive, positive attitude is necessary to better appreciate the problem and to help to prevent its future reoccurrence. The operating surgeon and team should strive to be the benefactors and not the victims of the experience. Denial that a complication occurred or exists only compounds the issue and makes it more difficult to identify, analyze, understand, and resolve the problem. The surgeon should admit mistakes but not necessarily advertise them. The heritage of the surgical morbidity/mortality conference should be a continued model for openness and honesty. Despite advances in surgical care, complications still occur. As caretakers for our patients, our primary goal is to resolve their medical problems. Our knowledge and experience (with specific emphasis on prevention, predisposing factors, and unpredicted complications) should be the major Curr Probl Surg, November 2000

745

TABLE 2. Preoperativeconsiderations Indications: relative/absolute Contraindications: relative/absolute Timing Techniques available/options Techniques used Complications Preoperative Operative Early postoperative Late postoperative Chronic/residua

focus. When complications occur, a precise approach based on an understanding of the relevant anatomic and pathophysiologic features will minimize, ameliorate, and hopefully resolve the complication or at least manage it. A complication can be defined as a deviation or departure from the expected outcome of a surgical procedure. Dorland's 13 defines a complication as a disease concurrent with another disease or the concurrence of 2 or more diseases in the same patient. Morbidity is a diseased condition or state, It can be further divided into expected or unexpected, predicted or unpredicted, and avoidable or unavoidable. Accumulated operative experience has afforded data regarding the morbidity and mortality rates for most thoracic surgical procedures. These objective data are documented and available. Unfortunately, complications can be accepted or unaccepted, or worse, not recognized or even neglected. In contrast, an iatrogenic disorder occurs when the adverse effects of a therapeutic or diagnostic endeavor cause a pathologic state that is independent of the condition for which the endeavor was attempted. Operative risk is the sum total of the abnormalities of all organ systems and their interaction. Recent endeavors are helping to better understand and predict surgical risk and outcomes. For example, a national database for pulmonary surgery is in progress. As Edwards 14 states, "The outcome models may also serve as powerful quality assurance/quality improvement tools." Clinical pathways are emerging to decrease the length of stay and cost while maintaining quality. Wright and colleagues 15 from the Massachusetts General Hospital compared 147 patients who underwent lobectomy in 1995 with 130 patients who underwent lobectomy in 1996. The clinical pathway reduced the associated costs and reduced the hospital length of stay from 10.6 to 7.5 days (target, 7 days). Inadequate pain control (28% of patients) and prolonged air leak (19% of patients) were the most common reasons for prolonged hospital stay. Zehr and col746

Curr Probl Surg, November 2000

TABLE 3. Observed 30-day mortality and morbidity rates by primary operative procedure Lobectomy (n = 2949) Variable

30day deaths 30day morbidity (1 or more complications) Respiratory complications Pneumonia Unplanned reintubation Failure to wean, more than 48 h Pulmonary embolism Cardiac complications Pulmonary edema Cardiac arrest with CPR Myocardial infarction Wound complications Superficial wound infection Deep wound infection Wound dehiscence CNS complications Coma more than 24 h Stroke with neurologic deficit Cerebral vascular accident Urinary tract complications Urinary tract infection Progressive renal insufficiency Acute renal failure Other complications Bleeding that requires transfusion >4 units Systemic sepsis Ileus/bowel obstruction Deep venous thrombosis Graft/prosthesis failure

Pneumonectomy (n = 567)

No.

%

No.

%

119 703

4.0 23.8

65 146

11.5 25.7

344 234 194 20

11.7 7.9 6.6 0.7

55 60 53 8

9.7 10.6 9.3 1.4

91 76 24

3.1 2.6 0.8

39 39 5

6.9 6.9 0.9

41 35 8

1.4 1.2 0.3

9 6 5

1.6 1.1 0.9

19 17 14

0.6 0.6 0.5

6 6 5

1.1 1.1 0.9

77 31 20

2.6 1.0 0.7

9 10 8

1.6 1.8 1.4

85 80 49 20 1

2.9 2.7 1.7 0.7 0.0

17 16 6 4 2

3.0 2.8 1.1 0.4 0.4

CPR,Cardiopulmonary resuscitation; CNS,central nervous system. From Harpole DH, DeCamp MM, Daley J, et al. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 1999;117:969-79. With permission.

leagues 16 from The Johns Hopkins Hospital compared, retrospectively, groups of patients who underwent esophagectomy or anatomic lung resection from 1991 to 1994 and 1994 to 1997. The length of stay and costs were reduced, and continued quality outcomes were maintained. The mortality rates were unchanged. The readmission rate, normally reported at 3% to 5%, was reduced. Severity scoring systems that are specific for thoracic surgery are being developed. Brtmelli and colleagues 17 applied a physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM) to a group of 250 patients undergoing lung resection. The logistic regression analysis was useful in predicting postoperative complications, with no difCurr Probl Surg, November 2000

747

TABLE 4. Guidelines for evidence-based medicine Level I

II III IV V

Guideline

Large, randomized trials with clear cut results; low risk of false-positive (c~) error or false-negative (1~)error Small, randomized trials with uncertain results; moderate-to-high risk of false-positive (a) error and/or false-negative (1~)error Nonrandomized, contemporaneous controls Nonrandomized, historic controls and expert opinion Case series, uncontrolled studies, and expert opinion

From Hollenberg SM. Preoperative cardiac risk assessment. Chest 1999;115:51S-7S. With permission.

ference between predicted and observed morbidity. Harpole and colleagues18 from the National Veterans Affairs Surgical Quality Improvement Program analyzed prognostic models for complications after major pulmonary resection. Thirty-day mortality rates were 4% for lobectomy (119 of 2949 patients) and 11.5% for pneumonectomy (65 of 567 patients). Thirty-day morbidity rates were 23.8% for lobectomy and 25.7% for pneumonectomy; cardiorespiratory complications were the predominant morbid events (Table 3). Independent risk factors included age, chronic obstructive lung disease, weight loss of more than 10% in the 6 months before operation, transfusion of more than 4 units of blood, hemiplegia, smoking, dyspnea, operative time, and intraoperative blood transfusion. These data become meaningful for the preparation and planning of the operation and for improved counseling of the patient and involved parties. Most hospitals have established risk management, quality assurance, or performance improvement programs that gather, analyze, and discuss surgical morbidity and mortality rates. In fact, some states require reporting of unusual complications (ie, retained foreign bodies) to the state board for further evaluation. Evidence-based medicine is the newest approach to assess the rationale for treatment strategies. This approach defines standard of care as a generally accepted principle for patient management, reflecting a high degree of clinical certainty. This implies "...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients .... ,,19 This combines the best aspects of clinical epidemiologic factors and critical appraisal to solve individual clinical problems. The integrated approach of combining clinical experience and judgment with information and evidence from multiple sources and methods will lead to a balanced, logical, and coherent solution to these clinical problems, especially complications if they arise (Table 4). Medical liability always looms in the background when complications 748

Curr Probl Surg, November 2000

TABLE 5. Suggestionsfor avoiding malpractice lawsuits2~ Usten patiently. Respect the patient's dignity and privacy. Return phone calls promptly. Be polite. Be on time. Have the patient (family) join in decision making. Keep patients' expectations in line with reality (prepare them for all eventualities). Be honest about a misadventure (complication); never cover up or try to blame others. Avoid high-risk situations, such as cases you are not fully equipped to handle or cases in which there is a personality clash with a patient or family. Treat the patient as you would like to be treated.

TABLE 6. Staging of death

Stage

Explanation Preoperative (expected, unexpected; intervening problem culminating in death) Operative (intraoperative [predicted/unpredicted]) Postoperative (immediately after operation) Perioperative After discharge (within 30 days) Procedure related Procedure unrelated (eg, auto accident) Late death (procedure related) Late death unrelated (eg, trauma, accident, comorbidity, disease-related death)

are discussed. Wells 2~ summarizes this subject. Negligence, culpability, and incompetence are terms that can be used to describe an untoward outcome. In a recent year, cardiothoracic surgeons accounted for 3% of malpractice claims and 2.2% of all indemnity payments. Approximately 70% of all cases were withdrawn, abandoned, or dismissed. Another 23% of cases were settled without a verdict, and 7% of cases were settled with a verdict. Only 19% of the malpractice claims related to general thoracic surgery compared with 64% claims for cardiovascular surgery. The most common alleged claim was "improper performance of a procedure" (35%). Failure to monitor care occurred in 7% of claims, and failure to diagnose complications occurred in 4% of claims. The avoidance of malpractice lawsuits may well be enhanced by following specific suggestions (Table 5). Death occurs at various stages (Table 6). It is the operative and early postoperative phase that involves the surgeon uniquely because the surgeon is identified as being the ultimate coordinator of care ("captain of the ship" theory). A relationship with the family is crucial, especially when issues related to living wills and autopsy are concerned. The involvement Curt Probl Surg, November 2000

749

TABLE 7. Causesof postoperative complications Predictive risk factors (particulady age, respiratory function, associated comorbidity, urgency of operation, and underlying pathologic condition) Inadequate or insufficient evaluation and preparation of the patient Improper timing or selection of the operative technique (ie, judgment or strategy error) Intraoperative technical complications (patient factor, surgeon factor) Postoperative complications (early, delayed, chronic)

of hospital resources (particularly patient representatives), risk management, chaplains, and hospital ethicists is crucial. These individuals can be invaluable in helping the family cope with the issues and smoothing over or resolving any problems or conflicts. The major goal is to provide both the objective data and the perception that the patient is receiving competent, ethical, and compassionate care. Complications of general or noncardiac thoracic surgery result from several causes (Table 7). Passaro and Organ 2a report Ernest A. Codman, in the early 1900s, classifying complications as errors caused by lack of diagnostic skill, surgical judgment, technical knowledge or skill, or lack of postoperative care. Complications can be further classified as general or specific to a particular operative procedure. A further breakdown of complications can be related to the disease process itself. As an example, operative procedures for trauma and inflammatory disorders usually carry a high complication rate. In addition, a precise definition of death and morbidity is necessary. The Society of Thoracic Surgery has defined an operative death as any death that occurs during the hospitalization in which the operation was performed. 22 All deaths after hospitalization but within 30 days of the procedure are also counted, unless the cause of death is clearly unrelated to the operation (eg, an automobile or airplane crash). Operative morbidity includes complications that occur during the hospitalization or within 30 days of the operation; late morbidity occurs after 30 days. Persistent operative complications are usually manifested at 1 month. Technical failures are obvious at 3 months, and design failures are obvious at 6 to 12 months (ie, recurrent hiatal hernia with reflux). Most retrospective reports of operative experiences document morbidity and mortality rates. There is bias in reporting favorable results, however. Many states publish raw unadjusted mortality rates for open-heart surgery (eg, New York, Pennsylvania) that are specific for both centers and individual surgeons. This is still unavailable for general thoracic surgery. To satisfy medicolegal requirements, it is essential to document in the operative report the indications for the operative procedure, the operative 750

Curt Probl Surg, November 2000

TABLE 8. Surgical complication grading system Grade I Ila lib III ~/

Explanation Non-life-threatening; does not require the use of drugs; treated only with bedside interventions; does not lengthen hospital stay longer than twice the median Potentially life-threatening; requires only drug therapy, total parenteral nutrition, or transfusion Life-threatening; requires therapeutic imaging or endoscopic procedure or reoperation Complications with residual or lasting disability or objective signs of life-threatening diseases Death

From Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;111:518-26. With permission.

findings, an accurate description of the procedure, and any unusual situations or complications. Postoperative events and complications should be documented clearly. In an evaluation of surgical results Belsey 23 categorized poor results temporally with (1) operative complications at i month, (2) technical failure at 3 months, and (3) design failure at 6 to 12 months. The preceding comments have focused on the recognition of complications and the documentation and quantification of these complications. Clavien and colleagues 24 introduced the concept of grading complications as well (Table 8). This adds a qualitative aspect to the overall assessment and analysis. Similarly, Shapiro and colleagues 25 devised a classification of the risk of respiratory complications (Table 9). Low-risk patients require little respiratory support, moderate-risk patients require more intense observation, and high-risk patients require an intensive-care environment.

Incidence of Complications The overall morbidity and mortality rates vary for specific thoracic surgical procedures. One useful model for comparison is the extensive operative experience with lung and esophageal cancer. Despite an increase in the complexity of these operations and increased patient age, mortality rates continue to fall. Mortality rates range from 1.6% to 6.6% for resection and 3.2% to 11.6% for pneumonectomy (Table 10). 26-34 In the Massachusetts General Hospital experience from 193 l to 1970, the results were similar (Table 11). 32 The mortality rates for esophagectomy for cancer range from 3.3% to 17% (Table 12). 36-39 The major causes of death after esophageal resection include respiratory failure, pneumonia, myocardial infarction, empyema, and pulmonary embolus. Interestingly, most patients experience the development of complications, but these complications are usually minor. The overall morbidity rate remains in the 30% to 50% range. The rates are higher in the older Curr Probl Surg, November 2000

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TABLE 9. Classification of risk of pulmonary complications after thoracic and abdominal procedures

Category

Points *

Expiratory spirogram (maximum 3 points) Normal (%FVC + %FEV1/FVC > 150) %FVC + %FEV1/FVC = 100-150 %FVC + %FEVJFVC < 100 Preoperative FVC < 20 mL/kg Postbronchodilator FEVJFVC < 50% Cardiovascular system (maximum 2 points) Normal Controlled hypertension, myocardial infarction without sequelae for more than 2 years Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, dependent edema, congestive heart failure, angina Arterial blood gases Acceptable PaCO2 > 50 mm Hg or Pao2 < 60 mm Hg on room air Metabolic pH abnormality > 7.50 or < 7.30 Nervous system Normal Confusion, obtundation, agitation, spasticity, discoordination, bulbar malfunction Significant muscular weakness Postoperative ambulation Expected ambulation (minimum sitting at bedside) within 36 hours Expected complete bed confinement for at least 36 hours

0 1 2 3 3 0 0 1

0 1 1 0 1 1 0 1

FVC, Forcedvital capacity. *0 Points, low risk; 1-2 points, moderate risk; 3 points, high risk, Adapted from Shapiro BA, Kacmarek RM, Cane RD, PeruzziWT, Hauptman D. Clinical application of respiratory care. 4th ed. St Louis (MO): Mosby Year-Book; 1991. p 430.

age groups and in patients with comorbid factors (ie, diabetes, peripheral vascular disease, obstructive lung disease). Kohman and colleagues 29 analyzed 476 patients who had undergone cancer resection over a 12~A-year period; the operative mortality rate was 5.67%. Thirty-seven preoperative factors predicted only 28% of the operative risk, whereas 72% of the risk was associated with no factors or was random.

Preoperative Evaluation History and PhysicalExamination Anticipating complications should always be a concern of the surgeon. 4~ In this regard, a proper history and physical examination are essential (Table 13). With the advent of managed care and socioeconomic pressure to do same-day admissions for major thoracic surgical procedures, surgeons must now admit patients the same day of the operation, even for major cases. The patient at increased risk for the development of postoperative complications c a n o f t e n be identified during the preoperative evaluation. A 752

Curr Probl Surg, November 2000

TABLE 10. Representative mortality rates after lung resection

Specific procedure mortality rate (%)

Study

Overall mortality No. of rates cases (%)

Time period

Nagasaki et a126 1973-1980 Ginsberg et a127 1979-1981 Keagy et al2~ 1970-1983 Kohman et a 1 2 9 1972-1984 Romano and Mark 3~ 1983-1986 Damhuis and Schutte 31 1984-1992 Duque et a 1 3 2 1993-1994 Knott-Craig et a133 1991-1996 Ucker et a134 1990-1997

961 2200 369 476 12,439 7899 605 173 634

2 3.7 2.2 5.25 3.1 6.6 1.7 3.2

Wedge/ segment resection

Lobectomy

Pneumonectomy

3/10 1.4

2/11 2.9

6/15 6.2

3.8 1.4

4.2 4.4

11.6 5.7

2.2

1.0

3.2

TABLE 11. Mortality rates after lung resection at the Massachusetts General Hospital, 1931-1970

Time period Lobectomy 1931-1940 1941-1950 1951-1960 1961-1970 Pneumonectomy 1931-1940 1941-1950 1951-1960 1961-1970

No. of cases

Mortality rate (%)

8 66 126 219

37.5 10.4 4.7 9.1

23 116 145 108

56.5 14.7 13.8 11.1

thorough cardiopulmonary history is important. The patient should be questioned about smoking habits (past and present) and any occupational exposure to pulmonary irritants. The presence of underlying pulmonary disease may be ascertained by the presence of cough, sputum production, dyspnea, wheezing, or hemoptysis. Underlying pulmonary disease with a positive smoking history increases the risk of complication 2- to 6-fold over that of a nonsmoker.41-47 Cessation of smoking is recommended 2 to 8 weeks before operation to improve mucociliary transport (even though physiologic function can take months to return to normal). Cardiovascular complications can be as devastating as pulmonary complications. Although the procedure is thoracic, the cardiovascular system will be stressed. The patient history should include any angina (stable or unstable), congestive heart failure, myocardial infarction, arrhythmias, hypertension, or previous cardiac surgery. The patient's cardiac medications should be reviewed and continued. A careCurr Probl Surg, November 2000

753

TABLE 12; Mortolily rates after esophageal resection for cancer Study: Postlethwait36 Tsutsui: et al~7 Orringer et a138 Ellis et a139

No, of cases

Operative mortality rate (%)

283 141 417 455

17 8:5 5 3.3

TABLE 13. Summary of preoperative evaluation Cardiovascular

:History of stable or unstable angina, arrhythmias, myocardial infarction, congestive heart failure, cardiac surgery, rheumatic fever, valvular disease,-endocarditis, stroke, claudication Pulmonary Recent pneumonia, exposure to pulmonary irritants, dyspnea, productive or nonproductive cough, wheezing, hemoptysis, history of pulmonary tuberculosis, asthma, bronchitis, fungal exposure, smoking history, cyanosis or aspiration; availability of previous chest radiographs, CT scans Renal Renal insufficiency (recent or in the past); renal stone Hematologic History of blood dyscrasia, reaction to blood transfusion, bleeding disorders, easy bruising, use of nonsteroidal anti-inflammatory drugs, aspirin, or antiplatelet medications; note previous history of deep vein thrombosis or pulmonary embolism, religious concerns (Jehovah witness), information regarding blood donation and autologous blood program Gastrointestinal Note history of gastrointestinal bleeding or previous operations for ulcers or carcinoma, gastroesophageal reflux disease Endocrine History of diabetes, thyroid disease, long-term steroid use, pituitary or adrenal insufficiency Infection History of bacterial or viral pneumonia, chronic bronchitis, pulmonary tuberculosis, fungal infection, hepatitis, cytomegalovirus, or HIV Medication Use of prescription and nonprescription drugs, previous radiation or chemotherapy Previous operation Especially thoracic or abdominal operations Nutntion Note overall appearance of nutritional status, weight loss or gain, obesity, and overall eating habit Patient directives Organ donation, living will, next of kin, privacy request, points of contact pedoperatively, logistical and social issues regarding costs, home care, rehabilitation, case cancellation protocols, preoperative counseling CT, Computed tomography; HIV, human immunodeficiencyvirus.

ful cardiovascular examination includes listening for murmurs, bruits, and gallops. The surgeon should investigate (as part of a good history and physical examination) any hematologic, endocrine, renal, or infectious problems the patient has had in the past: Previous operative procedures, especially thoracic or abdominal operations, may influence the choice of procedure. The time to gather information is in the preoperative setting, not the day of the procedure. After all, careful planning of the procedure is a combination of skillful history and physical examinations, proper preoperative laboratory and auxiliary tests, and correct procedure selection for the individual patient. 754

Curr Probl Surg, November 2000

Risk Factors The high-risk patient should be identified early. This does not mean that the patient should not be considered for an operation because of an increased morbidity and mortality rate, but this does add extra challenge for the surgical endeavor. Smoking, preexisting pulmonary dysfunction, and cardiac dysfunction are major risk factors for postoperative complications. Although there is increased risk for the patient who is older than 70 years, age alone is no longer a contraindication to surgery.48-52Naunheim and colleagues48 reported a series of 50 patients over the age of 80 years who underwent major thoracic procedures; the overall operative mortality rate was 13%, with a 38% morbidity rate. Naunheim and colleagues49 also reported 38 patients over the age of 70 years who underwent esophagectomy for carcinoma, with an operative mortality rate of 18%, an anastomotic leak rate of 11%, and a pneumonia rate of 29%. Roxburgh and colleagues5~ compared 2 groups; 136 patients were between the ages of 50 and 69 years, and 43 patients were over the age of 70 years. The mortality rates were found to be 4.4% and 6.9%, respectively. Additional data suggest that age alone, in an otherwise healthy patient, is not a contraindication to a thoracic procedure51,52; but the surgeon should use caution because the mortality rate for most elective thoracic operations is less than 5%. Electrolyte imbalances should be corrected preoperatively, and electrolyte monitoring should be continued throughout the postoperative period. A coagulation profile should be drawn as part of the preoperative evaluation. Any abnormality should have a proper evaluation and be corrected before the procedure. Two to 4 units of packed red blood cells should be available for transfusion, if necessary. The proper timing for blood crossmatching is at least 24 hours before the day of the procedure and not the morning of the operation. When blood is needed during operation, i t should be in the operating room not in the blood bank. Occasionally, a patient will have a rare blood type that requires blood to be obtained from another blood bank. Preoperative anesthesia consultation will help to allow the intraoperative course to run smoothly and efficiently. An evaluation of the patient's airway, a review of medical problems, and a physical examination facilitate t h e planning of the most appropriate anesthetic technique. A doublelumen endotracheal tube is standard for most major thoracic procedures. A pediatric bronchoscope must be available for checking the position of 9the double-lumen endotracheal tube. Epidural analgesia is now commonly used to control postoperative pain. 53-55Its use has greatly reduced postoperative atelectasis and pneumonia; the result has been early ambulation and improved postoperative recovery. Curr Probl Surg, November 2000

755

Cardiac Risk Of the 25 million patients who undergo noncardiac operations each year in the United States, 3 million patients are at risk for coronary artery disease. More than 50,000 patients will have a perioperative myocardial infarction, and more than 50% of the postoperative deaths are cardiac related. Goldman and colleagues, 56 in a study of 1001 patients who underwent noncardiac surgery, correlated several variables with life-threatening or fatal cardiac complications: (1) third heart sound or jugular venous distension, (2) "myocardial infarction within 6 months, (3) more than 5 premature ventricular contractions per minute, (4) non-sinus rhythm, and (5) significant valvular stenosis. With no history of a myocardial infarction preceding general anesthesia, the cardiac mortality rate was 1% to 1.2%. It rose to 6% within 6 months of a myocardial infarction and to 16% to 37% at less than 3 months after a myocardial infarction. Because of these findings, the cardiovascular system has been investigated as a predisposing risk. Ginsberg and colleagues 27 in the lung cancer study group reported that 22.5% of the postoperative deaths were cardiac in origin. Ferguson, 57 in a review of a series of pneumonectomy cases, noted a 25% incidence (147/682 cases) of cardiac complication (arrhythmia, 21%; heart failure, 10%; myocardial infarction, 1%). In general, heart failure, recent myocardial infarction, and unstable angina are initial relative contraindications for thoracic operations without further evaluation and potential treatment of the underlying cause. The preoperative evaluation of cardiac function includes (1) evaluation of underlying cardiac disease, particularly coronary artery disease, (2) exercise/physiologic dysfunction, (3) predictive right heart dysfunction after pulmonary resection, and (4) prophylaxis for supraventricular arrhythmias. 58 Miller,59 in a review of collected data, reported an incidence of myocardial infarction for general anesthesia of 0.15% in a series of 46,425 patients. This rate rose to a mean of 6% with a history of previous myocardial infarction within 6 months. In his series of 2340 patients who underwent thoracic procedures, there were 7 myocardial infarctions, with 4 deaths (0.15%; Fig 4). Miller 6~ also evaluated 151 consecutive patients with thallium-201 imaging and found that 10.3% of these patients had serious asymptomatic coronary artery disease. The management was altered in 50% of these patients. His routine approach to the cardiac evaluation (Fig 5) included (1) exercise treadmill testing for asymptomatic patients between 45 and 60 years of age and (2) thallium-201 imaging for asymptomatic patients who were older than 60 years or who had a history myocardial infarction, angina, or congestive heart failure. Patients with a fixed defect on thallium imaging have a lower risk (compared with those patients with reversible or ischemic defects) for a perioper756

Curr Probl Surg, November 2000

historyofC ~

~istoryofCAI~

1 I l

~xerciseThalliun~

, Lobectomy

T Pneumonectorny

Lobectomy

Pneumonectomy

2 Fig 4. Algorithm for cardiovascular evaluation of patients older than 45 years of age. CAD, Coronary artery disease;ET/',exercisetreadmill test; CATH,cardiac catheterization. Reprintedwith permissionfrom the Society of Thoracic Surgeons(Miller JI. Thalliumimaging in preoperative evaluation of the pulmonary resection candidate. Ann Thorac Surg 1992;54:249-52.)

ative cardiac event. For patients undergoing lobectomy, intensive medical treatment and monitoring are employed. For those patients who need pneumonectomy, a cardiac catheterization is performed with subsequent angioplasty or possible coronary artery bypass grafting before elective lung resection. Goldman's multifactorial index includes preoperative factors that are related to the development of postoperative life-threatening or fatal cardiac complications. 56 From this index, a computation of risk was determined (Tables 14 and 15). For example, a 70-year-old man with no comorbidity who undergoes elective lobectomy for cancer has a point total of 8 with a class II status, a 5% risk of cardiac complications, and a 2% risk of cardiac death. Curr Probl Surg, November 2000

757

No Hx of CAD

.--Negative

Hx of CAD, MI, CHF

Patient > 60 years

o, a0e.

Positive

Surgery Negative

D.

J

Exercise

Thallium

Fixed

1 Surgery

/

Positive

defect / Lobectomy planned

Catheterization

Pneumonectomy planned

Fig 5; Exercise:thalliumscreeningfor coronary artery disease.Hx, History; CAD, coronary artery disease; M1, myacardiol infarction; CHF, congestive heart failure; ETT, exercise treadmill test. (From Miller JI. Preoperativeevaluation: ChestSurg Clin N Am 1992;2:701-11. With permission.)

The 53% sensitivity* and 99% specificityt for the Goldman index are an improvement over t h e 35% sensitivity and 89% specificity of the traditional American Society of Anesthesiology criteria (Table 16), With coronary artery~ bypass grafting within the past 5 years, the mortality rate decreased from 2.4% to 0.1%. An abnormal electrocardiogram in asymptomatic patients should be evaluated because the mortality rate is higher in that group of patients. Eagle and colleagues 61 presented the abridged version of the guidelines for the perioperative cardiac evaluation for noncardiac surgery (Tables 1720). The goal is to streamline the preoperative evaluation and testing to provide better patient management and outcomes.

Right Heart Function The effects of major lung resection on right heart function are not well established. 62After occlusion of the right or left pulmonary artery, the pulmona_ry artery pressure rises to 30% above the control value. Pulmonary artery pressures' greater than 33 mm Hg after pneumonectomy are associated with a higher mortality rate. The ability of the fight heart to adjust to

*The ability to correctly identify those patients who truly have the disease in question (number positive/total number with disease), expressed in percent. ~The ability to classify as negative those patients who do not :have the disease (number negative~total number without disease), expressed in percent. 758

Curr Probl Surg, November 2000

TABLE14. Computation of the cardiac.risk index

Criteria

Multivariate discriminantfunction coefficient

History Age > 70 y MI in previous 6 mo Physical examination S3 gallop or JVD Important VAS Electrocardiogram Rhythm other than sinus or PACs on last preoperative ECG >5 PVCs/min documented at any time before operation General status PO2 < 60 or PCO2 > 50 mm Hg, potassium level < 3.0 mEq/L or bicarbonate level < 20 mEq/L, BUN level > 50 mg/dL or creatinine level >3.0 mg/dL, abnormal, AST level, signs of chronic liver disease o r patient bed dddenfrom noncardiac causes Operation Int raperitoneal,intrathoracic, or aortic operation Emergency operation Total possible

Points

0,191 0.384

5 10

0.451 0.119

11 3

0.283 0.278

7 7

0.132

3

0.123 0.167

3 4 53

MI, Myocardial infarction; JVD,jugular-vein distention; VAS,valvular aortic stenosis; PAC,premature atrial contraction; ECG,electrocardiogram; BUN, blood urea nitrogen; AST, aspartate aminotransferase (level). From Goldman L, Caldera DL, Nussbaum SL, et al. MultJfactorial index of cardiac risk in noncardiac surgical procedures, N Engl J Med 19/7;297:845-50. Copyright 9 1977 Massachusetts Medical Society. All rights reserved.

this acute change is:crucial, Anticipated changes in right ventricular function after pulmonary resections are unknown. The subsequent effect on morbidity and mortality rates is therefore difficult to assess. A presumed decrease in right ventricular performance is due either to decreased right ventricular contractility or to loading conditions. Reed and colleagues63 showed a decrease in right ventricular ejection fraction and increased right ventricular end,diastolic volume in a series of 15 patients who underwent major pulmonary resection. Reed and colleagues64 conceded that control of heart rate rather than changes in the ejection fraction or pulmonary afterload enhanced right ventricular function. Arnar and colleagues65 advocated the use of perioperative Doppler echocardiography. Eighty-six :patients who were: to undergo lobectomy (n = 4 7 ) or pneumonectomy (n = 39)had no preoperative differences in right atrial pressure or estimated right ventricular systolic pressure. After operation, the pneumonectomy group of patients had mild pulmonary hypertension but no significant right ventricular systolic dysfunction. The investigators concluded that routine assessment of preoperative right ventricular function is Curr Probl Surg, November 2000

759

TABLE 15. Cardiac risk index

Class

Point total

I (n = 537) II (n = 316) III (n = 130) IV (n = 18)

0-5 6-12 13-25 _>26

No or only minor complication (%; n = 943) 532 295 112 4

No. of life-threatening complications* (%; n = 39)

(99) (93) (86) (22)

4 16 15 4

Cardiac deaths (%; n = 19)

(0.7) (5) (11) (22)

1 5 3 10

(0.2) (2) (2) (56)

*Documented intraoperative or postoperative myocardial infarction, pulmonary edema, or ventricular tachycardia without progression to cardiac death. From Goldman L, Caldera, DL, Nussbaum SL, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845-50. Copyright 9 1977 Massachusetts Medical Society. All rights reserved.

TABLE 16. Physical status classification of the American Society of Anesthesiologists Class I U III

V E

Patient characteristics No organic, physiologic, biochemical, or psychiatdc disturbance; localized pathologic process for which operation is to be performed; no systemic disturbance Mild-tomoderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes Severe systemic disturbance or disease from whatever cause, with the potential for perioperative complications Severe systemic disorders that are already life-threatening, not always correctable by operation Moribund with little chance of survival Emergency operation (the letter E is placed beside the numeric classification to indicate increased risk and poorer physical condition associated with emergency procedure)

From Dripps RD, Lament A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA 1961;178:261. Copyrighted 1961, American Medical Association.

unwarranted. However, Okada and colleagues66,67 showed that postoperative assessment of right ventricular function may be valuable in critically ill patients who experience associated respiratory failure.

Dysrhythmias A considerable body of literature has accumulated about arrhythmias during thoracic surgery. Shield and Ujiki, 68 in a nonrandomized study, reported a 4% mortality rate for patients who received digitalis prophylaxis and a 14% mortality rate in patients who did not receive digitalis prophylaxis in whom dysrhythmias developed after thoracic surgery. However, Ritchie and colleagues, 69,7~showed no advantage to prophylactic digitalis therapy after pulmonary or esophageal operation. The overall incidence of arrhythmias was the same. Although a spectrum of supraventricular and ventricular arrhythmias (with varying degrees of heart block) 760

Curr Probl Surg, November 2000

TABLE 17. Clinical predictors of increased perioperative cardiovascular risk*

Major Unstable coronary syndromes Recent myocardial infarctiont with evidence of important ischemic risk based on clinical symptoms and noninvasive study Unstable or severet angina (Canadian class III or IV)w Decompensated congestive heart failure Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Intermediate Mild angina pectoris (Canadian class I or II) Previous myocardial infarction based on history or pathologic waves Compensated or previous congestive heart failure Diabetes rnellitus Minor Advanced age Abnormal electrocardiographic findings (left ventricular hypertrophy, left bundle branch block, ST-T abnormalities) Rhythm other than sinus (eg, atrial fibrillation) Low functional capacity (eg, unable to climb I flight of stairs while carrying a bag of groceries) History of stroke Uncontrolled systemic hypertension *Myocardial infarction, congestive heart failure, or death. r America College of Cardiology National Database Library defines recent myocardial infarction as >7 days but _<30days. ~May include "stable" angina in patients who are unusually sedentary. w L. Grading of angina pectoris. Circulation 1976;54:522-3. From Eagle KA, Brundage BH, Chairman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: an abridged version of the report of the ACC/AHA task force on practice guidelines. Mayo Clin Proc 1997;72:524-31. With permission.

can appear after thoracotomy, the most common arrhythmias are supraventricular arrhythmia, usually atrial fibrillation (90%), and flutter with a rapid ventricular response. Ferguson 57 reported an incidence of supraventricular arrhythmias that ranged from 8% to 40% for pneumonectomy and 7% to 8.5% for lobectomy. Only in 1 study, by Baldi and colleagues,71 was it shown that arrhythmias were a risk factor for death (4.8%-11%) and that digitalis prophylaxis reduced the incidence of both arrhythmias and postoperative deaths. Amar and colleagues72 have shown that age and the extent of resection are the only consistent risk factors for an increased incidence of supraventricular arrhythmias. The role for prophylaxis was uncertain, aside from pointing out an increased incidence with known risk factors. For prophylaxis, diltiazem, a calcium channel blocker with less inhibition of vascular smooth muscle activation and therefore less systemic vasodilation, has been advocated. 73Amar and colleagues 74 randomized 70 Curr Probl Surg, November 2000

761

TABLE 18, Estimatedenergy requirementsfor various activities

Metabolic equivalents 1to 4

4 to >10

Energy requirement Can you take care of yourself?. Eat, dress, or use the toilet? Walk indoors around the house? Walk a block or 2 on level ground at 2-3 mph or 3.2-4.8 km/h? Do light work around the house, such as dusting or washing dishes? Climb a flight of stairs or walk up a hill? Walk on level ground at 4 mph or 6.4 km/h? Run a short distance? Do heavy work around the house, such as scrubbing floors or lifting or moving heavy furniture? Participate in modorate recreational activities, such as golf, bowling, dancing, doubles tennis, or throwing a baseball or football? Participate in strenuous sports, such as swimming, singles tennis, football, basketball, or skiing?

From Eagle KA, Brundage BH, Chairman BR, et al. Guidelinesfor perioperative cardiovascular evaluation for noncardiac surgery: an abridged version of the report of the ACC/AHA task force on practice guidelines. Mayo Clin Proc :1997;72:524-33.. With permission. TABLE 19. Cardiac risk* stratification for noncardiac surgical procedures High (reported cardiac risk, often >5%) Emergent major operations, particularly in elderly patients Aortic and other major vascular operation Peripheral vascular operations Anticipated prolonged surgical procedures associated with large fluid shifts or blood loss (or both) Intermediate (reported cardiac risk, generally <5%) Carotid endarterectomy Head and neck operation Intraperitoneal and intrathoracic operation Orthopedic operation Prostate operation Lowt (reported cardiac risk, generally <1%) Endoscopic procedures Superficial procedures Cataract operation Breast operation *Combined incidence of cardiac death and nonfatal myocardial infarction. CFurther preoperativecardiac testing is generally unnecessary. From Eagle KA, Brundage BH, Chairman BR, et al. Guidelinesfor perioperatJvecardiovascular evaluation for noncardiac surgery: an abridged version of the report of the ACC/AHA task force on practice guidelines. Mayo Clin Proc 1997;72:524-31. With permission.

patients who underwent pneumonectomy to receive either digoxin or diltiazem. The incidence of arrhythmias was reduced from 31% to 14% in the group of patients who received diltiazem. Given the limitations of prophylaxis, the approach to treatment is crucial. 75 Proper assessment includes clinical and laboratory evaluation of 762

Curr Probl Surg, November 2000

TABLE 20. Indications for coronary angiography* in perioperative evaluation before and after noncardiac surgery Class It (patients with suspected or proven CAD)

IIt

II1~

Indication High-risk results during noninvasive testing Angina pectoris unresponsive to adequate medical therapy Most patients with unstable angina pectoris Nondiagnostic or equivocal noninvasive test in a high-risk patient who undergoes a noncardiac surgical procedure Intermediate-risk results dudng noninvasive testing Nondiagnostic or equivocal noninvasive test in a lower-risk patient who undergoes a high-risk noncardiac surgical procedure Urgent noncardiac surgery in a patient who is convalescing from acute myocardial infarction Perioperative myocardial infarction Low-risk noncardiac surgery in a patient with known CAD or low-risk results on noninvasive testing Screening for CAD without appropriate noninvasive testing Asymptomatic after coronary revascularization, with excellent exercise capacity (_>7 METS) Mild stable angina in patients with good lee ventricular function, low-risk noninvasive test results Not a candidate for coronary revascularization because of concomitant medical illness Technically adequate normal coronary angiographic findings within the previous 5 years Severe left ventricular dysfunction (eg, ejection fraction, <20%) and not considered a candidate for revaacularization procedure Patient unwilling to consider a coronary revascularization procedure

CAD, Coronary artery disease; METS, metabolic equivalent. *If results will affect treatment. tConditions in which there is evidence for or general agreement that a procedure be performed or a treatment is of benefit. ~'Conditions in which there is a divergence of evidence or opinion about the treatment. w in which there is evidence or general agreement that the procedure is unnecessary. From Eagle KA, Brundage BH, Chairman BR, et al. Guidelinesfor perioperative cardiovascular evaluation for noncardiac surgery: an abridged version of the report of the ACC/AHA task force on practice guidelines. Mayo Clin Proc 1997;'72:524-31. With permission.

hypoxia, hypovolemia, myocardial ischemia, congestive heart failure, electrolyte abnormalities (especially hypokalemia and hypomagnesemia), and bronchodilator therapy. Hemodynamic instability warrants electrical cardioversion. Otherwise, rate control is the primary goal, with chemical cardioversion the secondary goal. The recommended treatment and drug doses are summarized in Fig 6 and Table 21. 75

Pulmonary Function As an independent variable, preoperative pulmonary function is the most predictive of postoperative pulmonary function. Yet, given the fact that surgical resection offers the best chance for improved survival in patients with Curr Probl Surg, November 2000

763

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Curr Pr0bl Surg, November 2000

765

Anticoagulant therapy with heparin

I Drug to control heart rate

1

Electrical cardioversion if necessary ,

I

I "ecorreoce I

I "~176

I

I

Warfarin

I

I"~176176 I

It ~

rate-control drug at 4-8 weeks

1 I attempt cardioversion L at 6-12 weeks

I

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Ii o=-

rate-control drug at 12 weeks

Recommended Treatment

Techyarrhythmiec.

I Discontinue [ antiarrhythmic drug t at 4--8weeks

I

I .ecorroo~e I I

I

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Antiarrhythmic drug i and cardioversion I

I

I

of PostoperativeAtdal

Fig O. Algorithm for perioperative treatment of atrial fibrillation. {From Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 1997;336:1429-34. Copyright 9 1998 Massachuseffs Medical Society. All rights reserved.) TABLE 22. Pulmonary function guidelines that indicate high risk of morbidity and death Spirometric Maximal breathing capacity, <50% predicted FEV1, <2 L Arterial blood gases Arterial PaCO2, >45 mm Hg Hypoxemia, unreliable Pulmonary vasculature Pulmonary arterial pressure during temporary uni/ateral occlusion of left or right main pulmonary artery, >30 mm Hg Modified from Tisi GM. Preoperative evaluation of pulmonary function. Am Rev Respir Dis 1979;119: 293-310; and from Wolfe W, Smith PK. Preoperative assessment of pulmonary function. In: Sabiston DC, Spencer FC, editors. Surgery of the chest. 5th ed. Philadelphia: Saunders, 1990.

lung cancer, it is reasonable to accept a higher complication rate in the high-risk or marginal patient. The primary goal is to identify and improve patients at high risk and to deny operation to those patients at prohibitive 766

Curr Probl Surg, November 2000

I

Pulmonary function

FEV 1 > 2L MVV > 50%

1

Proceed

te ,\

FEV 1 < 2 FEV~ > 1 MVV < 50%

FEV1 < 1 MVV < 35%

Perfusion lung scan

No elective surgery

+

1

Careful assessment

1

Appropriate pulmonary intervention Fig 7. Algorithm for evaluation of pulmonary function. (From Miller JI. Preoperativeevaluation. Chest Surg Clin N Am 1992;2:701-11. With permission.) TABLE 23. Pulmonary I:unction criteria For lung resection

Acceptable values Pulmonary function test

Normal value

Pneumonectomy

MW (%) FEV1 (L) _FE'V2~_TS(L)

>80 >2 <1.6

>55 >2 >1.6

Lobectomy >40 >1 >0.6

Wedge/segment resection Inoperable >35 >0.6 <0.6

<35 <0.6 <0.6

risk. Respiratory complications include atelectasis, bronchospasm, pneumonia, retained secretions, exacerbation of underlying chronic lung disease, need for reintubation, respiratory failure with long-term mechanical support, long-term pulmonary dysfunction and disability, and death, either early or late. The mortality rate ranges from 1.7% to 6.6% for resection and 5.7% to 11.6% for pneumonectomy. Bryant and colleagues 76 showed increased morbidity and mortality rates in a group of patients with less than 60% of the predicted value for at least 2 of 4 spirometric tests (vital capacity [VC], maximum breathing capacity, forced expiratory volume in 1 second [FEV1], and maximal midexpiratory flow). Keagy and colleagues 77 showed that an FEV t of less than 1.7 L was associated with an increased rate of postoperative pulmonary complications. Tisi 78 summaCurr Probl Surg, November 2000

767

TABLE 24. Bronchodilator agents and inhaled corticosteroids Aerosolization

Metered-dose inhaler puffs

Short-term ~-2 agonists Albuterot Pirbuterol Terbutaline Long-term ~2 agonists Salmeterol Formoterol Anticholinergic a~e~ Ipratropium Corticosteroids Beclomethasone Budesonide Fluticasone

Puffs

Aerosolization

Puffs

100 pg 200 lag 250 lag

2 • 2-6/d 2 • 2~/d 2 • 2-6/d

5 mg 5 mg 5 mg

l~/d l~/d 1-6/d

25 ~tg 50 pg 12 pg

2 • 2/d 2 x 2/d 1 • 2/d

0.5 mg

1-6/d

20 pg

2 x 2/d

250 lag 200 pg 250 I.tg

2 • 2-3/d 2 • 2-3/d 2 x 24/d

0.5 mg

1-2/d

From Bisson A, Stern M, Cauberrere I. Preparation of high risk patients for major thoracic surgery. Chest Surg Clin N Am 1998;8:541-55. With permission.

TABLE 25. Responseto bronchodilator therapy and changes over time

Measure of response

Percent change in FVC or FEV 1 required for a substantial response*

Current ATS recommendation Change from week to week Normal subjects Patients with chronic obstructive pulmonary disease

12

Comment

Both a 12% improvement and an absolute improvement of 200 mL are required

_>12 _>20

FVC, Forced vital capacity; ATS, American Thoracic Society. *Changes in forced vital capacity must not be due to a longer exhalation time in persons with airflow obstruction. From American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis 1991;144:1202-18. With permission.

rized the preoperative risk factors (Table 22). In general, routine pulmonary function tests, arterial blood gas tests, and pulmonary exercise stress tests should be performed on all patients who will undergo thoracic surgery. Spirometry includes VC, FEV 1, and maximum voluntary ventilation (MVV). Miller 59 summarized a practical approach to pulmonary resection using pulmonary function tests (Table 23). He described a useful algorithm with the use of this approach in a series of 2340 cases, with an overall mortality rate of 0.64% (Fig 7). An FEV 1 of 1.7 to 2.0 L is the usual limit for pneumonectomy. An FEV 1 of 800 mL is considered the limit, but this parameter has not been studied prospectively or substantiated. 768

Curr Probl Surg, November 2000

TABLE 26. Preoperativeregimen for preventionof pulmonary complications

Cessation of smoking (ideally 6-8 weeks) Thinning and mobilizing secretions with hydration, chest physiotherapy, and coughing Use of incentive spirometry Dilatation of airways with inhaled 13fagonists, inhaled atropine analogue, oral theophylline, or steroids (Table 24) Antibiotics for purulent sputum, smoldering, or active pulmonary infection Rehabilitation program, especially in the lung transplantation and lung reduction surgery groups of patients (Table 27)

Dyspnea can be evaluated with stair climbing. Bolton and colleagues 79 showed that climbing 5 flights (127 steps) correlated with an FEV 1 greater than 2.0 L 94% of the time. Holden and colleagues 8~ showed that a 6minute walk of more than 1000 feet and a stair climb of more than 44 steps were predictive of a successful surgical outcome. A history of wheezing is suggestive of asthma or allergies. A trial of bronchodilators 81 and steroids may help to improve pulmonary function (Tables 24 and 25). Patients with abnormal puhnonary function test results warrant further evaluation before lung resection. Wang and colleagues 82 calculated predicted postoperative diffusing capacity. A less than 50% diffusing capacity was associated with a higher operative mortality, but there was no statistically significant change in operative mortality in those with less than 50% or a predicted figure of more than 50%. Pulmonary resection requires a knowledge of the predicted postoperative lung function. Initially described by Nakahara and colleagues, s3* and subsequently by Keamey and colleagues, 84 the lungs are divided into 19 bronchopulmonary segments, each contributing 5.26%. The predicted postoperative FEV 1 = preoperative FEV 1 • (1 [S • 5.26]/100), where S represents the number of segments removed. The number of segments was defined by wedge resections (1 segment), right lower lobectomy (5 segments), left lower lobectomy (5 segments), fight middle lobectomy (2 segments), fight upper lobectomy (3 segments), and left upper lobectomy (4 segments). For each 0.2 L of decrease in the predicted FEV v the odds ratio for complications was 1.46. In addition to an adequate preoperative evaluation, prevention of pulmonary complications should be emphasized. A useful preoperative regiment is shown in Table 26. 81 *VC/ FEVj (F) = [1 - (b - n)/42 - n] • f where f represents VC or FEV 1, b represents subsegments (42 branches), and n represents the number of subsegments obstructed. This equation provides an objective method to determine postoperative pulmonary function. Curr Probl Surg, November 2000

769

TABLE 27. Respiratory training program Basic training (repeat 10 times; perform 10 times daily) Arm exercises (sitting or standing position) Arms out at shoulder level Breathe in, raise arms above head, hold for 2 seconds Breathe out, lower arms slowly, exhale through pursed lips Stop when arms are parallel to floor Leg exercises (sitting position) LiR leg off chair, tightening muscles on top of thigh, extend leg straight, hold for 3 seconds, bend knee, and lower slowly; relax, then repeat Exercise training Walk Climb stairs Ergovelometry Respiratory training (repeat 10 times; perform 10 times daily) Sniff and blow (sitting position) Sniff twice, hold breath for 2 to 3 seconds Tighten stomach muscles and blow out slowly Mobilization (sitting position) Breathe in, raise arms above head, crossing wrists Breathe out, pursed lip breathing Lower arms to floor Uncross arms Breathe in Raise upper body upright Stretch arms above head Physiotherapy (4 times daily) Sitting position Breathe in deeply 5 times; then hold breath for 2 seconds Contract abdominal muscles Cough, maintaining contraction of abdominal muscles From Bisson A, Stern M, Cauberrere I. Preparation of high risk patients for major thoracic surgery. Chest Surg Clin N Am 1998;8:541-55. With permission.

These measures are particularly helpful for patients with increased sputum production (>2 T/d), decreased exercise tolerance (<1 flight of stairs), obesity, age greater than 70 years, smoking, asthma, cystic fibrosis, pulmonary hypertension, lung transplant candidates, and chronic obstructive lung disease, especially those patients undergoing lung reduction surgery (Table 27). Exercise testing with measurement of the myocardial oxygen consumption (MVO2) complements pulmonary function testing in marginal operative candidates, Morice and Peter 85 studied 37 patients with an FEV 1 less than 40% of predicted, a nuclear scan predicted postoperative FEV 1 less than 33% of normal, and a P c o 2 greater than 45 mm Hg. Eight patients with an MVO 2 greater than 15 mL/kg/min underwent lung resection, with no deaths. Pate and colleagues 86 studied prospectively 12 patients with 770

Curr Probl Surg, November 2000

TABLI= 28. Thromboembolismprophylaxis scheme* at the University of Massachusetts Medical Center

Classification Low risk

Description Uncomplicated surgery in patients who are <40 y of age (no other VTE risk factors) t Major surgery in patients >40 y of age (no other VTE dsk factors)

Prophylaxis option No specific treatment; early ambulation

Elastic stockings or heparin 5000 units, subcutaneously, twice daily, or IPC boots Heparin 5000 units, subcutaneously, High risk Major surgery in patients >40 y 3 times daily, or IPC of age and have I or more of the boots or LMWH following: MI, CHF, immobility (>3 d), or elective neurosurgery LMWH or warfarin and IPC boots Very high risk Major surgery in patients >40 y or elastic stockings of age and have i or more of the following: pelvic, femur, tibial fracture, malignancy (not skin cancer), history of VTE, spinal cord injury, or paralytic stroke Orthopedic Total hip arthroplasty LMWH or warfarin* LMWH or IPC boots Total knee arthroplasty HeparJn 5000 units, subcutaneously, Medical patients Acute MI or paralytic stroke twice daily Moderate risk

VTE,Venousthromboembolism; /PC, intermittent pneumatic compression; MI, myocardial infarction; CHF, congestive heart failure; LMWH, low-molecular-weightheparin. *Venousthromboembolism prophylaxis should be selected according to each patient's level of risk, be initiated at or near the time of surgery (when applicable), and be continued until the patient is fully ambulatory. *Common risk factors for venous thromboembolism: previous venous thromboembolism, acute myocardial infarction, congestive heart failure, cancer, trauma, paralytic stroke, immobilization (>3 d), increasing age (>40 y of age), and hypercoagulablestates. ~Adjusted-doseheparin is also effective after total hip arthroptasty. Adaptedfrom American Collegeof Chest PhysiciansConsensus. Chest 1995;92:$312-34. With permission.

borderline function (FEV~, 1.38 L; predicted postoperative FEV~, 700 mL; stair climb, 3 flights for lobectomy and 5 flights for pneumonectomy). All of these patients achieved an MVO 2 greater than 10 mL/kg/min, and all of these patients underwent operation, with 1 operative death.

Infection Prophylaxis The incidence of infection in elective, noninfectious thoracic operations is low. Cruse and Foord 87 reported a 5-year prospective study of 23,649 surgical wounds. The risk of wound infection was 1,8% for clean cases, 8.9% for clean contaminated cases, and 38.3% for dirty cases. The morbidity of wound infection, bronchopneumonia, and empyema is considerable, particularly in the postpneumonectomy space (PPS). Prophylaxis, although controversial, has been advocated for many years. Burke 88 summarized the role of prophylaxis in surgery. Bryant and colleagues 89 Curr Probl Surg, November 2000

771

reported a reduction in wound infections from 18.4% to 4.8% with the use of both systemic and local antibiotics (cefuroxime 1.5 g intravenously 30 minutes before incision; 0.75 g intravenously every 8 hours for 24 hours). Cameron and colleagues 9~ found no advantage to prophylaxis in a randomized study that compared cephalothin with placebo, although local antibiotic lavage was used. Ilves and colleagues, 91 in a prospective study, showed a decrease in deep (5% vs 1%) and superficial (18% vs 5%) infections with the use of cephalothin. Olak and colleagues 92 advocated a sin-' gle-dose antibiotic (cefazolin 1 g intravenously at the induction of anesthesia). Bernard and colleagues, 93 in a randomized double-blind trial, showed that a 48-hour regimen (cefuroxime 1.5 g intravenously on induction; 1.5 g intravenously 2 hours later; then 1.5 g intravenously every 6 hours for 48 hours) had a decreased rate of deep infections and empyema. The current consensus is to use prophylactic antibiotics, particularly in patients who are undergoing pulmonary resections including pneumonectomy. A single preoperative dose is adequate. However, in patients with established infection, underlying infectious processes (eg, fungus, tuberculosis, opportunistic infection, suppurative disease), immunosuppression, or preoperative chemoradiotherapy, a longer perioperafive regime should be administered. As always, microbiologic sensitivity should dictate the appropriate antibiotics. Without identification of an organism, antibiotics covering Gram-positive (eg, Staphylococcus aureus), Gramnegative (eg, Escherichia coli, Klebsiella pneumonia, Haemophilus influenza), and anaerobic organisms should be used. Along this line, prophylaxis regimens should also be reevaluated. Recently, Boldt and colleagues 94 showed a regimen of sulbactam plus ampicillin (group 1) more effective than cefazolin (group 2). All organisms in group 1 were susceptible, whereas there was no efficacy in 13% of group 2 patients, and 32% of the isolated bacteria were not susceptible. The antibiotic should be administered intravenously on call to the operating room or at least 30 minutes before the incision to allow for an adequate tissue level.

PulmonaryThromboembolismProphylaxis The incidence of pulmonary thromboemboli after thoracic operation is low (0.5%). Ziomek and colleagues 95 reported a 19.5% incidence of thromboemboric complications after thoracotomy, particularly in patients with malignant disease. Yet patients over 40 years of age, patients with associated malignancy, and patients with an operation lasting longer than 1 hour are at a higher risk. 96 The objective of prophylaxis is the prevention of deep venous thrombosis. Deep venous thrombosis occurs in approximately 20% of patients who undergo general surgical procedures. 97 Preventive measures include intraop772

Curr Probl Surg, November 2000

erative pneumatic boots, early ambulation, leg elevation, and the administration of low molecular weight heparin (20 mg/kg subcutaneously 2 hours before the operation and daily until full mobilization is achieved). The regimen of subcutaneous calcium heparin (5000 units subcutaneously 2 hours before the operation and every 12 hours for 7 days or until fully ambulatory) may also be used. The University of Massachusetts Medical Center (UMMC) regimen is summarized in Table 28. The diagnosis can be difficult, and the outcome can be unfavorable if the condition is unrecognized and untreated. The approach to diagnosis includes ventilation/perfusion scanning, but this is usually indeterminate. Two-dimensional echocardiography, spiral computed tomography (CT), and pulmonary angiography are the best diagnostic modalities to confirm the diagnosis, ff the suspicion for deep venous thrombosis is high, heparinization is initiated. Once the diagnosis of deep venous thrombosis is confirmed, a 3- to 6-month course of anticoagulation is continued. A massive pulmonary embolus with hemodynamic compromise may warrant thrombolytic treatment and/or surgical pulmonary embolectomy.98 Thrombi rarely develop in the pulmonary artery stump (right more often than left) with subsequent embolization to the opposite lung. 99Avoiding a long stump and a smooth linear closure rather than ligation may minimize this occurrence. Over time, the thrombus may grow and propagate and cause chronic pulmonary artery obstruction and the clinical picture of cot pulmonale. Pulmonary angiography and subsequent removal of the thrombus and shortening of the pulmonary artery stump may be warranted.

Renal Dysfunction A history of hypertension, ischemic heart disease, preoperative diuretic use, chemotherapy, acute or chronic renal failure, and abnormal renal function is associated with postoperative renal dysfunction and acute renal failure. 1~176 Renal dysfunction occurs in 5% to 30% of postoperative patients, depending on the type and severity of the operation and the patient's preoperative status. Golledge and Goldstraw 1~ reviewed a series of 130 patients who underwent major thoracotomy; renal impairment developed in 24% of the patients, with a 19% mortality rate. In addition to the preoperative risk factors, pneumonectomy, infection, and blood loss were perioperative risk factors. Intraoperative gentamicin and epidural analgesia were less significant. Hemodynamic instability is the common variable contributing to renal dysfunction.

Human Immunodeficiency Virus Infection Infection by the human immunodeficiency virus (HIV) and progression of the acquired immunodeficiency syndrome have increased in recent Curr Probl Surg, November 2000

773

years. 1~ The common procedures in this patient group include open lung biopsy, tube thoracostomy, and diagnostic procedures (eg, bronchoscopy, mediastinoscopy, VATS). Safety issues for medical and operating room personnel are well standardized. Miller 1~ reported a I-year mortality rate of 66% for 38 patients who underwent a variety of thoracic procedures.

Nutritional Status A 15% weight loss over the immediate 3 to 4 months preceding operation, a serum albumin level less than 3.0 g/dL, anergy to skin tests, and a serum transferrin level less than 200 mg/dL are all associated with an increased rate of operative complications. Deslauries and colleagues 1~ noted an 11% increase in the morbidity and mortality rates in patients with lung cancer who experienced a weight loss of more than 10%. In patients with chronic lung disease, a hypennetabolic state may exist. Englemann and colleagues 1~ analyzed 5168 patients who underwent cardiac surgery. The body mass index (weight[kilograms]/height[meters squared] was measured (high-risk thin group, <20; high-risk obese group, >30), and an analysis of the body mass index and albumin level was conducted, A low body mass index and albumin level correlated with poor outcome.

Preoperative ImmunosuppressiveTherapy Chronic debilitating disease, malignancy, and immunosuppressive therapy (iv, in transplant recipients) predispose to deconditioning and poor nutritional indices. In the transplant recipient, the incidence of early graft dysfunction, infection (particularly opportunistic), and anastomotic failure is high. The average treatment-related mortality rate is 6.4% for patients who receive combined preoperative chemotherapy and radiotherapy for advanced lung cancer.l~ The rate of postoperative nosocomial pneumonia approaches 17% in this group of patients. Radiation alone is associated with a 12% to 28% decrease in pulmonary function in the long term. 1~ Lung and mediastinal radiation may have deleterious effects on the healing process, particularly at the bronchial stump. Regnard and colleagues 1~ noted that a dose of more than 60 Gy of radiation compromises bronchial and wound healing. Tribble and colleagues 1~ documented the "systemic" effects and increased complication rate in a group of patients who underwent transhiatal esophagectomy after preoperative radiotherapy. Increased blood loss, ventilator time, and mortality rates were noted, The recent use of combined neoadjuvant therapy for patients with lung cancer has also been associated with increased morbidity and mortality rates but not discussed with great detail. Fowler and colleagues ~0 reported an aggressive protocol of multichemotherapy and 60 774

Curr Probl Surg, November 2000

Gy of radiation. Sixty-two percent of patients (8/13) experienced the development of complications, and 43% of patients (3/7) who underwent pneumonectomy died. Respiratory failure and bronchopleural fistulas (BPFs; 3/13 fistulas) were the major complications. The use Of steroids for patients with chronic pulmonary disease is not uncommon. Stress dose steroids (100 mg methylprednisolone [Solu-Medrol]) should be administered before the operation, with postoperative taper doses (50 mg intravenously every 8 hours for 2-3 doses). In contrast, Sonnett and colleagues 111 reported 19 patients who received more than 59 Gy radiation; 16 of those patients received chemotherapy. There were no operative deaths. These investigators noted that hilar fibrosis makes dissection difficult and often hazardous and that differentiation of tumor from scar may be difficult; they advised the use of an intrapericardial approach to avoid the fibrotic hilum and the covering of all bronchial stumps with vascularized tissue.

Neurologic Problems Neurologic complications after general thoracic operations are rare. Nonetheless, screening for previous cerebral vascular accident, transient ischemic attack, carotid endarterectomy, cervical bruits, and severe peripheral vascular disease is important. Selective carotid duplex ultrasound scanning is recommended in those situations. Grichnik and colleagues 112 recently reported a cognitive decline after major noncardiac operations (44.8%), which was a severe decline in 24.7%. This decline may be masked as delirium, altered consciousness, altered psychomotor activity, sleep disturbances, and clinical depression. The cause is unknown, and the severity is unpredictable. Patients who receive preoperative chemoradiotherapy are at risk for central and peripheral nerve damage.l~ Radiation-induced spinal cord damage and chronic myelopathy are encountered less commonly. Neurotoxicity from chemotherapy should be appreciated, especially with vincristine and cisplatin.

Blood Transfusions The incidence of blood transfusions for patients who undergo thoracic operation is difficult to determine. Because of the cost and the possibility of hepatitis B, C, or G or of HIV transmission, blood conservation is very important. Griffith and colleagues113 studied 516 patients who underwent thoracic operations; 16.1% of patients received transfusions. Fifty percent of these patients received 2 units or less. The clear predisposing factor for transfusion was the complexity or severity of the operation. Risk factors for transfusion included previous thoracic operation, inflammatory disease, decortication of empyema, chest wall resection, and thoracoplasty. Curr Probl Surg, November 2000

775

TABLE 29. Modified Child-Pugh score Points* Presentation Albumin (g/dL) Prothrombin time Seconds prolonged International normalized ratio Bilirubin level (mg/dL) t Ascites Encephalopathy

1

2

>3.5

2.8-3.5

<2.8

3

<4 <1.7 <2 Absent None

4-6 1.7-2.3 2-3 Slight-moderate Grade I-II

>6 >2.3 >3 Tense Grade Ill-IV

*Class A, 5 6 points; class B, 7-9 points; class C, 10-15 points. tFor cholestatic diseases (eg, primary biliary cirrhosis), the bilirubin level is disproportionate to the impairment of the hepatic function, and an allowance should be made. For these conditions, assign 1 point for bilirubin level < 4 mg/dL, 2 points for bilirubin level 4 to 10 mg/dL, and 3 points for bilirubin level > 10 mg/dL. From Patei T. Surgery in the patient with liver disease. Mayo Clin Proc 1999;74:593-9. With permission.

TABLE 30. Liver disease risk assessment* Bilirubin level > 2.0 mg/dL Albumin level < 3 g/dL Prothrombin time > 16 seconds Encephalopathy Presence or history of esophageal varices *All factors are assigned 1 point: 1 point, 43% mortality rate; 3 points, 85% mortality rate; 4 points, 100% mortality rate.

Efforts to decrease blood transfusion included autologous blood donation, autotransfusion with cell-saving systems, and administration of recombinant erythropoietin. An incompletely understood concept is the effect of blood transfusion on survival rates in patients with lung cancer. Transfusion-associated immunomodulation has been reported. Yet the effect of perioperative allogeneic blood transfusion (PABT) on lung and esophageal cancer survival rates is conclusive. Swisher and colleagues 114 reviewed 316 patients who underwent esophageal resection. High-volume blood transfusions (>8 units) were associated with decreased survival rates, mainly because of increased postoperative complications. Craig and colleagues 115 studied 524 patients who underwent esophagogastrectomy for carcinoma over a 10-year period. Sixty-four percent of the patients received PABT. The long-term survival rate was not affected by PABT.

Liver Disease Underlying liver dysfunction, especially cirrhosis, is associated with an increased rate of perioperative complications, especially encephalopathy 776

Curr Probl Surg, November 2000

exi/ldqroll {

ekl/rocaa/e I

Fig 8. Appropriate preparation in the lateral decubitus position. (From Edmunds LH, Norwood WI, Low DW, editors. Atlas of cardiothoracic surgery. Philadelphia:Lea Febiger; 1990. p 185. With permission.)

and coagulopathy (Table 29). Wirthlin and colleagues 116 created a risk assessment tool (Table 30). Pate1117reviewed the issue of operation in the patient with liver disease. The liver is a major site of anesthetic drug metabolism, and operation should be postponed in patients with acute hepatitis.

Other Preoperative Considerations The proper staging of the patient's disease determines the proper treatment. Proper staging includes a chest radiograph, chest CT scan, bronchoscopy, and possibly mediastinoscopy. Bronchoscopy often allows for a tissue diagnosis and can predict resectability. All segments should be visualized carefully. Mediastinoscopy should be performed for patients with mediastinal lymphadenopathy (ie, for lymph nodes >1 cm). Metastatic disease in certain lymph node groups stages the patient to nonoperative treatment. Curr Probl Surg, November 2000

777

Operative Phase The prevention and avoidance of complications in the operating room require attention to detail. A review of the patient's medical record before the operation is recommended to double check all the clinical and diagnostic information. The surgeon must take responsibility for the correct patient being in the operating room. The correct operation and the side on which the operation will be performed must be confirmed as well. The appropriate instruments, equipment, sutures, and other special needs must be available for the planned operative procedure. Discussing the operative plan or strategy with the anesthesiologist, surgical assistant(s), operating room technician, and circulating nurse is crucial. The availability of surgical pathology expertise and other laboratory support should be confirmed, especially for various diagnostic studies or cultures. The operating room is an expensive place; decreasing operating room time substantially decreases the overall hospital costs. Control of the room temperature, noise, and room traffic is also essential. The anesthesiologist generally places 2 large-bore intravenous lines, a central line, and an arterial line and attaches the appropriate monitoring lines (eg, electrocardiography, pulse oximetry). If used, the location of the balloontipped pulmonary artery catheter should be confirmed with a chest radiograph because the balloon-tipped pulmonary artery catheter should not be on the side of a planned pulmonary resection. Epidural catheters and double-lumen endotracheal tubes usually require extra time and technical expertise. An experienced and dedicated thoracic anesthesiologist and/or a Certified Registered Nurse Anesthetist may facilitate these procedures. Once the patient is anesthetized, positioning must accomplish 2 objectives: adequate exposure of the operative site and avoidance of head, limb, or torso injury on the operating table (Fig 8). 118The key is to avoid stretching or compressing, Making use of table rotation with splitting the bed is important. Scalp alopecia is avoided with a pillow or soft "doughnut." This also avoids extreme neck hypertension. Padding of the torso and peripheral pressure points avoids neuropathy, particularly the peroneal nerve. Hyperextension of the arm may cause brachial plexus stretch injury. The testicles and scrotum should be checked for compression when the patient is in the lateral decubitus position. Pneumatic compression boots should be placed properly and secured. The electrocautery grounding pad or plate must be checked. Proper taping or securing the "beanbag" prevents movement or slippage of the patient. Prepping and draping must allow adequate exposure of the operative field. Complex operations or procedures that last more than 1 hour usually require a urinary catheter to monitor the urine output and fluid administration adequately. The most common positions are supine and lateral decubitus. Neck incisions involve cervi778

Curr Probl Surg, November 2000

cal hyperextension to either the fight or left side. The prone posterior (Overholt technique) position is rarely used. Supine positions are well tolerated with the arms at the side, but radial and ulnar nerve compression injury can occur. The lateral decubitus position predisposes to ventilation/perfusion mismatch, with the lower lung better perfused but less compliant, lls The operative principles of asepsis, hemostasis, and gentleness to the tissues are important. Minimal access should not compromise the need for adequate exposure. A planned operative strategy and the anticipation of problems should be paramount. Over-zealous exposure may be harmful. Extensive opening of the median stemotomy may cause brachial plexus injury or fractures. Excessive thoracotomy spreading can cause rib fractures and stretch injury of the intercostal nerves. The rib spreader should be opened slowly. Aside from rib resection, resection of a short segment of rib posteriorly may prevent rib fractures. If fracture occurs, the fractured segments should be resected or repaired. Instrumental retraction of the cervical trachea to expose the esophagus may injure the recurrent laryngeal nerve. Gentle dissection techniques include blunt finger, Kitner ("peanut"), sharp (scalpel), Metzenbaum scissor, electrocautery, or laser. Gentle pushing and short spreading moves will avoid unnecessary bleeding or damage. The common incisions or approaches include anterior, lateral, or posterolateral thoracotomy, median sternotomy, and the rarely used thoracoplasty.

Median Sternotomy Originally described by Julian and colleagues, 119the median sternotomy or sternal split is most commonly used for open heart surgery. Sternal wound complications, including deep infections (mediastinitis) occur in 0.7% to 2.1% of patients. 12~The indications in general thoracic operation for median sternotomy include lung reduction operation, bilateral lung metastases, and lung transplantation. The major complications include sternal instability and dehiscence, with and without superficial or deep infection. 12~ In general, median sternotomy is well tolerated, with less pain and pulmonary compromise than other incisions. The variety of approaches to treat sternal instability and mediastinitis, including muscle flaps and omentum, are beyond the scope of this monograph. The omentum technique, although not new, has a variety of applications for intrathoracic processes as well. 122

Muscle-sparingThoracotomy The muscle-sparing thoracotomy involves sparing the latissimus dorsi muscle and splitting of the serratus anterior muscle. No rib resection is performed. Mitchel J23 showed an advantage with decreased operative time, blood loss, pain, and cost. Hazelrigg and colleagues 124 documented a Curr Probl Surg, November 2000

779

TABLE 31. Major anesthetic complications Inefficient or inadequate monitoring Difficult intubation; airway obstruction Traumatic intubation with hypopharyngeal, laryngeal, or tracheal trauma Displacement of double-lumen endotracheal tubes or bronchial blocker; 1 lung anesthesia intolerance Access complications Aspiration of gastric contents Injudicious fluid administration Adverse effects of anesthetic drugs

decreased narcotic requirement, and shoulder girdle strength was preserved. There was, however, no statistical difference in the pulmonary function in 2 groups compared at 1 week and 1 month after operation. Landreneau and colleagues 125 concluded no appreciable differences between the standard and muscle-sparing groups. However, preservation of chest wall muscle allows for its future use for rotational flaps, if needed.

Thoracoplasty Thoracoplasty involves resection of a portion of the bony chest wall. 126 Subperiosteal resection of the ribs allows collapse of the chest wall and obliteration of the pleural space. The morbidity and mortality rates for this approach are related to the underlying pathologic condition. First-fib resection may damage adjacent neurovascular structures. Posterior-rib resections may damage the thoracic duct or subarachnoid space. Residual ribs at the T5-T7 level posteriorly may cause trapping of the scapula.

Anesthesia Anesthesia has assumed an increasingly important role in thoracic surgery. 127,]28 The goal of general anesthesia is to provide analgesia, amnesia, and muscle relaxation. The anesthesiologist is responsible for airway control, anesthesia, monitoring, fluid administration, and drug use (both anesthetic and nonanesthetic). Sophisticated intubation techniques require a dedicated thoracic anesthesiologist with technical expertise. Additionally, the presence of a pneumothorax, a full stomach (as in trauma), superior vena cava syndrome, tracheal obstruction, and mediastinal masses with extrinsic tracheobronchial obstruction requires experience and sophisticated techniques with ready availability of rigid bronchoscopy and tracheostomy. An epidural catheter placement with expanded monitoring (eg, balloon-tipped pulmonary artery catheter, arterial pressure, and transesophageal echocardiography) requires increased involvement of the anesthesia staff. Internal and external defibrillator and temporary pace780

Curr Probl Surg, November 2000

Mask Ventilation with 100% Oxygen ShortActing , * " ~ J ~ " ~ ~ , , . ~ Muscle Relaxant~.......__ ~ andControlled ~ ~ Oral Intubationt ~

t

/

Jaw Thrust Maneuver # Mask Ventilation

~

t

t

t

Mask Ventilation t Piberoptic Nasal or Oral Intubation

Oral and Nasal Airway Mask OVentilation 0

tnetteet~e t Allow Patient to Awake

and Maintain Spontaneous

/

/

Ventilation*

Direct Oral Intubation / / ~ t * *

# Mask Ventilation~

Intubation Directed by Transtracheal Guide Wire

,_

AllowtPatiant to Awake and Maintain Spontaneous Ventilation*

///_o.,o~

t

Tracheostomy

t t mnseuve

~ ?

Emergency Cardiopulmenary Bypass

Emergency Cardi0pulmonary Bypass

Patent Airway Fig 9. Airway obstruction protocol during operative intubation in the anesthetized patient. *May not be possible if high dosesof narcotic have been given. **If rapid deterioration occurs, the surgeon should be prepared for tracheostomy. (From Hensley FA, Larach DR, Martin DE. Intraoperative anesthetic complications and their management. In: Waldhausen JA, Orringer MB, editors. Complications in cardiothoracic surgery. St Louis[MO]: Mosby-YearBook; 1991. p 3-19. With permission.}

maker capability should be available along with blood-warming devices and cell savers. The anesthesiologist is intimately involved in the preoperative assessment and preparation of the patient and advises on issues relating to smoking cessation, airway dilators, use of steroids, use of antibiotics beyond prophylaxis, secretion management, and pulmonary physiotherapy. The history of previous anesthesia and complications is important. The traditional anesthesia evaluation includes the American Society of Anesthesiology risk assessment (Table 16). An assessment of the teeth (especially loose teeth), temporomandibular joint cervical mobility, and neck size (distance of mandible to thyroid with neck extended is normally 6.5 cm in adults) is documented. It should be stressed that, despite all Curr Probl Surg, November 2000

781

TABLE 32. Complications of central venous cannulation Complication

Internal jugular

Infection X Air embolism X Catheter shearing X and embolization Thrombophlebitis X Local extravasation of X fluid and drugs Pneumothorax X Hemothorax X Pericardial tamponade X Tissue trauma Nerve Brachial plexus Artery Carotid, subclavian Vein Superior vena cava Other Sites of fluid infusion in malpositioned catheter

Subclavian

Femoral

External jugular

X X X

X X X

X X X

X X

X X

X X

X X X Brachial plexus Femoral Subclavian Femoral Superior vena Inferior vena cava cava Thoracic duct (left)

Thoracic duct (left), cervical nerve roots Mediastinum, Pleural cavity, pericardium, mediastinum pleural cavity

Superior vena cava

Retroperitoneum, Retrograde up peritoneal ipsilateral or cavity contralateral internal jugular

From SkeehanTM, Thys DM. Monitoring the cardiac surgical patient. In: Hensley FA, Martin DM, editors. The practice of cardiac anesthesia. Boston: Little Brown; 1990. p 150. With permission.

the advances in anesthesia (including techniques, drugs, and monitoring), the mortality rate related to anesthesia as the primary cause ranges from 1.6 to 12 deaths per 10,000 patients. The major anesthetic complications are listed in Table 31.

Monitoring Guidelines for monitoring are well established. 129 Safe and adequate monitoring is necessary both intraoperatively and perioperatively.4~ Routine monitoring includes arterial blood pressure (manual or automated blood pressure cuffs or intra-arterial pressure monitoring), continuous electrocardiography (4 limb leads), temperature (blood and rectal), pulse oximetry, and capnography (measurement of expired carbon dioxide). Additional measures include central venous pressure and balloon-tipped pulmonary artery catheters. Transesophageal echocardiography is extremely useful during complex or complicated procedures, particularly where the troubleshooting of hemodynamic compromise is necessary. 782

Curr Probl Surg, November 2000

TABLE 33, (ntrc~operotivetroubleshooting

Problem: inability to ventilate/decreasing 02 saturation Endotracheal tube Out/kinked/twisted Inability to tolerate single lung anesthesia Occluded endotracheal tube (blood and/or secretions) Bronchospasm Tension pneumothorax (contralateral side) Atelectasis/collapse Solution: Ambu/hand ventilate Check system/anesthesia machine/circuit Endotracheal tube suction Fiberoptic bronchoscopy; laryngoscopy Treat bronchospasm Resume double lung ventilation Problem: Hypotension Bleeding Arrhythmia Myocardial depression caused by congestive heart failure/myocardial infarction/drugs Cardiac tamponade Cardiac herniation Increase in pulmonary artery pressure especially with occlusion of pulmonary artery/fight ventncular failure Solution: Evaluate for occult or visible sources of bleeding; control bleeding; cell saver; transfusion of blood/blood products Electrical or drug treatment of supraventricular arrhythmia; correct K§ ++ Transesophageal (except esophageal cases) 2-dimensional echocardiogram to assess valve/muscle function; pericardial fluid/blood; acute right to left shunt Balloon-tipped pulmonary artery catheter assessment of cardiac output/cardiac index, pulmonary artery pressure

Airway complications are avoided if the problems are anticipated. Patients with partial intrinsic (ie, tracheal stenosis) or extrinsic (ie, superior vena cava syndrome) tracheal compression require inhalational or awake intubation techniques. A useful algorithm for airway difficulties is outlined in Fig 9. le8 The availability of rigid and/or fiberoptic bronchoscopy, tracheostomy, and (in rare situations) cardiopulmonary bypass should be ensured. Once intubation is completed, end-tidal carbon dioxide measurement and fiberoptic bronchoscopy are the most reliable adjuncts to ensure proper tube placement and function. The complications of double-lumen endotracheal tubes include impaired oxygenation, malposition, traumatic injury to the larynx or tracheobronchial tree, and suturing or stapling of the tube to the bronchus.~3~ Prevention strategies include avoiding a malpositioned tube, avoiding overinflation of the cuff, securing the tube during turning, checking the Curr Probl Surg, November 2000

783

TABLE 34. Assessmentof the postoperative chest radiograph (immediate film)

Bronchial obstruction Atelectasis or lobar collapse Air/fluid levels Edema Torsion Effusion Pneumoperitoneum Gastdc distension Pneumothorax (upright and supine) Hemothorax Widened mediastinum Increased cardiac silhouette Mediastinal air Subcutaneous air Location of Endotracheal tube Nasegastric tube Chest tubes Balloon-tipped pulmonary artery catheter Other foreign bodies (eg, retained sponge or needles) Staple lines Esophageal surgery Stomach position and gastric distention Colon position or distention

position with clamping, listening to the chest, and liberally using flexible bronchoscopy to check the position of tube. Bronchial blockers are favored by some anesthesiologists. One disadvantage, however, is the inability to suction or ventilate the occluded lung. Also, if the blocker migrates into the trachea, ventilation can be impaired, or blood or contaminated fluid can migrate to the other side. If ,~he double-lumen endotracheal tube or bronchial blocker cannot be used, corrected, or tolerated (desaturation) to allow lung collapse, the procedure may have to be canceled, or the traditional use of lung packing and retraction can be used. Venous access complications can occur with peripheral or central placement (Table 32). 131 Brachial or femoral nerve injury can occur with antecubital vein or femoral vein punctures. Internal jugular and subclavian vein punctures are complicated by pneumothorax, local bleeding/ hematoma, arterial cannulation, and catheter emboli. The morbidity of pulmonary artery catheters is well recognized. However, Ivanov and colleagues, 132 in a meta-analysis from 1970 to 1996, showed decreased overall patient morbidity rates in pulmonary artery catheter-guided strategies. Arterial cannulation injury of the radial artery is uncommon, but if ulnar artery collateral flow is absent or compromised ("positive" Allen test), 784

Curr Probl Surg, November 2 0 0 0

TABLE 35. Criteria for exttJbation Patient alert and able to clear secretions and protect airway; anesthetic agents have been cleared. Chest radiograph taken and checked, with no evidence of bleeding. Mechanical efficiency Inspiratory force at least > 20 cm H20 VC > 15 m L / k g Tidal volume > 2-5 m L / k g

Oxygenation Pad2 > 60 on Fio2 of 0.50; PEEP < 5 cm H20 pH > 7.35 Pco 2 < 45 mm Hg

Respiratory rate < 30/min, not shallow or labored A-aDO 2 < 2 5 0 Qs/QT > 0 . 2 0

Left ventricular function Blood pressure does not increase > 20 mm Hg with weaning, indicating work of breathing is excessive Blood pressure does not drop significantly

PEEP,Peak end-expiratory pressure; A-aDO2, arterio-alveolar oxygen tension difference; Qs/Qr, flow shunt/flow total; VC, vital capacity. Adapted from Geisman LK. Advances in weaning from mechanical ventilation. Crit Care Clin N Am 1989;1:697-705. With permission.

hand ischemia can occur. Nasopharyngeal injury from nasotracheal or nasogastric tubes can cause bleeding or submucosal injury or incite sinusitis. Esophageal perforation or mucosal injury with bleeding or stricture is rare after transesophageal echocardiography. Urethral or bladder injury from Foley insertion can occur. Frequently, a urethral stricture and inability to insert the Foley catheter warrant urologic consultation. Intraoperative fluid management is important. 133 Crystalloid, volume expanders, and blood are the available choices. The goal is to maintain a euvolemic state, with additional administration for blood loss and fluid shifts (third-space requirement). For thoracic procedures, the traditional formula of 10 to 15 mL/kg/h is reduced to 5 to 7.5 mL/kgha of operative time and even lower, at 3 to 5 mL/kg/h for patients who are undergoing pneumonectomy. In summary, the anesthesia team plays an active role, particularly in the trouble-shooting phase (Table 33).

Postoperative Phase After the operation has been completed, the patient is transported to the recovery room or directly to the intensive care unit. Extubation in the operating room can be accomplished in many cases. However, it is ofttimes prudent to exchange the double-lumen endotracheal tube for a sinCurr Probl Surg, November 2000

785

"rtYee I~ttle ~

System F

F

4-

Ittr~'~

J

G

Fig 10, Traditional 3-bottle or 3-chamber system. (From Symbas PN. Cardiothoracic trauma. Philadelphia: Saunders; 1989. p 9. With permission.)

gle-lumen tube. Once the patient is awake with reversal of anesthesia (particularly muscle relaxants), responsive, and exhibiting adequate pulmonary mechanics, extubation is performed, usually in the recovery room. An immediate portable chest radiograph should be obtained and checked before extubation (Table 34). Atelectasis or collapse can be treated with bag-valve-mesh ventilation or flexible bronchoscopy through the endotracheal tube, if larger than 9 mm. The criteria for extubation are summarized in Table 35. Unplanned extubation in the recovery room or intensive care unit is a serious problem. The incidence of deliberate extubation (eg, patient extubation or accidental extubation) was 7.3% in a recent series. 134 Reintubation was required in 45.8% of these patients. Failed early extubation demands prompt attention. The patient who has been extubated requires careful triage. The level of 786

Curr Probl Surg, November 2000

TABLE 36. Common problems with chest tubes Falling outside chest space Clotting Bleeding around chest tube site Twisting, kinking, compressing Subcutaneous emphysema Residual pneumothorax or hemothorax

consciousness, respiratory function, absence of bleeding, pain control, and hemodynamic stability are the primary parameters to monitor. Patients undergoing pulmonary resection should not receive excessive fluid (usually sufficient urine output, 0.5 mL/kg/h). A nasogastric tube, although uncomfortable, may be necessary especially in "air swallowers" or to avoid gastric distension and possible aspiration and pressure on an esophageal anastomosis. A significant difference between thoracic and nonthoracic operations is the presence of chest tube drainage. An understanding of chest tubes and drainage systems is crucial to the avoidance of complications and the troubleshooting of problems. Usually a 32F or 36F chest tube is placed under direct visualization before closing the chest incision. One tube is often placed posteriorly, and another tube is placed anteriorly. These tubes help to ensure proper expansion of the lung and drainage of any pleural collections. Improper tube size or positioning can lead to residual air space or fluid, which can result in atelectasis, lung entrapment, and/or empyema. The chest tube is placed on 20 cm H20 suction until time for removal. The traditional 3-bottle collection/drainage system is illustrated in Fig 10. In general, chest tubes are rarely clamped, especially with an active air leak. An unrecognized tension pneumothorax can be a catastrophic consequence. The risk of infection from chest tube placement is less than 3%, with an increased incidence (1%-16%) among trauma patients. The use of antibiotics to reduce infection caused by chest intubation is controversial. Grover and colleagues 135 showed a benefit to the use of clindamycin (Cleocin) for patients with penetrating chest wounds; among patients who received antibiotics, only 2.6% experienced the development of empyema versus 16% of those patients who were untreated. However, some surgeons still believe antibiotics should be used whenever a chest tube is inserted, even for clean uncontaminated thoracic procedures. Some of the common pitfalls with chest tubes are listed in Table 36. A failure of the chest tube to drain may be due to the tube being in a poor position, falling outside the chest, clotting, twisting, kinking, or compressing. The postoperative chest radiograph and periodic chest radioCurr Probl Surg, November 2000

787

graph can help in avoiding these problems. The chest tube should be secured with a nonabsorbable suture in either a U stitch or a pursestring, which can be used to close the skin after the chest tube is removed. If the chest tube should become displaced, it should not be advanced into the pleural cavity (to avoid contamination of the pleural cavity). The specifics of chest tube insertion and care have been summarized by Lancey and Pezella. 136 Routine postoperative care in the recovery room or the intensive care unit includes frequent monitoring of the vital signs, pulse oximetry, urinary output, chest tube drainage, pain control, and laboratory parameters. The patient should be kept on continuous cardiac monitor to evaluate for dysrhythmias. Prophylaxis for deep venous thrombosis with a sequential compression device and subcutaneous heparin is continued. A nasogastric tube should be left in place if the patient is lethargic, has gastric distention, or has a history of aspiration. Patients with gastroesophageal reflux disease should have the head of the bed elevated to reduce aspiration.

General Complications Fever Fever is common after most operative procedures with elevation to 100.6~ (38~ being clinically significant. Because fever is a normal response to surgical trauma, a specific cause is identified in less than 20% of patients during the first 24 hours. As many as 25% to 50% of most patients who undergo major operations have fever in the first 24 hours. 137 In most patients, atelectasis is the most common cause. After 48 hours, fever becomes more significant. Urinary tract infection, especially if the bladder was instrumented, is encountered 48 to 72 hours after the operation. Early wound infection (before 24 hours) is uncommon, but anaerobic infection can occur early. Broad-based antibiotics can cause a paradoxic fever. Thrombophlebitis, especially at an intravenous site, should be evaluated. Parotitis and sinusitis can occur, especially in patients with long-term nasotracheal or nasogastric tubes. Delayed allergic transfusion reactions must always be suspected.

Wound Healing Asepsis (Semmilweis) and antisepsis (Lister) form the basis for wound care. The rate of postoperative wound infection is low (2%-4%) in thoracic surgery. Local bleeding from the skin and subcutaneous sources can occur. Hematomas and seromas are common, especially where subcutaneous dissections have been performed. Wound failure includes skin 788

Curr Probl Surg, November 2000

TABLE 37. Classification of surgical wounds by level of bacterial contamination Wound type (% infected) clean (1%-5%)

Definition

Atraumatic wound; no inflammation; no break in aseptic technique; no entry of gastrointestinal, biliary, respiratory, or genitourinary tracts Clean-contaminated Atraumatic wound; no inflammation; minor breaks (5%-10%) in aseptic technique; entry of gastrointestinal, biliary, respiratory, or genitourinary tracts with either minimal spillage or prior decolonization Contaminated Traumatic wound; inflammation or purulence; major (10~ break in aseptic technique; entry of gastrointestinal, biliary, respiratory, or genitourinary tracts with gross spillage

Example Herniorrhaphy

Elective colectamy

Resection of perforated appendix

Adapted from Drebin JA, Mundy LM. Surgical wound infection. In: Cameron JL, editor. Current srugical therapy. 6th ed, St Louis (MO): Mosby, Inc; 1998. p 1079.

necrosis, dehiscence, and incisional hernia. Most wounds seal at 24 hours and should be cleaned sterilely and dressed at 24 to 48 hours (more often if there is increased drainage). Special attention should be paid to chest tube sites in which local skin necrosis and inflammation may occur. Local infection should be treated aggressively to prevent deep extension into the chest or mediastinum. Wound failure includes partial or total disrupture. Early failure causes dehiscence, and late failure causes an incisional hernia. Lung herniation may occur through a defect in the chest wall. Paresthesias and decreased sensation along the incision are usually related to the involved dermatome (usually the 5th or 6th intercostal nerve). Keloid formation (common) and gynecomastia (uncommon) are other wound complications. The incidence of wound infection in thoracic operation is low. The use of prophylactic antibiotics is efficacious. Surgical-site infections include superficial incisions, deep incisional surgical sites, and organ/space surgical sites. Factors involved in wound infection are patient related or surgery/hospital related. The traditional classification of surgical procedures includes clean, clean-contaminated, and contaminated cases (Table 37). Most thoracic surgical procedures are clean. Trauma procedures are either clean-contaminated or contaminated, whereas infected procedures (ie, decortication for empyema or drainage late perforated esophagus) are contaminated. Given the fact that clean wounds can become infected, the study of efficacy of nosocomial infection control project in 1974138 identified, by multivariate analysis, 4 risk factors in predicting wound infections: abdominal operations, operation lasting more than 2 hours, contaminated or dirty operation, and 3 or more discharge diagnoses. Curr Probl Surg, November 2000

789

TABLE 38. Anatomic approach to surgical bleeding Skin subcutaneous, muscle bleeding Intercostal vessels, internal mammary, inferior pulmonary ligament Posterior interspace Pleural adhesions Lung parenchyma Arterial and venous bleeding, especially in lymphatic beds and peribronchial areas Major vascular bleeding: pulmonary artery, vein

Persistent drainage, especially serosanguineous occurs around chest tube sites. After 24 to 48 hours, other sources or causes of persistent drainage must be evaluated. An unobliterated chest space may be the source. Foreign body, infection, and malignancy should also be considered. Anterior thoracotomy wound drainage, especially purulent and associated with pain and tenderness, raises the suspicion of infected cartilage.

Gastrointestinal Complications Gastrointestinal complications are uncommon after general thoracic procedures. 139 The incidence is higher (2%-5%) after cardiac surgery. Cardiopulmonary bypass, with nonpulsatile perfusions, has been implicated. Acute gastric dilatation is not uncommon, especially with anxious patients and "air swallowers." Short-term nasogastric decompression is common after most thoracic procedures and is used longer after esophageal resections. Gastrointestinal bleeding that is the result of stress ulcers and peptic ulcer disease occurs in less than 5% of patients, yet the mortality rate is greater than 50%. A history of use of nonsteroidal antiinflammatory drugs and Helicobacterpylori infection increases the risk of bleeding from peptic ulcer disease. Clostridium difficile colitis causes severe diarrhea and is associated with patients who are debilitated and the use of broad-spectrum antibiotics. Intestinal ileus is common and usually resolves over 3 to 4 days. The more severe colonic pseudoobstruction (Ogilvie's syndrome) is more common in respirator-dependent patients. Acute acalculous cholecystitis is probably related to biliary status.- Early recognition, broad-spectrum antibiotics, and cholecystectomy are warranted in most patients. Pancreatitis is uncommon but should be suspected in patients who undergo esophageal resection with dissection in the lesser sac and mobilization of the stomach. Postvagotomy syndromes are important to appreciate, especially after vagal nerve damage or resection. Dumping, diarrhea, gastric atony, and bile reflux are debilitating and require expert gastroenterologic evaluation and treatment. 790

Curr Probl Surg, November 2000

Complications of General Thoracic Surgery Most complications occur early and usually acutely. An awareness and high degree of suspicion and an aggressive approach to treatment are necessary for proper evaluation and resolution of these complications.

Bleeding/Hemothorax Major bleeding that requires reoperation occurs in 3% of patients who undergo thoracotomy, with a mortality rate of 2.3%. Intraoperative bleeding must be controlled early and completely. Intraoperatively, the principles of digital control, proximal control, electrocautery, ligation, and continued observation before closure are mandatory. The usual sites of major hemorrhage are the pulmonary artery or vein, bronchial arteries, raw tissue surfaces, intercostal vessels, internal mammary artery, and inferior pulmonary ligament (Table 38). 14~ Surgical bleeding and coagulopathy are the 2 sources of perioperative blood loss. Transfusion in excess of 10 units will usually create coagulopathy. Coagulation studies and appropriate correction with blood products (eg, platelets, fresh frozen plasma, cryoprecipitate) along with protamine, DDAVP, calcium, and vitamin K will correct or reverse most coagulation problems. Surgical bleeding control requires the initial correction of the associated coagulation problems, if possible, and subsequent surgical exploration. Serial chest radiographs and frequent determinations of the hematocrit level are helpful early. In delayed situations, ultrasound and/or CT scanning may be necessary. The hematocrit level of chest tube drainage is usually less than 20% but rises in the face of significant bleeding. Chest tube drainage trends are important. Hemodynamic instability with minimal chest tube drainage mandates serial chest radiographs to evaluate for pooling of blood and ineffective chest tube drainage (ie, kinking, clotting tubes, ineffective draining of involved area). Suction and irrigation of the chest tubes or placement of additional tubes may be necessary. Clamping or mechanical stripping of the chest tubes should be avoided. The 2-dimensional echocardiogram is valuable to the assessment of pericardial bleeding and tamponade. In general, sudden chest tube drainage in excess of 1 L mandates surgical reexploration. Drainage of 200 mL/h over a 2- to 4-hour period also mandates surgical reexploration to determine the source of bleeding and to effect control. Despite active chest tube drainage, serial chest radiographs that demonstrate a progressive increase in the hemothorax also warrant surgical exploration. At surgical reexploration, a systematic search of the chest wall, lung surface, hilum, and mediastinum is performed. If after 30 minutes no source is found, the chest is closed. Delayed bleeding beyond Curt Probl Surg, November 2000

791

LOCAL ANESTHETICS

Mixed Spinal Nerve

MORPI-nNE ANALGESIA Opiate Receptor tia

EP CA

Fig 11. Site of action of local anesthetics and epidural agents. (From EI-Baz NM, Ivankovich AD. Management of postoperative thoracotomy pain. In: Kirtle CF, editor. Current controversies in thoracic surgery. Philadelphia: Saunders; 1986. p 215-21. With permission.)

24 to 48 hours may be related to local erosion as the result of infection, chest tube erosion, or rib puncture of the adjacent lung. Perioperative bleeding is classified as surgical or nonsurgical. There is no substitute for meticulous surgical technique with proper and precise control of the bleeding vessel. The application of coagulation agents is helpful for raw surfaces and minor bleeding. Electrocautery, staples, and suture ligations are the primary control methods. Underlying coagulation problems may be present before the operation or may be acquired during the operative procedure because of increased blood loss, hypothermia, or massive blood transfusions. Clinically surgical bleeding should be controlled during the operation. Blood in the operative field, sponges, and suction containers should all be noted. Appropriate hemostasis should be maintained. After the operation, the clinical trend in blood pressure, pulse, and urine output should be noted. An assessment of the cause of wound dressing saturation, chest 792

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"I'AI31.1=39. Options for analgesia Systemic opioids Spinal route (epidural and intrathecal) drugs Patient controlled anesthesia (PCA) Nonsteriedal anti-inflammatory drugs (NSAIDs) Intercostal analgesia Intrapleural analgesia Cryoanalgesia Transcutaneous electrical nerve stimulation analgesia (TENS)

"I'AI31.1~40. Pain management protocol at the UMMC Narcotics orders must be rewritten every Monday and Thursday. Pain is a fTequent companion of our patients in the intensive care setting. There is rarely a reason for our patients to be in pain. Whether a patient's pain is being adequately controlled should be evaluated, at a minimum, on a daily basis. Many studies have demonstrated that nurses and physicians alike (but particularly physicians) underestimate the extent of a patient's pain. Therefore, if there is any question, one should err on the side of giving more pain medication, not less. Narcotics are the most fTequently used and generally preferred agents. Narcotics are potent, and potency is required, given the severity of injury in the trauma population and those undergoing major surgery. Narcotics provide some independent element of sedation, which can be helpful for the patient whose condition requires mechanical ventilation. This effect is at least additive to that of other sedative agents. Contrary to popular belief, narcotics do not include addiction in those patients who truly have pain and are receiving titrated doses. Morphine is the preferred agent because it is the least expensive, works as well as other agents, and has a side-effect profile that is no less favorable. It is best used as an infusion because it provides for more uniform pain control. Patients should first receive intravenous morphine with doses that range from 2 to 20 mg. Bolus doses should be administered slowly (minutes) to avoid hypotension as the result of histamine release. Infusion rates begin at 1-3 mg/h, but can exceed 30 mg/h. An as-needed order for morphine should also be provided for all patients. In addition to the intravenous infusion of narcotics, the following methods may also be considered in appropriate patients: Patient-controlled analgesia Epidural analgesia Intrapleural catheter Trancutaneous electrical nerve stimulation Intercostal nerve block

tube drainage, or appearance of hemoptysis should be made. Serial determinations of the patient's hematocrit level and chest tube drainage along with serial chest radiographs are standard.

Pain and Pain Control The primary goal of postoperative pain control is patient comfort and well being. This allows for effective sighing, coughing, early ambulation, and Curr Probl Surg, November 2000

793

Fig 12. Chest radiograph after left pneumonectomy.

physical therapy. Thoracotomy is a painful procedure (less so with median sternotomy), despite attempts at limited and muscle-sparing incisions. Pain is most severe the first 3 to 5 days. However, pain can persist longer. Inadequate pain control leads to splinting, anxiety, depression, agitation, hypoventilation, inability or reluctance to cough, and inability to effectively complete adequate physiotherapy. Subsequently, the risk for atelectasis, collapse, pneumonia, and respiratory failure rises with reintubation and mechanical ventilation. A variety of techniques have evolved for pain control after thoracotomy; these often involve a detailed knowledge of the relevant anatomy (Fig 11). Options for analgesia are summarized in Table 39. The pain management protocol at UMMC is summarized in (Table 40). 142-144 Systemic Opioids. Data from patients who used parental morphine pain control have shown that postoperative pulmonary mechanics are decreased considerably (77% decrease in VC, remaining 50% to 24 hours; 57% decrease in MVV). For these patients, improved methods are necessary, especially in the highest risk groups. 794

Curr Probl Surg, November 2000

Intercostal Nerve Block. Usually 2 to 4 mL of a long-acting local anesthetic is injected into the intercostal nerve at the level of the incision; care is taken not to inject too far posteriorly near the spinal area. Two intercostal nerves above and below the incision are also injected. Allergic reactions are uncommon, and toxic effects may be suppressed during general anesthesia. When patients are awake, however, generalized seizures may occur.

Epidural Anesthesia. An epidural catheter is placed in the lower thoracic spine before thoracotomy. A variety of agents can be used, including local anesthetics (eg, bupivacaine) or narcotic (eg, morphine, fentanyl). Continuous or intermittent epidural anesthesia has been shown to be very effective and is the preferred method for control of postoperative pain. 5355 The disadvantage of this method of pain control includes possible hypotension, urinary retention, and somnolence. Respiratory depression can occur if the infusion rate is too high. Puritis is a common side effect of a morphine epidural that is not usually encountered if fentanyl is used instead. Once the epidural is discontinued, intravenous narcotic or oral medications are used for pain control. If pain continues to be a problem, intermittent intercostal blocks can be administered. Persistent Postthoracotomy Pain. Postthoracotomy pain syndrome is pain that recurs or persists along the incision at least 2 months after operation. The incidence of this complication ranges from 2% to 6 7 % . 145'146

Mediastinal Shifts After lung resection, including pneumonectomy, the mediastinum shifts to the resected side. The shift should be gradual, slowly compensating to obliterate the space. A rapid or excessive shift usually occurs with atelectasis of the resected side or contralateral lung hyperexpansion. With pneumonectomy, the empty space fills gradually with proteinaceous fluid, with mediastinal shift, elevation of the diaphragm, and narrowing of the interspaces (Fig 12).

Atelectasis Atelectasis is a common postoperative problem. 147 It occurs in most patients who undergo thoracic procedures and in most patients who undergo general anesthesia. The clinical findings include fever, tachypnea, and tachycardia. Decreased breath sounds, bronchial breathing, and rales are the major physical findings. Cough suppression (caused by sedation or pain) or retained or thick secretions are the major causes. As the bronchus and bronchioles obstruct, the distal lung collapses. Infection can ensue if the obstruction is partial and unrelieved. Pulmonary physiotheraCurr Probl Surg, November 2000

795

TABLE 41. Criteria for reintubation

Stridor Cyanosis Agitation, anxiety, restlessness, combative Inability to speak short sentences because of dyspnea Increased hypertension or tachycardia pH < 7.25 Oxygen saturation < 85%

TABLE 42, Indications for mechanical ventilation Clinical factors Spirometry Respiratory rate (per minute) Vital capacity (mL/kg) Tidal volume (mL/kg) Inspiratory force (cm H20) FEV1 (mL/kg) Oxygenation Pao2 room air (mm Hg) Pao2 100% 02 (ram Hg) P(A-a)o2 room air (ram Hg) P(A-a)o2 100% 02 (mm Hg) Qs/QT(%) Ventilation Paco2 (mm Hg)

Values

>35 <10 <3.5 >-20 <10 <50 <200 >60 >450 >40% >55

Qs,/Qr, Flow shunt/flow total.

py, including coughing, ambulation, incentive spirometry, and percussion/postural drainage is the mainstay of treatment. Pain control is crucial to allow for the increased mobility required. However, therapeutic bronchoscopy, be it flexible or rigid, still has a place in the treatment of atelectasis or collapse.

Respiratory Failure Postthoracotomy acute lung injury and secondary respiratory failure are defined as the need for mechanical ventilation beyond 48 hours, whether initially or at reintubation. This is a major complication of thoracic operation, particularly after lung resection operations. The incidence varies from 0.2% to 2.6%. Respiratory failure is the single most important determinant of the operative mortality rate in 40% to 100% of cases. Kutlu and colleagues ~48 reported 1139 patients over 7 years who underwent pulmonary resection. The incidence of lung injury was 3.9%. The overall mortality rate was 3.5%, with acute lung injury the cause in 72.5% cases, dysrhyth796

Curr Probl Surg, November 2000

TABLE 43. Goals of mechanical ventilation Support oxygenation Optimize effective gas exchange Rest inspiratory muscles Allow more aggressive pain control, sedation, controlled ventilation and pulmonary toilet Physiologic weaning fTom mechanical ventilation

TABLE 44. Techniquesfor preventing respiratory insufficiency Aggressive bronchial toilet and control of secretions; incentive spirometry Early ambulation and physiotherapy Aspiration prevention, by avoiding early feeding in patients with edema of the hypopharynx and vocal cords; nasogastric decompression of gastric distension Avoidance of over-zealous fluid administration with risk of pulmonary edema Effective pain control Aggressive treatment of lung atelectasis and collapse, including nasotracheal suction and early bronchoscopy

mias in 12.5% cases, pneumonia in 5% cases, and pulmonary embolism in 5% cases. Attention to operative details and early postoperative treatment will prevent or decrease this morbid complication. Lung expansion, avoidance of atelectasis, prevention of fluid overload, control of secretions, and pain control are important considerations. After extubation, chest physiotherapy that includes incentive spirometry and early ambulation is stressed. The vulnerable period for respiratory distress is the first 36 to 48 hours after extubation. Heart failure may sometimes mimic respiratory failure and at times coexist. The usual causes of early respiratory failure (<24-48 hours) include atelectasis/collapse, an inability to cough and clear secretions, fluid overload, congestive heart failure, pneumothorax, and sepsis. Beyond 48 to 72 hours, the usual cause expands to include adult respiratory distress syndrome (ARDS) and acute lung injury. The incidence of respiratory failure after thoracotomy that requires shortor long-term mechanical ventilation is 5% to 15%. The criteria for reintubation and subsequent mechanical ventilation are summarized in Tables 41 and 42. The goals of mechanical ventilation are listed in Table 43. Despite attention to predisposing risk factors, operative techniques, and perioperative weaning guidelines, patients may experience failure to wean or require reintubation. Epstein and colleagues 149 reported a 15% reintubation rate in a series of 289 patients in a medical intensive care unit. Similar data regarding patients who undergo thoracic operation are not available. Patients who underwent reintubation had a higher ultimate mortality rate and need for long-term care. Attention to several aspects of the Curr Probl Surg, November 2000

797

]'ABLE 45. Diagnostic criteria for ARDS*

Diagnostic criteria may include: Underlying disease or injury known as a factor in ARDS development Hypoxemia Clinically relevant respiratory distress Tachypnea Pao2/Fio2 <150, or <200 with PEEP Radiographic evidence of multilobar infiltrates Evidence of generalized process on the chest radiograph Presence of patchy inhomogeneity on chest CT Cardiac filling pressures low enough to ensure a noncardiac cause of the pulmonary infiltrates Associated with ARDS and sometimes included as diagnostic criteria: Reduced pulmonary compliance (stiffening of lung parenchyma) Improved oxygenation in response to increased PEEP Thrombocytopenia Increased pulmonary artery blood pressures PEEP,Peak end-expiratory pressure. *Can include a variety of criteria, and specific entry criteria often vary between studies. From Russell GB, Campbell DB. Thoracic trauma and adult respiratory distress syndrome. Semin Thorac Cardiovasc Surg 1992;4:241-6.

postoperative care (Table 44) can minimize and hopefully prevent respiratory insufficiency. Respiratory insufficiency should be treated aggressively. Early intubation provides control of the airway and allows aggressive suctioning until the underlying problem can be corrected. If a patient's condition fails to respond to extubation or if a patient has thick secretions or experiences severe respiratory failure that requires extended intubation, the patient should undergo tracheostomy early. Tracheostomy is more comfortable for the patient and improves the management of pulmonary toilet.

Pulmonary Edema Pulmonary edema generally is encountered as respiratory failure. The patient is tachypneic, cyanotic, and agitated. The most common cause of postoperative pulmonary edema is overhydration. Other causes include myocardial infarction, pulmonary capillary injury, or hypoproteinemia. Treatment includes diuresis, morphine, oxygen, and fluid restriction. For severe pulmonary edema or congestive heart failure, positive-pressure ventilation and inotropic agents may be required, ff cardiac failure is due to a dysrhythmia, the underlying problem should be corrected first.

Adult RespiratoryDistressSyndrome ARDS is the most severe form of respiratory insufficiency (Table 45). 15~ This condition may be due to aspiration, sepsis, systemic inflammatory response syndrome, or massive transfusion. It is similar to pulmonary 798

Curr Probl Surg, November 2000

TABLE 46. Criteria for organ dysfunction or failure Organ or system

Dysfunction

Pulmonary

Hypoxia that requires respirator-assisted ventilation for at least 3 to 5 days Hepatic Serum bilirubin level _>2 to 3 mg/dL or liver function tests >_twice normal Renal Oliguria <__479 mL/24 h or rising creatinine level (_> 2 to 3 mg/dL) Intestinal Ileus with intolerance to enteral feeding > 5 days Hematologic PT and PIT levels elevated > 25% or platelet count < 50 to 80,O00/mm a Central nervous Confusion, mild disorientation system Cardiovascular Decreased ejection fraction or capillary leak syndrome

Advanced failure Progressive ARDS that requires PEEP > 10 cm H20 and Fio2 > 0.50 Clinical jaundice with bilirubin level -> 8 to 10 mg/dL Renal dialysis Stress ulcers requiring transfusion, acalculus cholecystitis Disseminated intravascular coagulation Progressive coma Hypodynamic response refractory to inotropic support

PEEP,Peak end-expiratorypressure. From Deitch EA. Multiple organ failure. Ann Surg 1992;23.6:117-34.

edema, but on the chest radiograph, this process is more global, with classic patchy infiltrates. The patient is hypoxic with hypercarbia. The patient should be intubated at the first sign of the syndrome. Diuresis can also be helpful. Positive end-expiratory pressure of 5 to 10 cm H20 is used initially. It should be remembered that there is a fine line when balancing increased airway pressure and the potential bronchial stump "blowout." The patient has decreased compliance with increased peak airway pressures. Early tracheostomy is indicated. Patients are often sedated to increase compliance. Pressure control ventilation can be used with caution: Pressure control ventilation will recruit alveoli, but it can cause bronchial stump "blowout." ARDS in the patient who has undergone pneumonectomy is almost uniformly fatal. In the patient after lobectomy, the mortality rate is also high. Zwischenberger and colleagues ~51 summarized the approach to early respiratory failure. An emphasis is placed on high-frequency ventilation modalities and the newer therapies of nitric oxide, surfactant, partial liquid ventilation, and sophisticated extracorporeal techniques.

Long-term Ventilation The most dreaded complication of a major thoracic procedure is the need for prolonged or long-term mechanical ventilatory assistance. ~52 Most of these patients also have varying degrees of multiple organ failure. Complications specific to long-term ventilation include pulmonary barotrauma, pulmonary fibrosis, respiratory muscle deconditioning and fatigue, and pulmonary emboli. Curr Probl Surg, November 2000

799

"I'AFI.E 4"/', Definition of individual organ system failure"

Cardiovascular failure (presence of I or more of the following): Heart rate _<54/min Mean arterial blood pressure _<49 mm Hg Occurrence of ventricular tachycardia and/or ventricular fibrillation Serum pH _< 7.24 with a Paco2 of < 49 mm Hg Respiratory failure (presence of I or more of the following): Respiratory rate _<5/min or _>49/min P~co2 _>50 mm Hg AaDO2 >_3 5 0 mm Hg (AaDO2 = [713 Fio=] - Paco2 - Pao2) Dependent on ventilator on day 4 of organ system failure (eg, not applicable for the initial 72 h) Renal failure (presence of I or more of the following): Urine output _<4 7 9 m L / 2 4 h or _< 159 m L / 8 h Serum BUN level >_ 100 m g / l O 0 dL Serum creatinine level > 3.5 m g / l O 0 dL Hematologic failure (presence of I or more of the following): White blood cell count _< 1 0 0 0 mm 3 Platelets -< 20,000 mm 3 Hematocrit level _<20% Neurologic failure Glasgow Coma Score _<6 (in the absence of sedation at any 1 point in a day) Liver failure Prothrombin time > 4 sec over control (in the absence of systemic anticoagulation) Bilirubin level > 6 mg/dL *if the patient has 1 or more of these criteria during a 24-hour period (regardless of other values), organ system failure exists on that day. From Knaus WA, Wagner DP. Crit Care Clin 1989;5:221-32.

Barotrauma is associated with a 13% to 35% mortality rate. Pneumothorax and the associated BPFs are the major manifestations. Chest tube thoracostomy and sophisticated management techniques for complicated BPFs are required. Pulmonary fibrosis or diffuse alveolar damage is related to longterm positive-pressure ventilation and high oxygen concentrations. Patients who undergo pneumonectomy pose additional problems that may require long-term ventilation. The loss of effective lung volume or function is the major factor. 153

Multisystem Organ Failure Multisystem organ failure is responsible for 50% to 80% of all surgical intensive care unit deaths. The incidence of multisystem organ failure after thoracic operation is unknown. The criteria for dysfunction or failure were summarized by Deitch 154 (Table 46). Heard and Fink 155 elaborated the definition further (Table 47). The cascade of failure, in order, is pulmonary, hepatic, intestinal, and renal. Hematologic falure and myocardial failure occur later. Preexisting comorbidity may modify the cascade, 800

Curr Probl Surg, November 2000

TABLE 48. Centers for Disease Control criteria for diagnosis of adult pneumonia*

Rales of dullness to percussion plus any of the following: New-onset purulent sputum or change in character of sputum Organism isolated from blood culture Organism isolated from sputum obtained by Transtracheal aspirate Bronchial brushings Biopsy New chest radiographic examination that shows progressive infiltrate, consolidation, cavitation, or effusion plus any of the following: New-onset purulent sputum or change in character of sputum Organism isolated from blood culture Organism isolated from sputum obtained by Transtracheal aspirate Bronchial brushings Biopsy Isolation of virus or viral antigen in respiratory secretions Diagnostic single antibody titer (IgM) or 4-fold increase in paired serum samples (IgG) for pathogen Histologic evidence of pneumonia *One or the other must be present. From Clevenger FW. Postoperative pneumonia. In: Fry, editor. Surgical infections. Boston: Little Brown; 1995. p 327-36.

however. For example, shock or renal dysfunction may cause renal failure to precede hepatic failure.

PostresectionPulmonaryEdema Pulmonary edema after pulmonary resection is a rare complication and occurs in 1% to 7% of patients undergoing lobectomy, bilobectomy, or pneumonectomy. It is more common after pneumonectomy, especially right pneumonectomy, than after lobectomy, with a mortality rate close to 80%. It was originally believed to be due to fluid overload. However, recent studies have shown that barotrauma, release of cytokines, microembolism, changes in pulmonary permeability with moderate pulmonar-y artery hypertension and increased pulmonary capillary pressure (pulmonary capillary pressure = pulmonary wedge pressure + 0.4 [pulmonary artery pressure - pulmonary wedge pressure]), and the type of chest tube drainage are contributing factors. 156']57 This is a diagnosis of exclusion, so it is imperative to exclude other diagnoses such as pneumonia, congestive heart failure, BPF, and pulmonary embolism. Pulmonary edema frequently occurs within 24 to 96 hours after operation and is manifested by progressive respiratory distress, hypoxia, and pulmonary infiltrates, with noncardiogenic pulmonary edema on the chest radiograph. There are usually no signs of sepsis, pneumonia, or aspiration. Curr Probl Surg, November 2000

801

Mechanical ventilatory support is usually required, and treatment is mostly supportive. The role of steroids is unproved. The use of a continuous positive-pressure airway mask recommended by Nabers and colleagues, 158 nitric oxide inhalation, and extracorporeal membrane oxygenation may provide temporary relief. 151 Recently Mathisen and colleagues 159reported the use of inhaled nitrous oxide. Eight patients who had undergone pneumonectomy were treated, and the Pao2/Fxo2 ratio improved from 95.2 to 127.6, with nitrous oxide administered at 10 to 20 ppm.

Aspiration Pneumonia The mortality rate associated with massive aspiration pneumonia has been reported to be as high as 70% and remains a dreaded postoperative complication. The aspiration syndrome is characterized by dyspnea, hypoxemia, bronchospasm, and shock. Tinstman and colleagues a6~reported 54 patients over a 3-year period with aspiration pneumonitis; of these patients, 20% underwent thoracic operation. This study also found that 50% of the patients experienced aspiration pneumonitis despite a normal level of consciousness. Most surgeons agree this problem must be addressed quickly and aggressively. Patients should have aggressive suctioning, bronchoscopy, and supplemental oxygen. The patient often needs intubation. High doses of intravenous corticosteroids have been recommended, t61 Broad-spectrum antibiotics are administered for the prevention of secondary bacterial infection.

Pneumonia In all thoracic procedures, pneumonia remains a significant cause of morbidity and death. The presence of preoperative pneumonia should be noted (Table 48). 162 It is important to distinguish contamination from colonization and infection. An asymptomatic untreated infection will almost certainly manifest itself perioperatively. Both community- and hospitalacquired (nosocomial) pneumonia carry equal risks. The anesthetic process is known to decrease immunity and increase the risk for pneumonia. Patients with chronic obstructive pulmonary disease or chronic bronchitis have colonization with H influenza and S pneumonia. Patients with HIV infection or acquired immunodeficiency syndrome are prone to tuberculosis and nosocomial infections. In these high-risk patients, elective broadened antibiotic coverage should be provided. An obstructing bronchial lesion may cause an indolent pneumonia in a collapsed or atelectatic lung. Attempts at preoperative identification may be prudent for the debilitated patient. A 5- to 7-day preoperative course of antibiotics is usually recommended for all patients with suspected or documented pulmonary infection. 162,163 802

Curr Probl

Surg, November 2000

Fig 13. Open decorfication. After 3 to 4 weeks, a fibrous peel develops that allows a precise stripping and subsequentexpansion of trapped lung. (From Hood RM, editor. Techniquesin thoracic surgery. 2nd ed. Philadelphia: Lea and Feblger; 1993. p 55. With permission.)

Intraoperative cultures of suspected or infected areas should be taken. Spillage requires sterile irrigation with saline or antibiotic solution. Recent data, however, warn against local topical vancomycin solutions in view of the rising incidence of methicillin-resistant S aureus. The most conmlon thoracic pathogens include streptococcus, pneumonia, staphylococcus, H influenza, and Gram-negative organisms, particularly Pseudomonas and proteus. The evaluation of perioperative pneumonia includes a general fever evaluation, chest radiograph, and CT scanning. Aspirated sputum, bronchial washing, bronchoalveolar lavage, protected specimen brush, transtracheal needle aspirate, and open lung biopsy have all been used to obtain an adequate specimen for cultures and sensitivity. Empiric broad-spectrum antibiotics should be selected on the basis of the clinical response and identification of specific pathogens. Antibiotic treatCurr Probl Surg, November 2000

803

~Post-LobectomyEmpyem~

\

~,VithoutBP~ [Closedchest draina8~

~losed chest draina~

[[Decoricatio~

J

,k

~istula close~

~ecortication/Myoplasty]

[Myoplasticclosurd

iThoracoplasty]

~ecorticatio~

~vlyoplasty/Thoracoplas~

Fig 14. Algorithm for treatment of postlobectomy empyema space. (From Miller .11.Acute and delayed space problems after pulmonary resection.Chest Surg Clin N Am 1996;6:615-21. With permission.)

ment must include the monitoring of serum levels, intervals, and durations. Central intravenous access may be necessary for long-term (4-6 weeks) treatment regimens.

Empyema Empyema is uncommon after lobectomy but not uncommon after pneumonectomy. The incidence of postoperative empyema is 2% to 5%. 44'164 The mortality rate is higher with postpneumonectomy empyema (PPE) and is usually associated with BPF. Inadequate control of perioperative pulmonary infections or residual postresection pleural spaces can lead to empyema. The contributing factors include surgery for suppurative lung disease; a break in sterile technique with gross contamination; prolonged air leak, BPF, or chronic postresection space; preoperative radiation and/or chemotherapy; and unrecognized esophageal injury. The clinical presentations of malaise, fever, leukocytosis, and pleural effusions are early markers of postresection empyema. Early treatment should include effective drainage of the pleural cavity, broad-spectrum antibiotics, and obliteration of the pleural postresection space. 165 For apical loculation, resection of the anterior second rib will provide adequate drainage. Empyema that is loculated in the base may be drained by thoracotomy and/or resection of the overlying rib. Pleural sterilization by the 804

Curr Probl Surg, November 2000

~Post-pueumonectorny Empyen~

~VIodifiedClat:ett Proceduret

~yoplastic closure/Thoracoplast~

~

~,lyoplasty/Thoracoplast~

\ ,/~losed chest drainage~

~dodified Claggett I

Fig '15. Algorithm for treatment of postpneumonectomyompyemo space. (From Miller Jl. Acute and delayed space problemsafter pulmonaryresection.ChestSurg Clin N Am 1996;6:615-21.With permission.)

Clagett procedure or space filling with muscle or omental transplant may be used. If the empyema is chronic and there is trapped lung, the patient may require decortication (Fig 13), closure of a BPF if present, and subsequent surgical obliteration of the pleural space. Most empyemas will resolve with adequate drainage and antibiotics. Further treatment depends on the size of the cavity and includes antibiotic coverage, open or closed drainage, and residual space reduction by partial thoracoplasty or muscle flap transposition (apical space empyema usually requires more than simple drainage, although inferior space empyema may respond to drainage/antibiotics). Algorithms for the management of postlobectomy and PPE spaces are given in Figs 14 and 15. The Eloesser flap (thoracic fenestration) remains a useful technique for patients with complications or who are debilitated (Fig 16).

SubcutaneousEmphysema Subcutaneous emphysema occurs when air in the pleural space is trapped under tension and dissects into the subcutaneous tissues. Air dissection usually occurs through chest wall incisions or chest tube sites around nonfunctioning tubes. Air may dissect onto the chest, neck, arms, face, eyelids, abdomen, and scrotum. It is usually uncomfortable but rarely severely symptomatic or critical in effect. It could, however, be Curr Probl Surg, November 2000

805

Pleura-~

B~ B

:m'~,i~y

~

C =k

A

DrBin~e

N D

Fig 16. EIoesserflap technique. A, U-shaped flap of skin and fat is raised. R, Base of flap is at level of lowest rib. Rib at bose is resected with periosteum and intercostal vessels.C, Tip of flap is turned up into chest and sutured to the pleura. (From Ravitch MM, Steichen FM, editors. Atlas of general thoracic surgery. Philadelphia: Saunders; 1988. p 291. With permission.)

complicated by a tension pneumothorax. If chest tubes are in place with an active air leak, the tube may be occluded or leaking into the subcutaneous tissues. If the chest tubes have already been removed, then a subtle leak was missed or recurred after the tubes were removed. Treatment consists of replacing nonfunctional or previously removed chest tubes. If the indwelling chest tube is patent, an additional chest tube may be needed. Occasionally a bronchial stump leak may have occurred. The use of surgical skin incisions is not indicated because they treat the effect and not the cause. The CT scan may provide useful definition of undrained air spaces and guide the placement of new or additional chest tubes. There are no long-term complications of subcutaneous emphysema, if recognized early and massive progression into the neck is prevented.

Air/Space Complications Persistent Air Leak. The incidence of persistent air leak varies from 3% to 20%, depending on the disease process, the extent of pulmonary resection, and the nature of the underlying pulmonary disease. 166,167Air leak is a common complication and persistent morbidity issue after operation for emphysematous or suppurative lung diseases. Undoubtedly, air leak is procedure-dependent, and there is some variation in the definition of per806

Curr Probl Surg, November 2000

TABLE 49. Intraoperative maneuversto minimize air leak and space problems

Staple incomplete fissures Oversew parenchymal leaks Buttress staple closure (ie, pericardium, polytetrafiuoroethylene) of emphysematous lung tissue Glue - fibrin Free up inferior pulmonary ligament Phrenic nerve injection, pinch, or crush Apical pleural tent Lyman Brewer maneuver (dissection of cardiophrenic attachments or phrenoplasty) Muscle flap closure Rarely, tailored thoracoplasty Pneumoperitoneum (placement of catheter through diaphragm, into peritoneal cavity, out intercostal space, with intraoporative and postoperative instillation of air) Pericardial fat pad Transplanted diaphragm

sistent air leak, an air leak that persists for more than 7 days. Air leak may be from a BPF or from a disrupted visceral surface of the lung after decortication, A small visceral pleural defect in an air-trapped bullous lung will give a persistent large volume air leak and require surgical intervention for closure. The significance of persistent air leak is not in its duration but in its impact on outcome and resource use, measured in terms of prolonged hospital stay and costs. Ideally, an air leak should be controlled adequately at the time of operation, taking into consideration the disease entity, the amount of lung to be resected, and the pulmonary reserve of the patient. The best treatment for this enigmatic problem is prevention by paying careful attention to the preoperative evaluation. Rice and Kirby 166 found male gender, the presence of pneumothorax on the first postoperative chest radiograph, and FEV1/FVC ratio less than 50% to be independent predictive factors for the development of persistent air leak. Patients who undergo lung volume reduction operation should routinely have the staple lines buttressed with bovine pericardium 168'169or polytetrafluoroethylene strips to reduce postoperative air leak. In general, it is advisable to divide all lung parenchyma (particularly incomplete fissures) with a stapler technique. 17~ Preoperative evaluation of the chest CT and greater attention to pulmonary function testing will help the surgeon in choosing the best intraoperative maneuver to reduce pleural space and consequently minimize air leak. Brewer and colleagues 171 developed the pleural partition to prevent overexpansion of the lung. This procedure, which is now better known as "pleural tent," is commonly used to reduce pleural space, especially after bilobectomy and upper lobectomyf127j32-134 Burdette 172 and Brewer and Gazzaniga 173 transplanted the diaphragm to a Curr Probl Surg, November 2000

807

7 DAYS

/ CHECK SYSTEM

OBSERVE

INCREASE SUCTION

1

STOP SUCTION MOVE TUBE

14 DAYS

/

PULL TUBE SCLEROSIS

/ PULL TUBES

WATERSEAL

=

REOPERATE

HEIMUCH VALVE

BACK TUBE OUT Fig 17, Algorithm for a practica] approach to postoperative air leaks. {From Picciane W, Faber LP. Management of complicationsrelated to pulmonary resection. In: Waldhausen JA, Orringer MB, editors. Complicationsin cafdiothoracicsurgery.St Louis[ME)]: Mosby-YearBook; 1991.p 336-53. With permission.)

higher level to obliterate part of the inferior dead space. The use of the pericardial fat pad to seal alveolar leaks has also been used with great success. 174 A summary of the techniques is shown in Table 49. Most air leaks will resolve spontaneously within 3 to 5 days. When an air leak persists beyond 5 to 7 days, the initial approach is to reduce or discontinue suction from the drainage system or add another apical chest tube. The use of talc or chemical pleurodesis a75 will often suffice, but several authors have had success with the use of an autologous blood patch. 176,177If the air leak is due to BPF from a segmental bronchus, the use of endobronchial fibrin glue 178 or cyanoacrylate gluO 79 has been found to be successful. In some patients, the induction of pneumoperitoneum 18~ will help to elevate the diaphragm and thereby reduce the residual inferior space. If there is no reason to keep the patient in the hospital and if expansion of the lung is maintained without chest tube suction, a Heimlich valve device can be placed, and the patient can be followed as 808

Curr Probl Surg, November 2000

CT on suction until POD#2 Then water seal

I I CXR showed no pneumothorax

I

CT letl on water seal

I ~CXRwithpneumothorax I I

IfA/L CT 10cm suction

I

I

If no A/L CT 2gem suction

Fig 18. Approach to air leaks (A/L), based on presumption that air leaks ore expiratory only. POD, Postoperativeday; CXR, chest radiograph. Reprintedwith permissionof the Society of Thoracic Surgeons (Cerfolio RJ, Tummala RP, Holman WL, et al. A prospective algorithm for the management of air leaks after pulmonary resection.Ann Thorac Surg 1998;66:1726-31 .)

an outpatient. 181 An air leak that persists for more than 4 weeks, or suddenly increases, should prompt consideration for reoperation to control the air leak. A practical approach to most persistent air leaks is summarized in Fig 17. Cerfolio and colleagues 175 developed an algorithm (Fig 18) in which they concluded that air leaks were expiratory only. Conversion from suction to water seal was effective. Treatment of Residual Spaces. After thoracotomy, one of the primary goals is to restore the intrathoracic environment. 18z With lung resection, the remaining lung fills the remaining thoracic cavity with restoration of a negative intrathoracic pressure. Chest tube drainage with suction is the principal method of restoring this negative pressure. The most common causes of residual apical space are restrictive lung disease (fibrosis), contracted lower lobe (trapped and/or atelectasis), resection of more than 1 lobe (significant lung/thoracic cavity mismatch), and undrained, loculated, postresection air/fluid collections. Eighty percent of postoperative residual spaces are benign and asymptomatic and require no further treatment.t83 Another 10% will remain persistent, but stable and minimally symptomatic, and will require minimal drainage maneuvers. Eight percent of the remaining group will obliterate with additional drainage procedures. The final 2% will require an additional operation for complete obliteration. Most postresection space problems resolve from a combination of physiologic events after lobectomy. The remaining lung hyperinflates; the mediastinal structures shift to the operative side; the hemidiaphragm elevates; the rib spaces narrow and Curr Probl Surg, November 2000

809

4~kcute[< 14days~

1. Apicalchesttube

/~hronic(> 14da~s%

~o Infeetion]Notreatmenl

~3penDrainagd I[Clagett/ Eloesser]l

2. HeimlichDrainage System

~nfection- Treat as BP~ 3, EloesserOpen Drainage

1. Muscle flap 2.

Thoracoplasty 4. ApicalThoracoplasty Partial/Tailored

3.

Thoracoplasty 5. CompletionPneumonectomy

6. MuscleFlapThoracoplasty Fig 19. Algorithmfor treatment of postresection apical space. 8PF, Bronchopleural fistula.

approximate; and fluid collects in the recesses and fissures. The management of postresection spaces depends on several factors. Space problems can be divided into apical or inferior and can be classified as acute or chronic. 182 The algorithms for the management of these conditions are shown in Figs 19 and 20.

BronchialStumpLeak Attention to the bronchial stump closure is the key to avoidance of bronchial stump leak or "blowout." Careful closure with manual suture or a mechanical staple technique is essential (Fig 21). A bronchial artery blood supply is necessary. Too meticulous dissection of the bronchus is unnecessary and unwarranted. Lymph node dissection must be performed carefully to avoid excess devascularization of the bronchus. In general, the left bronchial stump rarely needs coverage because it is up and under the aorta. In patients with infection, radiation, or compromised blood supply, more attention is warranted. If bronchial stump skeletonization occurs, vascularized pedicle coverage 810

Curr Probl Surg, November 2000

TABLE 50. Riskfactors for the development of bronchopulmonary fistula Risk factor Need for prolonged ventilatory support Operation for suppurative lung disease Post-radiation (steroid therapy/chemotherapy) Right pneumonectomy Completion pneumonectomy Residual tumor on bronchial stump Inadequate closure of stump Devascularization of bronchial stump Mediastinal lymph node dissection

Percentage 1g.3 8.1 6.7 5.8 5.4 3.5 3.0 2.5 1.5

is necessary. Intercostal muscle, pedicled pleura, pericardial fat pad, pericardium, omentum, and even diaphragm have been applied and advocated. A bronchial stump leak or rupture ("blowout") is disastrous, with a mortality rate as high as 23%. The overall rate of bronchial stump "blowout" is less than 3%. Scarred areas from infection or radiotherapy can cause difficult dissection with an increased risk of damage and devascularization. Radical lymph node dissection may also cause local compromise of the bronchial blood supply to the area. There is controversy regarding the issue of hand-sewn suture closure or mechanical stable devices. 184-186The parallel-jaw stapler is far superior to the hinged-jaw stapler. Long bronchial stumps should be avoided. Testing of any closure technique should be done intraoperatively with the closure submerged in saline solution and tested for leak at 30 to 40 cm H20 of direct airway pressure, Coverage of the exposed bronchial suture line should be performed in most cases with a vascularized pleural flap or omenturn, especially in patients who receive neoadjuvant chemoradiotherapy.

Bronchopleural Fistula Postpneumonectomy BPF remains a serious and often life-threatening complication. It may occur days, weeks, months, or even years after the operation. The incidence varies from 2% to 6%. Kaplan and colleagues 187 reported an incidence of 4.5% among 674 patients who underwent pulmonary operation between 1980 and 1986 in which the staple closure technique was used. Vester and colleagues ]86 reported an incidence of 1.6% after 2243 stapled pulmonary resections at the Rush-Presbyterian-St Luke's Medical Center. These investigators found the stapler to be expedient and simple to use while producing a hermetic and uniform closure. However, they cautioned against the use of a stapled closure when the bronchus is thickened, inflamed, or shortened. Wright and colleagues 188 noted an incidence of BPF of 3.1% among 256 patients who underwent pneumonectomy Curr Probl Surg, November 2000

811

---- ~nferiorSpac~

~Pneumoperitoneun~

Ii. No Infectiot~

Open Drainag~ /

treat as infected)

Allow fluid to fill space

/

[1. No Infection/// Allow fluid / to fill s p 7

-

Decortication with

- Muscle flap/

muscle flap or

- Thoracoplasty

- partial thoracoplasy 12. Infectio~

-

Open drainage by Eloesser flap

- Closed drainage by Clagett procedure -

Muscle flap thoracoplasty

- Partial or tailored thoracoplasty Fig 20. Algorithm for treatment of postresection inferior space. BPF, Bronchopleural fistula.

at the Massachusetts General Hospital. This diagnosis requires a high index of suspicion in a patient with persistent air leak, space infection, fever, and hemoptysis. The diagnosis is confirmed with bronchoscopy or bronchography or with methylene blue when the fistula is not readily apparent. Risk factors for the development of BPF are summarized in Table 50. In approximately 30% of patients, closure of the BPF occurs spontaneously, after a period of space drainage by tube or thoracic window. Various surgical interventions to obliterate the residual empyema space are successful in 80% of cases. 189 These interventions include noninfected postlobectomy or postsegmentectomy in patients with no residual tumor of the stump, ff there is concem intraoperatively about difficulty in stump closure, intercostal muscle or abdominal myocutaneous flaps, 19~ pericardial strip or pericardial fat pad, 194 and omentum195 have been found to be useful for buttressing the bronchial stump. In patients with early or delayed BPF with empyema, a very aggressive surgical approach is required for successful management. Immediate pleural drainage with continuous antibiotic irrigation, modified Claggett procedure196 or thoracoplasty,197and complete obliteration of the pleural space with muscle 812

Curr Probl Surg, November 2000

flaps, 198,199with the assistance of a plastic surgeon, are key to success. Even in those cases, the mortality rate approaches 50% to 80%. Death is usually from fulminating sepsis, ARDS, and multiple organ failure. The goal of reoperation is closure of the bronchial stump and obliteration of the remaining space. Reamputation of the stump with transposition of tissue for coverage should be performed when possible. If the patient is too ill to undergo a major operation, a permanent open thoracostomy with an Eloesser flap (Fig 16) can be performed and is usually well tolerated by the septic and cachectic patient. Chronic daily irrigation and packing will lead to resolution of sepsis and promote granulation. Nutritional supplementation for the patient is crucial. Lateral thoracotomy wound infections and dehiscence are uncommon. The wound will have erythema, edema, and increased tenderness. The wound should be opened, and any necrotic tissue should be removed. The wound should be opened, irrigated aggressively, and debrided periodically either at the bedside or in the operating room. The wound is closed after the drainage has stopped and when the cartilage and bone appear healthy. Closure is often accomplished with a pectoralis major flap because, after debridement, patients do not have enough skin and subcutaneous tissue to close the large defect adequately.

Esophagopleural Fistula Esophagopleural fistula usually follows esophageal injury at the time of pneumonectomy but is unusual (<1%). This complication can occur early or 1 to 25 years after operation and is usually due to recurrent tumor, erosion, or associated infiltration. It occurs more on the right, given the proximity of the esophagus to the hilar lymph nodes; and the segmental blood supply of the mid portion of the esophagus is the poorest. The esophagopleural fistula is often confused with a BPF; therefore, an esophagrarn is diagnostic. Treatment begins with prevention. A nasogastric tube inserted at the time of operation permits localization of the esophagus. In an inflamed hilum or during a completion pneumonectomy, the tissue planes are usually scarred and obliterated. If recognized at the initial operation, direct closure and a buttressed pleural flap and/or muscle are recommended. Delayed recognition demands initial drainage and subsequent operative repair. Acute and late fistulas are lethal, with a mortality rate approaching 60%. 2~176176

Subarachnoid Pleural Fistula Cerebrospinal fluid leaks after lung resection are rare and occur after avulsion of a nerve root from the dural sheath. Surgery in the posterior mediastinum or traction from extended exposure of a posterolateral thoCurr Probl Surg, November 2000

813

~r~hia/ ~tuttr c/ass:

/Aklrepted su/ates Fig 21. Bronchial stump closure with mechanical staples or interrupted sutures. (From Edmunds LH, Norwood WI, Low DW, editors. Atlas of cardiothoracic surgery. Philadelphia: Lea Febiger; 1990. p 185. With permission.)

racotomy can cause this problem. If recognized at the time of operation, careful closure and pleural flap reinforcement should be performed. If a period of postoperative closed drainage and partial Trendelenburg posture does not result in closure then surgical reexploration as a combined procedure with a neurosurgeon is appropriate. 2~176

Paraplegia Paraplegia after an intrathoracic procedure is almost always related to spinal cord injury rather than to a cerebrovascular accident. 2~ It is usually caused by injury at the posterior angle of the thoracotomy incision. Initially, this complication was described with the use of oxidized regenerated cellulase as a hemostatic agent for troublesome bleeding in the posterior angle. Subsequent migration into the spinal canal can occur. Attar and colleagues 2~ reported 40 cases of paraplegia after thoracotomy. 814

Curr Probl Surg, November 2000

Fig 22. Anatomy of the thoracic duct. The thoracic duct starts at the cisterna chyli, ascends near the esophagus through the aortic diaphragmatic hiatus, and eventually entersthe left subclavian vein. The single duct that enters through the aortic hiatus between T12 and T10 is consistentand the usual site for right thoracotomy and surgical ligation. (From Miller JI. Diagnosis and management of chylothorax. Chest Surg Clin N Am 1996;6:139-48. With permission.)

of the leak includes suture ligation of the leak with the use of nonabsorbable sutures and Teflon pledgets. Empyema is unusual in alkaline chyle media along with pleurodesis or pleurectomy. For complex situations in which the direct approach is inadvisable, the right thoracotomy or VATS approach is used. The duct lies low in the right chest above the right crus of the 816

Curr Probl Surg, November 2000

Intraoperative factors included bleeding at the costovertebral angle, migration of oxidized cellulase into the spinal canal, thrombosis of the anterior spinal artery, epidural hematoma, epidural narcotic, metastatic carcinoma, and hypotension. CT scanning or magnetic resonance imaging to demonstrate an area of block follows early clinical diagnosis. If a spinal block is noted, emergency laminectomy is performed to remove the compression area. Despite an overall incidence of 0.08%, the results are devastating, with most patients showing no improvement.

Lung Torsionand Gangrene Torsion of a lung lobe or an entire lung is r a r e . 2~176 Unrecognized, this condition can cause infarction, gangrene, and death. It occurs primarily after pulmonary resection, especially middle lobe torsion after fight upper lobectomy and subsequent impairment of pulmonary blood supply. Prevention is accomplished by affixing the middle lobe to the remaining lobe, especially when there is a complete transverse fissure.

Chylothorax The development of chylothorax that complicates intrathoracic operations is uncommon. This condition is encountered after transhiatal or transthoracic esophagectomy, extrapleural pneumonectomy, or mediastinal lymphadenopathy and vascular procedures around the descending aorta. It is manifested by milky whitish chest drainage, usually after the patient resumes an oral diet. The diagnosis is established if the pleural fluid triglyceride level is greater than 100 mg/100 mL. Lymphocytes predominate if the drainage is 400 to 500 mL per day. Cerfolio and colleagues, 2~ in a Mayo Clinic review of 11,315 patients who underwent general thoracic operations, reported an incidence of 0.42%. These investigators recommended surgical closure if the drainage is greater than 1000 mL per day and at 1 week, if after an esophageal operation. Merigliano and colleagues 2~ noted an incidence of 1.1% after esophagectomy. Reoperation was performed after the diagnosis was made. Also, since 1998, routine en bloc ligation of the thoracic duct above the diaphragm is performed during transthoracic esophagectomy. Hyperalimentation, cessation of oral intake, and a subsequent medium-chain tfiglyceride diet (usually 1 week later) constitute the initial nonoperative approach. Ferguson and colleagues 2~ advocated an ag~essive approach of reoperation after a 1-week trial in all patients. The operative strategy generally requires preoperative identification of the leak. Lymphangiography helps to identify the leak, to demonstrate any accessory ducts, and to illustrate the course of the main duct. Feeding the patient a high-fat diet several hours before operation may help. Operation on the side Curr Probl Surg, November 2000

815

TABLE 53.. Risk factors associated wilh increased mortality rales for pneumonectomy Underlying lung disease Right-sided pneumonectomy Pleuropneumonectomy Pneumonectomy with chest wall resection Pneumonectomy for trauma Comorbid medical disease (coronary artery disease, congestive heart failure, atrial fibrillation, hypertension) Age > 75 y

diaphragm on the vertebral bodies between the aorta and azygos vein (Fig 22). En mass ligation with pledgeted Teflon sutures is used. Low-volume but persistent chylous leaks may respond to talc sclerosis after a mediumchain triglyceride diet or intravenous hyperalimentation.

Tumor Embolus The frequency of tumor embolus after operation is unknown. Few cases have been reported in the literature. 2~176176 The incidence is less than 1% for patients who undergo pulmonary resection for lung cancer. Tumor embolism implies intrathoracic tumors that invade the heart chambers through the pulmonary veins and embolize into the systemic circulation. With the increasing use of CT scanning, magnetic resonance imaging, and 2-dimensional echocardiography, preoperative identification of masses that invade or involve the heart and vessels has increased. A left atrial mass usually indicates thrombus or myxoma. However, suspicion of a pulmonary venous tumor should be kept in mind. Further delineation may be needed, with a subsequent change in the operative strategy and approach. Direct extrinsic invasion or compression of cardiac structures is usually not a source of tumor emboli. To decrease the possibility of tumor emboli, it may be prudent to minimize manipulation of the pulmonary veins, especially with central tumors. With central or bulky tumors, a preoperative transthoracic or transesophageal echocardiogram may signal the presence of pulmonary venous or left atrial extension of tumor. Intrapericardial dissection and control are recommended to minimize embolization. Tumor embolization can also occur within the tracheobronchial tree. During double-lumen endotracheal tube, migration or embolization of left or fight stem bronchial tumors to the trachea or the opposite side can occur with operative manipulation, thereby obstructing ventilation. Bronchoscopy usually confirms this diagnosis and allows the removal of the obstructing tumor mass. Curr Probl Surg, November 2000

817

Complications Specific to Pneumonectomy Since the first successful en bloc pneumonectomy by Graham and Sanger in 1933, 211 a considerable wealth of experience has been gained in the conduct of more complex thoracic procedures. Surgeons now routinely perform pneumonectomy with en bloc resection of the chest wall, extrapleural pneumonectomy, completion pneumonectomy, bronchoplastic procedures involving the carina and great vessels, and pulmonary resection after chemoradiotherapy. The present day morbidity rates for pneumonectomy vary from 10% to 30%, and the operative mortality rate ranges from 3% to 12%. 212 A summary of the predisposing factors for morbidity and death is shown in Table 51. The major complications include respiratory failure, pneumonia, acute myocardial infarction, pulmonary embolus, arrhythmias, BPF, and empyema. Some of the rare complications that are unique to pneumonectomy were comprehensively reviewed by Kopec and colleagues.213 These include (1) postpneumonectomy syndrome (realignment, repositioning problem), (2) postpneumonectomy pulmonary edema, (3) esophagopleural fistula, (4) cardiac herniation, (5) chylothorax, and (6) diaphragmatic hernia associated with radical pneumonectomy. If future thoracic operation after pneumonectomy is planned, particularly a median sternotomy approach to the heart, the surgeon must keep in mind the mediastinal displacement of the heart toward the operated side. Damage to the hyperinflated lung on entry and inadequate exposure are possible and probable.

PostpneumonectomyEmpyema The frequency of PPE ranges from 5% to 10%. 44'212'214 It can occur at any time, but usually occurs in the first 10 to 14 days. PPE is usually classified as early or late (more than 3 months after operation). Late empyema is usually due to the hematogenous spread of infection from a distant source, although this complication can develop as the result of BPF or esophagopleural fistula. The signs and symptoms include fever, expectoration of purulent or serosanguineous fluid, and purulent drainage from the thoracotomy wound (empyema necessitatis). Suspicion must remain high for this diagnosis to be made. Often the patient has vague symptoms, weakness, anorexia, weight loss, and general malaise. This condition may mimic recurrent or active cancer. The signs and symptoms of PPE vary, especially in late onset (>3 months) empyemas. Imaging studies can be definitive, especially in early empyemas. On the chest radiograph, the mediastinum is observed to shift away from the PPS or to centralize and fail to move into the PPS. This 818

eurr Prob~ Surg, November 2000

reflects an increase in the PPS fluid because of exudation caused by empyema. The development of a new air/fluid level or the increase in size of an existing one may reflect a fistulous communication and associated empyema. In general, the sensitivity of chest radiographs in detecting empyemas is low. The chest CT scan may, however, demonstrate bulging of the PPS and locules or air fluid levels. The white blood cell count and erythrocyte sedimentation rate are elevated. But a nonspecific C reactive protein of less than 50 m/L on postoperative day 12 had a 100% negative predictive value for PPE. The diagnosis of PPE is confirmed by thoracentesis, with the finding of purulent fluid. The initial treatment is drainage of the PPS and intravenous antibiotics. The common organisms that cause empyema are S aureus and P aeruguiosa. Multiple organisms are common, however, in approximately 50% of cases. If a BPF is demonstrated to be associated with the PPE, then the treatment is complicated and requires sequential surgical procedures: open drainage (thoracostoma); a lengthy period of space packing and irrigation; and closure of both the BPF and empyema space by skeletal muscle transposition, often with a modified thoracoplasty. If PPE is unassociated with a fistula, then the space can be drained and irrigated to sterility. An antibiotic solution (based on appropriate organism sensitivities) is instilled, and the drainage tube is removed. This is a modified Claggett procedure. In approximately 25% of patients, BPEs will close after open drainage. These patients can now undergo sterilization and primary closure of the empyema space (classic Claggett procedure). The overall mortality rate for PPE is 25%. However, this increases to almost 50% if a BPF is present. 213,215

PostpneumonectomyBronchopleural Fistula Postpneumonectomy BPF occurs with an incidence that ranges from 1.5% to 4.5%. 216'217 The risk factors for the development of postpneumonectomy BPFs are the same as those for postlobectomy BPFs. Most cases of BPF occur early in the postoperative course; symptoms include fever, sepsis, empyema, purulent sputum, and respiratory failure, lv3 The diagnosis of late BPFs can be made from the chest radiograph. Normal postpneumonectomy changes include elevation of the hemidiaphragm, ipsilateral mediastinal shift, crowding of the ribs, and opacification of the pleural cavity as a result of fluid accumulation. The presence of BPF is strongly suggested on the chest radiograph by a new air/fluid level or a drop in the level of an existing fluid level. In some patients, there may be a mediastinal shift to the midline or to the contralateral side. The treatment for PPE and BPF is summarized in Figs 14 and 15. This complicaCurr Probl Surg, November 2000

819

tion occurs more often on the right side than on the left side. The associated mortality rate is very high, ranging from 50% to 80%.

PostpneumonectomySyndrome Postpneumonectomy syndrome, previously referred to as right pneumonectomy syndrome, is a rare complication that occurs after right pneumonectomy; but it has been reported after left pneumonectomy in patients with a right aortic arch. This syndrome is due to postoperative anatomic changes that cause extrinsic compression of the distal trachea or mainstem bronchus, usually caused by severe shifting of the heart and mediastinal structure to the fight and posteriorly. This leads to stretching and compression of the distal trachea and mainstem bronchus by the surrounding left pulmonary artery and the aorta or vertebral body. Compression then leads to tracheobronchial malacia and postobstructive bronchiectasisf118,219 Symptoms include signs of airway obstruction, recurrent pneumonia, and bronchiectasia. A delay in treatment may lead to respiratory failure and death. The diagnosis can be established by pulmonary function tests, chest CT scans, or bronchoscopy) 2~ The treatment is correction of the anatomic derangement by mediastinal repositioning and lysing of any adhesions between the lung and the mediastinum. In patients with left pneumonectomy, the expandable endobronchial stent may be useful. 221

Cardiac Herniation Cardiac herniation is a rare but fatal complication after intrapericardial pneumonectomy. This complication results from opening the pericardium and failure to prevent herniation. If the pericardium is left unclosed, the heart herniates out of the pericardium, which produces cardiac torsion and subsequent inflow and outflow obstruction. It occurs within the first 24 hours after pneumonectomy, but it has been reported to occur as late as 72 hours after pneumonectomy. Cardiac herniation occurs with equal frequency after right or left pneumonectomy and whether the pericardial defect is small or large. 222,223 The clinical picture is one of profound shock from inflow and outflow obstruction, cyanosis, and chest pain. Approximately 60% of patients with postpneumonectomy cardiac herniation have superior vena cava syndrome, usually after fight pneumonectomy. The chest radiograph demonstrates dextrocardia with marked mediasfinal shift. This condition can be hard to diagnose on the left in the patient whose condition is unstable. Prompt recognition and treatment are essential for survival. The patient should be returned to the operating room, and the heart should be replaced 820

Curr Probl Surg, November 2000

into the pericardium. Right herniation is treated with sutures, Dacron, or polytetrafluoroethylene patch to prevent recurrence. In patients with left herniation, closure of the pericardium should be avoided, and total pericardectomy should be performed (although this does not prevent herniation later). Some authors have advocated intraoperative prophylactic measures (such as closing the pericardial defect with a patch graft), whereas others have recommended surgically affixing the edges of the pericardial defect to the myocardium.

Acute Right-to-leftShunt In the acute setting, an increase in pulmonary artery pressure may cause fight ventricular dilatation, tricuspid insufficiency, and a subsequent increase in the pressure and volume in the fight atrium and a right-to-left shunt through a patent foramen ovale. This complication has been demonstrated in patients with acute right ventricular infarction and after pneumonectomy. 2z4 Unexplained cyanosis, decreased oxygen saturation, and a low PO2,despite an increasing FiO2, suggest the diagnosis, which can be established with transthoracic or transesophageal echocardiography after a bubble study to demonstrate both the patent foramen and the flow of bubbles across the defect. The treatment involves decreasing positive endexpiratory pressure (PEEP) and lowering the pulmonary artery pressures. Right-to-left shunting is a rare complication that occurs after fight pnuemonectomy and left pneumonectomy. It usually occurs weeks to months after operation, but it may become symptomatic within days of operation. It is characterized by dyspnea in the erect position (platypnea) that improves in the recumbent position. It is believed to be caused by the rotation of the heart after pneumonectomy, resulting in preferential drainage of the venae cavae into a patent foramen ovale or an atrial septal defect. In a review of the literature in 1991, Smeenk and Postmus z25 found only 21 cases, that two thirds of the patients had undergone right pneumonectomy, and that all of the patients had a fight-to-left shunt at the atrial level through a patent foramen ovale or atrial septal defect. Many of these patients had normal fight atrial pressure or equalization of both atrial pressures. However, Smeenk and Potmus also found that one half of the patients they reviewed had an elevated fight atrial pressure that accounted for the shunt. The diagnosis must be considered in patients with postpneumonectomy and unexplained recurrent dyspnea in the upright position, cyanosis, and productive cough without fever. The diagnosis is usually confuaned by Doppler echocardiography, cardiac catheterization, or magnetic resonance imaging. Closure of the atrial defect is easily accomplished by transcatheter clam-shell closure or by direct suture closure with the use of cardiopulmonary bypass. Curr Probl Surg, November 2000

821

Specific Procedure- or Disease-associated Complications

Bronchoscopy Flexible or rigid bronchoscopy is performed after local or general anesthesia has been administered to the patient. The Venturi technique allows continuous ventilation. Rigid bronchoscopy remains a valuable therapeutic technique for the removal of foreign bodies, control of hemoptysis, emergency airway control, and complicated pulmonary toilet. Flexible bronchoscopy is primarily useful to evaluate the tracheobronchial tree. The evaluation of pleural effusions is not very yielding, especially with a normal chest radiograph. The flexible bronchoscope is placed through the nasopharynx or through the endotracheal tube (usually 8F or 9F). Complications occur in a small percentage (0.8%-1.7%) of patients who undergo fiberoptic bronchoscopy. The mortality rate is less than 0.1%. Most complications are related to sedation, with a subsequent need for intubation and support. Seizures from topical anesthesia have been reported. Laryngospasm, bronchospasm, and glottic and subglottic edema are major causes of upper airway obstruction. Lip, teeth, pharyngeal, and laryngeal injuries are more associated with rigid bronchoscopy. Biopsies are associated with bleeding. Bleeding from transbronchial biopsy sites is usually bronchial arterial in origin. Occasionally, a parenchymal hematoma may rupture into the bronchus. With uncontrolled bleeding, the fiberoptic scope can be replaced with a rigid scope or endotracheal tube, which allows suctioning and avoids asphyxia. Control with pressure, local vasoconstrictors, and electrocautery can be used. A double-lumen endotracheal tube or bronchial blocker is used to gain local control with tamponade. At 24 to 48 hours, a decision is made regarding angiography with embolization or thoracotomy. Pneumothorax complicates transbronchial biopsy in less than 5% of cases. Most patients are treated with observation or needle aspirant. A symptomatic or expanding pneumothorax identified by serial chest radiograph warrants chest tube thoracostomy. 226-228

Esophagoscopy,EsophagealDilatation, and EsophagealStents Flexible esophagoscopy has supplanted rigid esophagoscopy as the most common diagnostic procedure for esophageal disorders. Significant bleeding is rare (0.03%). Aspiration is also rare. The incidence of perforation is 1% to 2%, with more than 50% of injuries occurring at the cervical esophageal level. Rigid esophagoscopy is avoided when the medical condition precludes the use of general anesthesia, muscle relaxants, or cervical spine positioning?z9 822

Curr Probl Surg, November 2000

Scalene LymphNode Biopsy Biopsy of the scalene fat pad in the supraclavicular area is performed infrequently today. Complications are related to stretch, electrocautery, or severance injury to the phrenic and, more posterolaterally, the spinal accessory nerve (trapezius muscle). The phrenic nerve lies on the anterior surface of the anterior scalenus muscle. Avoiding aggressive dissection with the electrocautery will decrease the frequency of most injuries. Deep dissection may produce a pneumothorax. Injury to the thoracic duct on the left side may cause a chylous leak.

Thoracentesis Thoracentesis is frequently performed by many physicians. The major complications include site pain, local hematoma, pneumothorax, hemothorax, local injury to the intercostal nerve, cough, vasovagal reaction, and injury to the spleen or liver. Pneumothorax occurs in 3% to 20% of cases; 20% require chest tube thoracostomy. Patients with chronic obstructive pulmonary disease have a higher risk of pneumothorax. With large pleural effusions, overly aggressive or rapid fluid aspiration with subsequent reexpansion of atelectatic or collapsed lung may cause intractable coughing or reexpansion pulmonary edema. With a trapped lung, a localized air space may remain. Closed pleural biopsy is usually performed in conjunction with thoracentesis to evaluate exudative effusions. The yield is highest for tuberculous pleurisy. Complications, particularly pneumothorax, are low (3%15%) if the fluid is free flowing.23~

Tracheostomy With the introduction of high-volume-low-pressure endotracheal tube cuffs, the incidence of tracheal injury has decreased. The duration of endotracheal intubation has increased, with a subsequent decrease in the need for tracheostomy. However, open tracheostomy and the recent percutaneous tracheostomy still remain viable and practical procedures for long-term mechanical ventilation, tracheal toilet, and removal of retained or purulent secretions and to bypass upper airway obstruction. An important technical consideration is to fenestrate the trachea without removal of tracheal cartilage. The incidence of complications varies from 6% to 50%, with a mortality rate of 0.9% to 4.5%. Early bleeding is common, but usually minor and venous. Major bleeding in less than 5% of patients is from larger veins or the thyroid isthmus. Early tube displacement or dislodgement, especially within the first 72 hours, requires airway control. Reintubation of the trachea may be difficult. Endotracheal intubation may be required. In a controlled area, usually tile operating room, Curr Probl Surg, November 2000

823

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Fig 23. Treatmentof tracheal innominate fistula. No attempt is made to reconstruct the damaged innominate artery. (From Leonard DJ, Rodriguez A. Tracheoinnominate artery fistula. In: Turney SF, Rodriguez A, Cowley RA, editors. Management of cardiothoracic trauma. Baltimore [MD]: Williams and Wilkins; 1990. p 373-8. With permission.)

the tracheostomy tube can be reinserted directly, over a wire or over a smaller endotracheal tube inserted through the stoma. 231 The percutaneous tracheostomy technique advanced by Ciaglia and colleagues 232 and Leonard and colleagues 233 has increased in popularity. The complication rate is generally lower (1 1%-14%). Paratracheal insertion and conversion to open tracheostomy are uncommon. The long-term complications of tracheomalacia and tracheal stenosis are comparable for open and percutaneous tracheostomy. Presently, the percutaneous technique is being performed increasingly in the intensive care unit setting. The anterior mediastinal tracheostomy is occasionally performed for malignancies of the cervicothoracic trachea and esophagus. Orringer 824

Curr Probl Surg, November 2000

reported 44 patients. 234 The mortality rate was 14%. Innominate artery erosion occurred in 1 patient.

Tracheal Innominate Fistula The incidence of tracheal innominate fistula that complicates tracheostomy is 0.3% to 0.7%. Unless recognized and treated, this complication is uniformly fatal. Even if treated surgically, the mortality rate is greater than 70%. Deaths occur from a combination of bleeding and asphyxiation. This complication occurs between 72 hours and 2 weeks after tracheostomy. The cause is either erosion of a low-lying tracheostomy tube into the innominate artery or erosion of the tracheostomy cuff balloon. Immediate treatment includes hyperinflation of the tracheotomy cuff. If this fails, the tracheotomy tube is removed and replaced with an endotracheal tube. Digital control is accomplished by placing the index finger between the trachea and anterior innominate artery. The artery is then compressed against the manubrium anteriorly. This temporizing method is followed by emergency operative repair, the details of which are summarized in Fig 23. 235

Tracheal Esophageal Fistula Extremely uncommon, this complication is encountered in patients with tracheostomy and prolonged mechanical ventilation. A combination of tracheostomy, debilitation, mechanical ventilation, and indwelling nasagastric tube all increase the risk of tracheal esophageal fistulas (TEFs). Aspiration of gastrointestinal contents from the tracheostomy stoma, insuffiation of air into the esophagus, and gastric distension highlight the diagnosis. The video esophagram confirms the diagnosis. Fiberoptic esophagoscopy is also helpful. In general, repair is not recommended while the patient is receiving mechanical ventilation. The operative technique is summarized in Fig 24. 235,236

Chest Tube Thoracostomy Originally described by Hippocrates, chest tube thoracostomy is the most common interventional thoracic procedure. In general, chest tubes with trocars should be abandoned. Closed chest tube thoracostomy is distinguished from open chest tube placement at the time of thoracotomy. The complication rate is 1% to 2%. Direct trauma to the rib, intercostal structures, lung, heart, mediastinal structures, diaphragm, and subdiaphragmatic structures (eg, liver, spleen, stomach) has been reported. Bleeding is the most significant complication, followed by lung parenchymal injury, usually in the setting of pleural adhesions. 136 Curr Probl Surg, November 2000

825

Mediastinoscopy Originally described by Chamberlain, the cervical mediastinal exploration is associated with low morbidity (2.5%) and mortality rates ~ (<0.5%). Knowledge of the local anatomy is essential to avoid major complications, particularly bleeding, pneumothorax, and tracheal injury. Digital or invasive monitoring of the right artery pulse warns the surgeon of anterior compression of the innominate artery. All biopsies should be preceded by local needle aspiration. The anterior chest should be prepped in case median sternotomy is required for massive bleeding. Most bleeding occurs with local nodal dissection or inadvertent injury to the aorta, azygous Vein, pulmonary artery, or superior vena cava. Minor bleeding is usually related to dissection and mobilization of lymph nodes with bleeding from nodal tissue or bronchial vessels. Clips, electrocautery of small bleeding areas, or local application of vasoconstrictors (eg, epinephrine) by either syringe or direct placement of hemostatic gauze packs is used to treat most bleeding. The origin is usually a bronchial artery or lymph node vessel. Major bleeding may require a median sternotomy to control innominate artery or pulmonary artery injuries. Subcarinal bleeding is approached better through a fight thoracotomy. A pneumothorax usually occurs on the fight side because of penetration of the mediastinal pleura. Routine closure of the cervical wound under water may prevent an occasional pneumothorax.229237

Anterior Mediastinotomy(Chamberlain Procedure) Anterior mediastinotomy is most frequently performed through the bed of the resected 2nd costal cartilage. Local long-term pain may occur. Ligation of the internal mammary artery precludes its use for future myocardial revascularization. With ligation of the internal mammary vein, there is also the risk of an arteriovenous fistula. Recurrent laryngeal nerve injury or major bleeding with nodal dissection in the aortopulmonary window can occurY 8

Video-assisted rhoracoscopic Surgery One of the greatest recent technologic advances in thoracic surgery is VATS. Thoracoscopic surgery has been available since Jacobaues 239first introduced the cystoscope in 1910 fo r urologic procedures and pleuroscopy in 1921 for lysing tuberculous adhesions. Recent advances in video technology have made the VATS procedure a valuable tool to the thoracic surgeon. A skilled operator and experienced operating room staff are essential. Complications after the VATS procedure have been classified as general and mechanical. Mechanical complications include failure 826

Curr Probl Surg, November 2000

f

Fig 24. Repair of tracheoesophagealfistula, A, Trachea is transectediust distal to the damaged segment. The esophageal defect is closed primarily, The distal trachea is intubated with sterile endotracheat tube. B, The esophageal repair is covered with a strap muscle. The trachea is then anastomosed with 4-0 polygJactin910 sutures.Reprintedwith permissionfrom the American Society of Thoracic SurgeoriS(from Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of aGquired nonmalignant trach~ esophageal fistula. Ann Thorac Surg 1991;52:759-65.)

of a stapling device to fire, failure of a stapling device to release, and mistaken identity of the targeted lesion. The general complications of VATS are diverse, and several authors have reported their experience in this area. 24~The most common complications attributable to VATS are bleeding, persistent air leak, tumor seeding at various operative sites, wound infection, pneumonitis, reexpansion pulmonary edema after talc pleurodesis for malignant pleural effusion, mistaken identity of targeted lesions, and the need for conversion to open thoracotomy. The rate of conversion to open thoracotomy has decreased significantly over the years because surgeons have become more adept and the indications for VATS have become more defined. Indeed, conversion to an "open" procedure is no longer regarded as a complication but rather as a continuum of the planned procedure. Needle localization of lesions deep in the lung parenchyma was used during the initial phase of Curr Probl Surg, November 2000

827

Fig 25. The maior types of bronchoplastic resections. A, Right upper sleeve Iobectomy; B, left upper sleeve Iobectomy; C, left lower sleeve Iobectomy; D, bronchoplastic repair. Partial sleeve resecting for benign tumor. (From LoweJE, Bridgman AH. The role of bronchoplastic procedures in the surgical management of benign and malignant pulmonary"lesions.J Thorac Cardiovasc Surg ]982;83:227-34.)

VATS with success, but the use of methylene blue for localization has not been as successful. However, needle localization is rarely used today. Kaiser and Bavaria ~41 reviewed 266 cases of VATS and found the rates of air leak, bleeding, and respiratory insufficiency to be 3.7%, 1.9%, and 7%, respectively. Yim and Liu z42 reviewed 1337 cases of VATS performed in Japan and found a morbidity rate of 4.2% and a mortality rate of 0.7%. Air leak, wound infection, and prolonged air leak were present in 1.6%, 1%, and 0.7% of patients, respectively. Jancovici and colleagues 243 reported 937 cases of VATS with an overall morbidity rate of 10.9% and a mortality rate of 0.5%. The most common complication in this series was air leak, which occurred in 6.7% of patients. Several authors have also compared the postoperative pain after VATS procedures with postoperative thoracotomy pain. 2443-45Although there is a decrease in postoperative pain 828

Curr Probl Surg, November 2000

and length of hospital stay after VATS procedures, there is no clear-cut evidence of improved outcome or reduction in the total hospital cost. Seeding of malignant cells after VATS procedures has also been a serious complication, which in at least one case resulted in a patient death. This complication was recognized during the early period of VATS when "endobags" were not used for retrieving surgical resection specimens. Downey and colleagues 246 sent out a questionnaire to thoracic surgeons who perform VATS procedures regarding their experience with tumor implants after operation. The survey revealed 21 cases of tumor implantations in various sites, with implantations in the port site as the most common location (two thirds of cases). It is now a common practice to use an "endobag" or "endopouch" for specimen retrieval for suspected malignant lesions. In patients with mesothelioma, tumor recurrence can occur at the thoracoscopy site, with an incidence of 1.6% to 4.2%. Prophylactic radiotherapy after VATS procedures may prevent this recurrence.

Laser Surgery The indications for laser surgery include photodynamic therapy for early bronchial and esophageal malignancy and palliative treatment of obstructive malignancies of the tracheobronchial tree and esophagus. Complications can occur to both the operating team and the patient. Laser induced injuries include retinal and macular bums, endotracheal tube damage, combustion and disposition of silica ask throughout the tracheabronchial tree, airway fires with extensive burns of the trachea, and bronchi and death by laser-induced air embolism. Low oxygen concentrations should be used, and nitrous oxide should be avoided. Laser palliation of malignant esophageal obstruction may be complicated by bleeding, perforation, and aspiration. With tracheobronchial procedures, the additional complications of smoke inhalation and secondary infection from inhaled tissue debris are also possible. In fact, tumor cells may be inhaled a s w e l l . 247

Bronchoplastic Procedures Traditional lung resections include wedge, segment, and lobe resections and pneumonectomy. Bronchoplastic procedures with preservation of uninvolved lung parenchyma have evolved for both benign and malignant conditions. A variety of procedures are now possible (Fig 25). The largest experience involves malignancy. Tedder and colleagues 248 reviewed the literature over a 12-year period that involved 1915 patients. The overall mortality rate was 7.5%, with respiratory failure the cause of death in 20.9% of patients. Complications included atelectasis distal to the anastoCurr Probl Surg, November 2000

829

Pericardial attachment

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Fig 26. Diaphragm incisions: A, radial incision; B, circumferential incision; C and D, incisions in safe areas. (From Merendino KA, Johnson RS, Skinner HH, et al. The intra diaphragmatic distribution of the phrenic nerve with particular reference to the placement of diaphragmatic incisions and controlled segmental paralysis. Surgery 1956;39:189.)

mosis, BPF, bronchovascular fistula, and benign stricture formation or stenosis. The local recurrence rate was higher after sleeve lobectomy (12.5%) than sleeve pneumonectomy (4.2%). Krugar and colleagues249 reviewed 79 patients treated over a 5-year period. The mortality rate was 5.1%. The specific morbidity related to the procedure was 13.9%, with bleeding from arterial erosion (5.1%) and BPF (3.8%) the most common.

Surgery of the Diaphragm Operations of the diaphragm are performed primarily for congenital defects, malignancy, and trauma. These operations may also be performed in conjunction with other operations in which resection or incision through the diaphragm is necessary. Operations that involve the diaphragm require knowledge of the innervation of diaphragm and the standard safe areas of surgical incisions (Fig 26). 25~ Injury to the diaphragm is characterized by elevation of the hemidiaphragm on the operated side. With lung resection or pneumonectomy, the diaphragm will normally gradually rise. If there is suspicion of injury, a sniff test under fluoroscopy will confirm the diagnosis. Intraoperative 830

Curr Probl Surg, November 2000

identification of the phrenic nerve with careful dissection and avoidance of electrocautery will prevent most injuries. Pinching, crushing, or local anesthetic injection of the phrenic nerve should be avoided.

Thoracic Outlet Syndrome The natural history of neurogenic thoracic outlet syndrome is variable. Between 60% and 90% of patients improve with conservative medical therapy alone. Failure rates from surgical approaches range from 1% to 57%. The reoperative failure rate is 50%. Surgical approaches (eg, transaxillary, supraclavicular, scalenectomy, posterior chest approach) are designed to relieve compression of the brachial plexus. A small number of patients need arterial repair or resection. Complications can be venous, arterial, lymphatic, or neurogenic. Subclavian vein injury results from lacerations because the first rib is mobilized anteriorly. The subclavian artery injury is uncommon, but repair may narrow the artery and cause hand ischemia or claudication. Lymphatic injury occurs on the left side during the supraclavicular approach. Neurogenic injury can involve the brachial plexus, the phrenic nerves, the long thoracic nerve, and the cervical sympathetic chainY 1,252

Surgical Access to the ThoracicSpine Surgical approaches to the spine include anterior, cervical, thoracic, and thoracolumbar access to the vertebral bodies. Performed mostly by orthopedic surgeons and neurosurgeons, the anterior neck approach to the cervical spine may cause esophageal injuries, especially if the anterior vertebral bodies erode or injure the esophagus,z53 Anterior thoracic approaches are performed in relation to the aorta on the left and the thoracic duct on the right. Injuries to both of these structures have been reported, especially with tearing of the intercostal arteries. Walsh and colleagues254 reported complications in 18 of 61 patients with cancer (29.5%), with underlying anterior resections of thoracic spine tumors, primarily for pain control.

Tracheal Surgery Mathisen 25s,256 reviewed all aspects of tracheal surgery and complications. The major consideration in patient selection is the avoidance of perioperative mechanical ventilation because the risk of anastomotic complications (including dehiscence) is prohibitively high. Other relative contraindications include steroids and previous radiation. The glottis must be functional. Traumatic intubation should be avoided. Most operations are performed for postintubation stenosis or tracheal tumors. The quality of the mucosa beyond the pathologic lesion is a major determinant of the Curr Probl Surg, November 2000

831

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complication rate. Tumor mucosa is usually normal, whereas postintubation mucosa has varying degrees of inflammation or fibrosis.

Mediastinal Operations The incidence of specific complications after mediastinal surgery is low. The approach to mediastinal masses is dictated by the location. An important aspect of mediastinal operation is the appropriate operative approach. 257,258Anterosuperior lesions are approached through a median sternotomy or anterolateral thoracotomy through the third or fourth interspace. Middle and posterior masses are approached through a lateral or posterolateral thoracotomy. Lesions that involve the posterior mediastinum and vertebral body or foramen require a posterolateral thoracotomy with extension along the vertebral column, as popularized by Grillo and colleagues259 (Fig 27). Respiratory failure, bleeding, infection, chylothorax, and neurologic injuries occurred in 9% of the Duke series of 400 patients, with 2% requiring reoperation; the mortality rate was 0.9%. Associated system syndromes pose an added risk. Myasthenia gravis, 832

Curr Probl Surg, November 2000

hypertension, hypercalcemia, thyrotoxicosis, and hypoglycemia are notable diseases to recognize and treat. Upper airway obstruction from anterosuperior masses and superior vena cava obstruction present anesthetic challenges in terms of intubation and maintenance of anesthesia. Local neurologic complications occur with aggressive median sternotomy exposure (eg, brachial plexus, stretch injury, especially with 1st rib fractures), posterior tumors with spinal extension (ie, spinal cord compression as the result of bleeding and hematoma), and thymomas with extensive dissection (unilateral or bilateral phrenic nerve injury). Thymectomy for myasthenia gravis is performed through the transsternal, transcervical, or VATS approach. 26~ The preoperative preparation and anesthetic management are essential. 261 The risk of respiratory dysfunction is increased with a duration of myasthenia gravis more than 6 years, coexisting respiratory disease, VC less than 3 L, and a pyridostigmine dose greater than 750 mg per day. Preoperative plasmapheresis removes circulating acetylcholine receptor antibodies and immune complexes. Steroids are weaned to minimize the risk of infection. Muscle relaxants are avoided. Cholinesterase inhibitors (eg, pyridostigmine [Mestinon], neostigmine [Prostigmine]) are decreased perioperatively.

Advanced Techniques Darteville 262presented several advanced techniques for pulmonary malignancies. Carinal pneumonectomy (mortality rate, 6.6%), superior vena cava resection and reconstruction (mortality rate, 7.1%), and extended operations for apical tumors that invade the thoracic outlet (mortality rate, 0%) were presented. Vanakesa and Goldstraw 263 summarized the anterosuperior approach (hemiclamshell operation). In a series of 22 operations, there were no deaths, and procedure-specific complications included thrombosis of an arterial graft, upper extremity edema after resection of the innominate or subclavian vein, and a chronic neurologic deficit in those patients undergoing resection of the T 1 and C 8 nerve roots. Lardinois and colleagues 264 reported 25 patients who underwent the herniclamshell approach (mortality rate, 87%; morbidity rate, 24%). Two patients with chylothorax required reoperation. Aside from a major wound complication that involved a trauma patient, there were no wound infections or other problems.

Lung Transplantation From 1985 to 1996, more than 4000 patients underwent lung transplantation worldwide. The 1- and 2-year survival rates approached 60% to 65%. 265 Meyers and colleagues 265 at Washington University reviewed 450 patients who received lung transplants over a 10-year period. The 5-year Curr prob[ Surg, November2000

833

actuarial survival rate was 54%. DeHoyes and Maurer266 summarized the early and late complications. Infection remains the major cause of morbidity and death. Immunosuppression is the primary risk factor for infection susceptibility. Anastomotic complications remain a major concern because of the lack of systemic bronchial arterial supply to the bronchial anastomosis. The technique of wrapping the anastomosis with omentum was a major advance,z67,z68Phrenic nerve injury occurs in 20% of adults, and recurrent laryngeal nerve injury occurs in 10% of adults. Early allograft dysfunction occurs in 15% to 20% of recipients. This condition is marked by hypoxemia, increasing pulmonary artery pressures, and pulmonary edema and is usually self-limited. This ischemic reperfusion injury has responded to inhaled nitric oxide. Acute rejection occurs in most patients and responds to steroids. Chronic rejection is usually refractory to increased immunosuppression. Fatal opportunistic infections result. Obliterative bronchiolitis is usually the late cause of death in these patients.

Lung VolumeReductionSurgeryfor Emphysema Chronic obstructive pulmonary disease affects 2 million people and is the fourth leading cause of death (more than 90,000 deaths per year in the United States). Strict selection guidelines have been established for the lung reduction operation, popularized by Cooper and colleagues.269 Presently, lung volume reduction surgery is being performed only in centers selected by the National Institutes of Health. 27~Severe kyphoscoliosis, a mean pulmonary artery pressure greater than 35 mm Hg, severe coronary artery disease, and previous thoracotomy are relative contraindications. Whether approached through median sternotomy, unilateral thoracotomy, or VATS, the principle is resection of emphysematous lung tissue by stapled resection or laser ablation. Yuson and colleagues271 reviewed 84 patients who underwent bilateral lung volume reduction surgery. The results were mixed and inconclusive. The overall mortality rate ranged from 2.4% to 6%. Prolonged air leaks (52%) and respiratory failure that required mechanical ventilation (4%) were the major complications. Reoperation and pneumonia were encountered in 10% and 11%, respectively.

Pediatric ThoracicSurgical Procedures There are anesthetic considerations unique to pediatric thoracic operationY 2 Intrapulmonary lesions and lung malformation may compromise the pulmonary function. Nitrous oxide and excessive positive-pressure ventilation should be avoided, especially when airway compression or expansion of communicating lung cysts or malformations may occur. Endotracheal intubation of the fistula in patients with TEF may occur. 834

Curt Probl Surg, November 2000

Regurgitation and aspiration of gastric contents through the fistula are hazards in patients with TEE Anterior mediastinal masses may cause acute airway compromise, especially if there is already greater than 33% luminal narrowing. Complications after a tracheostomy approach 10% to 30% and include the late complications of granulation tissue formation, tracheal stenosis, and tracheomalacia. Patients with pectus excavatum deformities have excellent results. Recurrent depression is a significant complication. Fonkalsrud and colleagues 273 reported 375 patients who were treated over a 30-year period and showed that the use of the sternal bar eliminated this complication.

Esophageal Procedures The common goal of operation of the esophagus is relief of dysphagia, with restoration of continuity and swallowing without obstruction, regurgitation, or aspiration. This involves both anatomic and functional considerations. The major diseases include cancer, motor disorders, reflux, congenital conditions, and trauma. Preoperative reflux with aspiration and malnutrition are significant risk factors. Hepatic dysfunction is also a significant factor. Operations are performed through a single incision or combined incisions and can be performed sequentially or staged. The general complications include bleeding, cardiorespiratory failure, and wound problems. Specific complications include anastomotic leak, perforation, and stricture formation. Anesthetic concerns include the avoidance of regurgitation and aspiration, which involves a rapid-sequence induction and intubation with cricoid pressure. Monitoring the hemodynamics is a particular concern during transhiatal blind posterior-mediastinal tunneling dissection. In these cases, hypotension that results from compression, arrhythmias, bleeding, tracheal injury, or pneumothorax c a n o c c u r . 274 Esophageal Resection. Since 1930, when the first successful esophageal resections were reported, the main difficulty has been anastomosis, principally because of the blood supply. 275'276Esophageal resection and reconstruction are performed for a variety of indications (both benign and malignant). Preoperative aspects, including risk assessment, and age have already been highlighted. Esophagectomy is the principal treatment modality for patients with resectable esophageal cancer. The mortality rate for resection for cancer, regardless of the approach, averages 5%. Cardiorespiratory complications occur in 15% to 50% of patients. Anatomic principles must be observed to avoid complications. The esophagus lies in close proximity to vital structures (such as the heart, aorta, vena cava, azygos vein, and thoracic duct and the vagus, phrenic, and recurrent laryngeal nerves). The hiatal area is in proximity to the Currprobl Surg, November2000

835

Fig 28. Cervical esophagogastric anastomosis. A, Gastric fundus "tacked" to prevertebrat fascia to decrease tension on anastomosis. A 2-cm button of stomach is excised9B, Posterior anastomosis with single layer 4-0 polyglycolic acid sutures with knots in lumen. The anterior anastomosis is completed with a 46F dilator in the esophagus to ensure an adequate, nonobstructed lumen. (From Orringer MG, Stirling MC. Cervical esophagogastric anastomosis for benign disease-functional results. J Thorac Cardiovasc Surg 1988;96:887-93. With permission.)

spleen and liver. The esophagus receives a segmental blood supply, yet the diffuse intramural vascular anastomoses permit adequate mobilization. There is no serosa, yet the submucosa is thick and strong. The organ is intimately related to the posterior aspect of the trachea, the aorta, the vagus nerve and its branches (notably the recurrent laryngeal nerves), and the thoracic duct. The surgical approaches include the left thoracotomy approach, left thoracoabdominal approach, the Ivor-Lewis approach (ie, abdominal and right thoracotomy incisions), and the transhiatal approach (Orringer technique). The stomach, jejunum, or colon is used to restore 836

Curr Probl Surg, November 2000

continuity. Preservation of the blood supply of the recipient organ and avoidance of local damage to structures and adjacent organs are important. Splenic injury may occur with capsular tears from adhesions or avulsion of the short gastric vessels. The preoperative evaluation must include an assessment of the suitability of the organs selected. The esophagus must be suitable proximally. The stomach must exclude mucosal or duodenal diseases. The colon must have an adequate blood supply; angiography is recommended in most situations. Mechanical and antibiotic bowel preparation is routine (neomycin/erythromycin 1 g each at 1, 2, and 11 PM the day before operation). The anastomotic technique at the Massachusetts Hospital has been successful since it was first described (Fig 28). Wilkins summarized the approach277: There is minimal dissection of the proximal esophagus ("2 cm). There is no tension and atraumatic handling of the edges. Cautery is avoided. An inverting two layer interrupted techniques utilizing 4-0 silk is used. This avoids pursestringing and undue pressure on the tissue edges. Given the mucosa is the strongest layer, inversion of this layer is crucial. The outer second layer covers the esophageal muscularis and the gastric submuscular layer. The inner layer is a simple suture, the outer horizontal mattress technique. Postoperative NG [nasogastric] decompression is done. If stomach is used, a layer of omentum is placed over the anterior suture line. Mathisen and colleagues 278 used this approach and reported an experience of 104 consecutive resections, with a 2% mortality rate and no leaks. The contemporary anastomotic leak rate ranges from 4% to 10%. Colon Interposition. Esophageal resection involves anastomosis to a distal organ (eg, stomach, colon, or jejunum). Performed mostly for benign disease, colon interposition involves an esophagocolic and cologastric anastomosis. The mortality rate has decreased in recent years from 11% to 4.9%. The morbidity rate ranges from 13% to 40%. Graft necrosis occurs in approximately 8% of cases and is the most frequent cause of hospital death. Anastomotic leak occurs in 5% to 10% of patients, most in the esophagocolic anastomosis and more frequently with the use of the right colon. Strictures, graft redundancy or torsion, and gastrocolic reflux with peptic colitis have been reported. The development of intensive disease (eg, cancer, inflammatory disease) in the transplanted colon is r a r e . 279,280 Transhiatal Approach. The transhiatal esophagectomy with esophagogastrostomy is used for both benign and malignant conditions. 281282 Intraoperative complications include splenic injury, hypotension during the mediastinal dissection, mediastinal hemorrhage (<1%), membranous Curr Probl Surg, November 2000

837

tracheal laceration (<1%), and pneumothorax (50%-75%). Postoperative complications include bleeding, left recurrent laryngeal nerve injury, chylothorax, hemiation of the intestine through the hiatus, gastric outlet obstruction, anastomotic leak (<9%), and benign anastomotic strictures. The approach to a tracheal laceration is highlighted because of the treacherous location. Control of the airway is accomplished by advancing a single-lumen endotracheal tube into the left mainstem bronchus or intubating the trachea directly through the tear, if visualized from the neck. Repair from the neck is preferred. An upper sternal opening may be necessary. If the surgeon is still unable to expose the laceration, then the esophagogastromy is completed, and a subsequent right thoracotomy is used to better expose the distal tracheal to the carina. Cervical anastomotic stricture formation is common (5%-46%). Leakage is associated with an increased incidence of stapled versus hand-sewn anastomosis. Orringerz75 emphasizes not "tubing" or trimming the stomach and avoiding tacking sutures on the stomach. Maloney bougies are the preferred method for dilatation (usually to a 46F or greater). Left Thoracoabdominal Approach. The transhiatal and Ivor-Lewis approaches are the most common operations for esophageal resection. The left thoracoabdominal approach is used for distal esophageal diseases, particularly cancer, and redo antireflux procedures. Kirby283 outlined the major complications related to this approach. The chest should be entered through the 6th intercostal space in most instances. A 2-cm segment of costal arch should be resected to avoid overlapping and clicking. The diaphragm should be opened in a circumferential manner (Fig 26). Anastomotic Leak. The most dreaded esophageal complication is the anastomotic leak. 284,285The incidence of this complication was reported to be 12.3% in a series of 2532 intrathoracic esophagogastromies for cancer reported by Postlehwait. 36 The cervical leak rate (10%-25%) is greater than the thoracic rate (<10%). Yet the mortality rate for anastomotic leak or fistula ranges from 15% with cervical anastomosis to 23% for intrathoracic esophagogastric anastomosis. Hand-sewn and stapled anastomoses have a similar leak rate of approximately 9%, but strictures are more common with stapled (40%) compared with hand-sewn (10%-20%) anastomoses. Early suspicion and recognition of a leak or breakdown are crucial to minimize the systemic toxicity and collapse. Fever, chest pain, tachycardia, and dyspnea are common. There is often radiographic evidence of atelectasis and pleural effusion. A contrast study with gastrografin confirms the diagnosis. I f no leak is demonstrated, barium should be used. The treatment of an anastomotic leak is variable. For small cervical leaks without systemic toxicity, no distal obstruction, and drainage back 838

Curr Probl

Surg, November 2000

into the esophagus, conservative management is warranted (ie, nasogastric decompression and local drainage). Small intrathoracic leaks are approached similarly. Large leaks with obvious local contamination and systemic toxicity require early aggressive treatment. In the neck, takedown of the anastomosis with cervical esophagostomy, returning the stomach to the abdomen, decompression gastrostomy, and feeding jejunostomy are the most predictable methods of control. Subsequent reconstruction with the remaining stomach or intestinal interposition must be individualized, with regard to timing and specific surgical route and technique. The thoracic anastomotic leak is more complex. The stomach is returned to the abdomen after takedown of the anastomosis. The esophagus is mobilized proximally. Through a separate neck incision, the remaining esophagus is exteriorized as a cervical esophagostomy. Again, delayed reconstruction is individualized. Gastric Outlet Obstruction~Delayed Gastric Emptying. Gastric outlet obstruction with gastric stasis is noted in 10% to 15% of esophagogastric resections. Extrinsic compression can occur at the diaphragmatic hiatus or upper thoracic inlet because of inadequate opening. Torsion of the stomach into the right paravertebral gutter may also occur. A redundant stomach may overlap the diaphragm as well. The drainage methods at the pylorus include no drainage, digital dilatation, pyloromyotomy, and pyloroplasty. Law and colleagues 286 reported gastric outlet obstruction in 13% of patients, with no drainage procedure. In a randomized trial of 92 patients, gastric outlet obstruction developed in 2 patients with pyloromyotomy and none with pyloroplasty. There were no leaks. Although not demonstrated in their study, duodenal and bile reflux can occur with a drainage procedure, especially when the patient is in the supine position. In patients with gastric outlet obstruction and an intact pylorus, balloon dilatation has been reported. In the absence of gastric outlet obstruction, an atonic stomach in the setting of vagotomy is a difficult problem. Metoclopramide, cisapride, or erythromycin has had limited success. Stricture. Anastomotic strictures (incidence, 5%-30%) are more common in the neck than the chest and are more common with stapled than with hand-sewn anastomosis. The incidence is higher in the setting of an anastomotic leak, Treatment follows the similar guidelines for peptic esophageal stricturesY 7 Early dilatation at 4 to 6 weeks is performed with direct endoscopic visualization followed, if necessary, by later mechanical (mercury weighed Maloney) dilatation. Late strictures always raise the suspicion of recurrent malignancy or reflux esophagitis. Chylothorax. Chylothorax results from injury to the thoracic duct during esophagectomy. When an injury is detected intraoperatively, the duct Curr Probl Surg, November 2000

839

SIGNS AND SYMPTOMSOF ESOPHAGEALPERFORATION

Chest x-ray,

watersolublecontrast esophagogram

I Walled off perforation, minimalsymptoms, no seps~s

Free perforation

If

Conservative I management

Lessthan

! Failure ~

Reinforced Primary

Repair

I

Longer than 72 hours

72 hours ....

t

* Gastric fundus * Pleural flap Muscle flap

~Consider

I Failure consider

I

Resection,

Cervical Esophagostomy, vI Gastrostomy, Jeiunostomy

Fig 29. Algorithm for treatment of esophageal perforation. (From Chen LQ, Duranceau A. Esophageal perforation. In: Cameron JL, editor. Current surgical therapy. 6th ed. St Louis [MO]: Mosby-Year Book; 1998. p 8-15. With permission.) should be ligated in bulk with the surrounding tissues. Otherwise, a milky-white drainage from the chest tube calls attention to the problem after the operation. Feeding cream through the jejunostomy increases the volume of drainage. Aggressive treatment is warranted within days if the flow persists. Thoracotomy and thoracic duct ligation below and above the point of leakage are usually successful. Rarely, a pleural peritoneal shunt may be required. 2~ Recurrent Laryngeal Nerve Injury. The nerve should be protected carefully during the cervical anastomosis. Pressure from metal retractors pressing directly on the nerve may be culpable. Impaired swallowing with the risk of tracheobronchial aspiration may occur if the nerve is damaged. Recovery is slow. Esophageal Perforation~Rupture. Perforation or rupture of the cervical or thoracic esophagus is the result of esophageal trauma. Iatrogenic trauma is either instrumental or surgical, accounting for more than 50% of the cases of perforation or rupture of the esophagus. Endoscopic instrumented perforation accounts for 50% of cases, and surgery accounts for another 10% of cases. The overall mortality rate is greater than 20%, but the mortality rate is less than 10% if the patient is treated surgically within 24 hours. Instrumental perforation occurs in 0.03% of cases during fiberop840

Curr Probl Surg, November 2000

Fig 30. Primary repair of esophageal perforation with buttressed pleural flap. Perforation is identified. Esophagus is mobilized. Repair must include the strong submucosal layer. The pleural flap is placed circumferentially and sutured to surrounding tissue precisely and carefully. {From Skinner DB. Atlas of esophageal surgery. New York: Churchill Livingstone, 1991. p 177-9. With permission.)

tic esophagoscopy and may occur more often with pneumatic dilatation (1.14%). Surgical causes of perforation are less common (not including anastomotic leaks or disruption) and are encountered after pulmonary resection with hilar dissection (especially the irradiated hilum or with completion pneumonectomy). Esophageal perforation or rupture may also occur during other operations (such as the HeUer myotomy, reflux operations, and vagotomy), zss Treatment strategies depend on the timing and accuracy of the diagnosis (Fig 29). Pain is the major symptom. Tachypnea and tachycardia are common. Plain neck and chest radiographs are helpful. Retroesophageal swelling and cervical emphysema with pneumomediastinum, pleural effusion, and hydropneumothorax are all suggestive of this diagnosis. A gastrografin esophagogram confirms the diagnosis. If no leak is present, liquid barium is used, if the index of suspicion is still high. In subtle cases CT scanning with contrast is useful to look for air in the mediastinum or thickening of mediastinal tissue. Esophagoscopy is rarely necessary. The objectives of treatment are to drain the periesophageal area adeCurr Probl Surg, November 2000

841

!

~--~-. ,~o~.I.

J

A

Fig 31. Complications after Nissen fundoplicatian: A, normal view; B, recurrent reflux symptoms with repair dehiscence; C, dysphagia with obstructed distal esophagus; D, "Slipped" Nissen; E, paraesophageal hernia. Other complications include supradiaphragmatic wrap, gastric stasiscaused By vagal nerve injury, gas bloat syndrome with excessive gas, distension, flatus and inability to belch, and esophageal perforation or fistula with subphrenic abscess. (From Daniel TM. Complications after hiotal hernia repair. In: Wolfe WG, editor. Complications in thoracic surgery. St Louis [MO]: Mosby-Year Book; 1992. p 212-24. With permission.)

quately, control infection and sepsis, and restore continuity (if possible) with a buttressed repair (Fig 30). Alternatively, the esophagus can be diverted with a subsequent delayed reconstruction, especially in patients who are critically ill and septic and who have a late examination and diagnosis. Traumatic perforation of the esophagus is a true emergency that may complicate diagnostic or therapeutic esophagoscopy or esophageal dilatation for stricture or achalasia. Perforation may also occur spontaneously (ie, Boerhaave's syndrome) or after foreign body aspiration. Early diagnosis after gunshot wounds or blunt chest trauma facilitates primary repair within 24 hours. Delayed recognition may lead to mediastinitis and pleural empyema and necessitate surgical drainage. In the worst case, esophageal resection may be required. Accidental or deliberate ingestion of caustic chemicals causes acute esophageal mucosal injury that may be treated nonoperatively. More severe, transmural drainage may result in esophageal necrosis or, later, in extensive fibrosis and nondilatable strictures. Resection and replacement may then be necessary. 842

Curr Probl Surg, November 2000

Antireflux Surgery for Gastroesophageal Reflux Disease. Failure to control reflux occurs in 5% to 10% of patients who undergo the Hill, Belsey, or Nissen repairs; the Nissen or total fundoplication is the most popular procedure. Failure rates are even higher after redo repairs. Other complications include vagus nerve injury, accidental splenectomy, bleeding from the short gastric vessels, dysphagia from a tight or long fundoplication, and a tight hiatus. Herniation of the repair and the intestine above a loose diaphragm may also occur. Repair of the crura behind the esophagus serves to prevent herniation. The "gas bloat syndrome" results from a watertight and airtight sphincter that produces difficulty or inability to belch. 289 The various complications are illustrated in Fig 31.29~ The Collis-Belsey repair poses the added risk of dysphagia from the created gastroplasty tube. Laparoscopic Nissen Fundoplication. Laparoscopic approaches to abdominal diseases gained widespread popularity during the 1990s. The open approach to Nissen fundoplication yields favorable long-term results in 85% to 95% of patients. The short-term results of laparoscopic Nissen fundoplication are good to excellent in 90% to 97% of patients. Richardson and Hunter TM summarized the complications in a contemporary series of 1012 patients. The conversion rate was 4.2%. There was persistent solid food dysphagia in 6.5% of patients, recurrent heartburn in 2.6% of patients, and perforated viscus in 1.9% of patients. The excellent results and low morbidity rates, with a less traumatic approach, will increase the number of patients who undergo this operation. Motor Disorders. Esophageal motor disorders include Zenker's diverticulum, oropharyngeal dysphagia, achalasia, and diffuse esophageal spasm. 292 Zenker's diverticulum is generally approached through the left neck, with division of the cricopharyngeal sphincter and excision of the diverticulum. The overall complication rate is less than 3%. Fistula, recurrent nerve injury, stenosis, and recurrence are the major complications. A recurrence rate of 3.1% rises to 6.4% at reoperation, with an increase in complications to 20%. Achalasia of the distal esophagus is associated with aspiration in 10% of patients before operation. The Heller myotomy should extend 5 to 8 cm on the distal esophagus and a few millimeters on the gastric serosa. The dissection should encompass 50% of the esophageal circumference. Intraoperative mucosal perforation should be recognized and repaired. Postoperative fistulas occur in 0.4% of cases. Paraesophageal hernia results from disruption or an opening in the hiatus or diaphragm. Recurrent dysphagia occurs in 5% to 10% of patients, particularly in advanced cases (ie, esophageal diameter > 6 cm, stage III). Some surgeons believe that megaesophagus is an indication for primary Curr Probl Surg, November 2000

843

esophagectomy. Reflux with esophagitis and stricture is the most frequent complication. There is considerable debate regarding the addition of an antireflux procedure to the myotomy. Ellis 293 believes an antireflux procedure is unnecessary because of the low incidence of reflux in his series and because an antireflux operation may delay or hinder esophageal emptying. There is a 1% to 7% incidence of esophageal carcinoma in patients with achalasia. Yet there is no convincing evidence that earlier surgical treatment will prevent it. Diffuse esophageal spasm demands an accurate diagnosis. Surgical treatment involves a long esophageal myotomy and resection of any associated epiphrenic diverticula. The goal is to reduce the amplitude, duration, and frequency of the contractions. The complications, aside from persistent dysphagia, are the same as those associated with myotomy for achalasia. Congenital Tracheoesophageal Fistula. Operations for congenital TEF are performed primarily in the neonate and infant. Associated congenital lesions of the lung and heart influence the timing and outcome of surgery. Engum and colleaguesTM reviewed 227 infants who underwent operation for esophageal atresia and/or TEF over a 20-year period. Complications associated with division of the TEF and repair of the esophagus included anastomotic leak (16%); symptomatic stricture because of poor healing and a healed leak (35%); recurrent TEF (3%); gastroesophageal reflux (58%), with 44% requiting an antireflux procedure; and tracheomalacia (15%), with 44% requiring treatment. Esophageal dysmotility occurred in 30% of cases. The operative mortality rate was 5%. Additional complications include recurrent laryngeal nerve dysfunction, especially in the H-type fistula repair (10%-15%), and the late complications of organic foreign body impaction that resulted from poor peristalsis and/or anastomotic stricture formation. Late strictures are most likely due to persistent gastroesophageal reflux. Staging the procedure allows the esophagus to grow; regardless of the gap length, most children may retain their native esophagus, thereby avoiding complications that result from gastric or colonic replacement. We thank Geri Reilly for her secretarial assistance and perseverence in the preparation of this manuscript.

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