Complications of Surgery

Introduction

Surgical resection remains a mainstay of therapy for patients with carcinoma of the lung.
Unfortunately, any surgical intervention carries with it the potential of morbidity and mortality.
Although many advances have occurred in the preoperative, intraoperative, and postoperative
care of these patients to minimize the risk of surgery, complications still occur.1 Complications
after surgery can never be totally eliminated, but they can be minimized by careful attention to
the many details of prevention. When complications do occur, proper management usually
yields a satisfactory result. Prevention includes accurate preoperative assessment,
meticulous surgical technique, and a knowledge of surgical maneuvers to minimize potential
problems.

Preoperative Assessment

Traditional attempts to assess surgical morbidity and mortality after pulmonary resection have
primarily focused on clinical assessment and static pulmonary function testing, such as
spirometry, radionuclide scans, and temporary unilateral pulmonary artery balloon occlusion.
Nagasaki and associates2 studied 961 patients undergoing surgical treatment for carcinoma
of the lung. Variables including age, gender, cell type, extent of resection, cardiopulmonary
status, and stage of disease were evaluated. The authors found that certain high-risk groups
could be identified:

1. patients older than 70 years of age in whom a major resection is necessary;

2. patients with a positive cardiac history;
3. patients with severely restricted pulmonary reserve, regardless of age.

Gender, stage of disease, and cell type were found to have little influence on the frequency of
postoperative complications. Kohman and colleagues3 studied 476 patients undergoing
thoracotomy more thoroughly by analyzing 37 preoperative risk factors, including the forced-
expiratory volume at 1 second (FEV1) and arterial blood gases, and their effects on morbidity
and mortality. Only three of these factors were found to have a significant association with
mortality. These consisted of age 60 years or older, need for pneumonectomy, and premature
ventricular contractions on admission electrocardiogram. However, all these preoperative risk
factors together were found to account for only 12% of the risk of mortality observed. The
authors speculated that most deaths after pulmonary resection might therefore be random,
unpredictable events. Clearly then, increased accuracy in preoperative assessment
necessitates measure of more physiologic parameters.

Boysen and colleagues4 studied the predictive value of simple spirometric testing with and
without more specific testing, and concluded that additional testing over spirometry did not
appear to add any predictive value. In contrast, most investigators believe that static
pulmonary function tests lack the specificity and sensitivity to predict postoperative
cardiopulmonary complications accurately.5,6 The dilemmas are to define which additional
patient parameters will add to the predictive value and to accomplish this task in a minimally
invasive, cost-effective manner. Keagy and associates7 sought to increase the predictive
value of preoperative spirometry in 90 patients undergoing pneumonectomy. All patients had
forced vital capacity (FVC), FEV1, and FEV1/FVC ratio measured. The results demonstrated
no correlation between postoperative morbidity and mortality with FVC, FEV1, and FEV1/FVC
ratio. A further limitation of standard spirometric measurements is that they do not
compensate for variations in body surface area. This reduces the usefulness of such
measures when applied to either very large or very small patients.

The diffusing capacity of the lung for carbon monoxide (DLCO) was included in the
preoperative assessment of 165 pulmonary resection patients by Ferguson and colleagues.6
Using logistic regression analysis, the authors found that the most important single predictor
of postoperative complications or death was the preoperative DLCO. The DLCO estimates
pulmonary capillary surface area and can reveal diffusion defects and emphysematous
changes even with acceptable spirometric values. This increase in sensitivity and predictive
value appears to justify measurement of diffusion capacity as part of the preoperative
assessment. In a retrospective review of 376 patients, Ferguson8 noted that the most reliable
predictor of postoperative complications was the percent predicted postoperative diffusing
capacity. Predicted postoperative FEV1 percent was also analyzed in this review, and
statistical analysis determined that there was no correlation between PPO FEV1 percent and
PPO DLCO percent in predicting morbidity or mortality after major lung resection. Each value
should be analyzed separately and correlated with the planned amount of lung tissue to be
removed. Ferguson9 concludes that a preoperative diffusing capacity under 60% of predicted
indicates an increased risk for complications following pneumonectomy. This increase in
sensitivity and predicted value appears to justify measurement of diffusion capacity as part of
the preoperative assessment.

Several investigators have sought a more accurate measurement of functional

cardiopulmonary reserve. The measurement of maximum oxygen consumption during
exercise (VO2max) has been used to predict postoperative complications. A postulate is that
oxygen consumption is directly related to cardiac output and that a reduced peak oxygen
consumption may correlate with increased postoperative complications. Bechard and
Wetstein10 reported minimal risk of postoperative complications in 50 consecutive patients in
whom the VO2max was greater than 20 mL per kg per minute. Patients with a VO2max of less
than 50 mL per kg per minute accounted for 75% of all postoperative complications observed.
Bolliger11 concluded that a VO2max under 10 mL per kg per min is predictive of a high risk of
complications following any pulmonary resection and could even be considered prohibitive. A
value greater than 20 mL per kg per min or greater than 75% of predicted normal is safe for
major pulmonary resection, including pneumonectomy.

Recent studies have evaluated exercise oximetry to predict operative risk. Rao12 carried out a
retrospective analysis of 299 patients who underwent both exercise oximetry and spirometry.
Sensitivity of oximetry was low, but compared with spirometry it more reliably predicted
prolonged hospital stay and respiratory failure. Ninin and colleagues13 evaluated 46
consecutive patients undergoing pneumonectomy with exercise oximetry and concluded that
exercise oximetry was predictive of morbidity and prolonged intensive care stay following
pneumonectomy. Prospective randomized trials are needed to confirm the reliability of this
test.

Although much effort has been expended to define high-risk patient populations for pulmonary
resection, the dilemma of choosing appropriate therapy for such patients remains.
Postoperative deaths are dreaded by all involved. However, a more conservative approach
might deny a patient a potentially curative resection. Vigorous preoperative respiratory
therapy, cessation of smoking, bronchodilator therapy, and even short-term corticose steroid
therapy have been shown to improve the operability of lung cancer patients with marginal
pulmonary reserve.14 Finally, tailoring the procedure to the patient, such as a segmentectomy
versus a lobectomy or sleeve lobectomy versus a pneumonectomy, might also offer an
otherwise marginal patient the chance of a curative procedure. For more discussion of
preoperative risks see Chapter 36.

Arrhythmias

Atrial and ventricular arrhythmias can occur after pulmonary resection. Many factors may
contribute to the development of arrhythmias postoperatively (Table 41.1), with potentially
serious complications. As early as the 1940s, several investigators noted the increased
incidence of arrhythmias after pulmonary resection.15,16 The incidence of arrhythmias after
pulmonary resection has been cited as 3.4% to 30%. Atrial arrhythmias are far more common,
consisting of fibrillation, flutter, and supraventricular tachycardia.1719 Loss of sinus rhythm
adversely affects cardiac output, with resultant decrease in coronary, renal, and cerebral
blood flow. When arrhythmias do occur, it is usually during the first few days after surgery and
most commonly on the second or third postoperative day. Shields and Ujiki18 studied 125
consecutive patients and reported a 22% mortality in those patients who developed a
postoperative arrhythmia, as compared with a 7% mortality in patients who remained in
normal sinus rhythm. These findings are consistent with a series of 236 pneumonectomy
patients studied retrospectively by the Mayo Clinic.15 In this study, the authors observed a
25% 30-day mortality in patients developing tachyarrhythmias after surgery.

Table 41.1: Potential Factors Relating to Postoperative Arrhythmias

Pericardial irritation
Increased sympathetic discharge
Atrial damage
Electrolyte disturbance
Atrial distention
Underlying coronary or valvular heart disease
Postoperative myocardial ischemia
Hypoxia
Preoperative theophylline use

The relation of age to the development of postoperative arrhythmias is somewhat conflicting

in the literature. Although some authors17 have reported a near linear relationship between
the incidence of arrhythmias with increasing age, Krowka and associates20 studied 236
pneumonectomy patients and failed to demonstrate any significant association between the
patient age and development of arrhythmias. It seems intuitive, however, that age should be a
strong predictor of postoperative arrhythmias, because the conduction system also ages, as
reflected by a decreasing number of functional sinus node pacemaker cells.21 In addition,
patients of advanced age are more likely to also have coexisting predisposing factors. This is
consistent with the findings of Wheat and Burford19 of a 50% incidence of postoperative
arrhythmias in patients 70 years and older who underwent pulmonary resection.

Several series have confirmed a direct relationship between the magnitude of resection and
the incidence of postoperative arrhythmias. Mowry and Reynolds17 reported an overall
incidence of 19.4% after pneumonectomy as opposed to 3.1% after lobectomy in their series
of 301 patients. Other series18,19 have observed a less dramatic disparity and have suggested
that the relationship between the incidence of arrhythmias and the magnitude of resection is
less pronounced in the older population. Krowka and associates20 studied the relationship
between preoperative pulmonary function and the incidence of postoperative arrhythmias.
Although they did not demonstrate a firm correlation, they did report an increased incidence in
patients with radiographic evidence of fluid overload after a pneumonectomy. This would
follow, because right heart distention is felt to be an important factor in the development of
postoperative arrhythmias. Wittnich and associates22 pointed out that Swan-Ganz
measurements of pulmonary artery pressures may not be accurate after pneumonectomy. In
this situation, the inflation of the balloon tip catheter to measure pulmonary wedge pressure
may in fact increase right ventricular afterload, with resultant decreased cardiac output and
therefore decreased left atrial pressure. The authors suggest that in this situation, central
venous pressure measurements may in fact be a more accurate measure of true cardiac
output.

Although many known factors contribute to postoperative arrhythmias, we still cannot

accurately identify patients that are of the greatest risk of developing them. In addition, while
may studies have used preoperative digoxin or low-dose beta-blockage in the prevention of
postoperative arrhythmias, the data are conflicting. Digoxin has long been the drug of choice
for the prevention of arrhythmias following thoracic surgery. However, potential side effects
and the development of newer pharmacologic agents have diminished its popularity. Digoxin's
predominant action is thought to be a slowing of conduction through the AV node, mediated
by enhanced vagal tone. This is consistent with the known effect of digoxin in slowing the
ventricular response to a rapid supraventricular rate while at the same time being relatively
ineffective in converting to a sinus rhythm. This mechanism is also consistent with the
observation of a reduced efficacy of digoxin in the immediate postoperative period, when
andrologic influences are more pronounced.

There is some evidence that low-dose beta-blockage may have a beneficial prophylactic
effect. However, many of the patients presenting for pulmonary resection have underlying
pulmonary disease or reduced ventricular function and are therefore not ideal candidates for
the administration of beta-blocking agents.23,24

The prophylactic administration of the calcium-channel-blocking agent verapamil has been

shown to reduced significantly the occurrence of postoperative arrhythmias following
thoracotomy.25 In addition, verapamil was found to lower right ventricular systolic and diastolic
pressures, an important action because elevated right-sided pressures are felt to predispose
to atrial arrhythmias.26 A recent study by Van Mieghem and associates27 demonstrated that a
relatively large dose of intravenous verapamil (10 mg bolus) following pulmonary resection
effectively reduced the incidence of atrial arrhythmias by 50%. However, side effects such as
bradycardia and hypotension seen with this dosage led to discontinuation of the drug in many
patients.

Diltiazem, also a calcium-channel-blocking agent, has been shown to be equally efficacious to

verapamil in treating atrial arrhythmias, but with fewer side effects. This has led to the greater
acceptance of this agent in the postthoracotomy patient.28,29 Amar30 recently reported on a
comparison of diltiazem and digoxin for the prevention of postoperative atrial arrhythmias in
pneumonectomy patients. They found that when compared to digoxin, diltiazem was safe and
more effective in preventing atrial arrhythmias in these patients. In addition, the observed
incidence of postoperative arrhythmias in digoxin treated patients was similar to that observed
in the untreated controls. Amiodarone has also been used in the treatment of postoperative
atrial arrhythmias; however, its association with the development of pulmonary infiltrates and
dysfunction has prevented its widespread acceptance in pulmonary resection patients.

Once postoperative arrhythmias such as atrial fibrillation occur, there are several therapeutic
guidelines that should be followed. First, the heart rate should be acutely controlled. Rapid
atrial fibrillation results in poor cardiac filling and therefore reduced cardiac output. Digoxin
can be administered intravenously over several hours to a total loading dose of 1 mg in the
adult patient. However, digoxin does not slow the ventricular rate acutely and often requires
several hours to produce an effect. In addition, digoxin does not reliably convert the patient to
a sinus rhythm nor maintain the sinus rhythm. Postoperative atrial fibrillation with a rapid
ventricular response requires prompt intervention and generally responds to intravenous
calcium-channel-blocking agents such as diltiazem, as previously discussed. In addition,
underlying predisposing conditions such as metabolic derangements or hypoxia should be
accurately sought and corrected. Digoxin may be used as an initial drug in patients with
compromised ventricular function and in patients not hemodynamically compromised by the
increased ventricular rate, which would require a more rapidly acting agent. Conversion to
normal sinus rhythm in patients with refractory atrial fibrillation or flutter generally requires
administration of other pharmacologic agents such as quinidine or procainamide. Rarely do
patients become so refractory that they require electrocardioversion unless they have a long
history of preoperative atrial fibrillation. Patients who require pharmacologic conversion
should generally be kept on these medications for at least three months after surgery.

Patients undergoing lobectomy are generally not prophylactically digitalized. If postoperative

atrial arrhythmias occur, the patient is treated pharmacologically. In contrast, pneumonectomy
patients are generally prophylactically digitalized and maintained on a daily dose
postoperatively. As previously mentioned, there are no data indicating that this prevents the
patient from experiencing atrial fibrillation, but it should prevent a rapid ventricular response
should atrial fibrillation occur. Occasionally a planned lesser resection results in a
pneumonectomy secondary to intraoperative findings. In these situations, the patient is
loaded with digoxin postoperatively and maintained on a daily dose. All pulmonary resection
patients should have cardiac monitoring for at least 24 hours postoperatively. We generally
extend the observation period in pneumonectomy patients and in older patients with other
comorbid conditions that might predispose them to arrhythmias.

Postresection Pulmonary Edema

Noncardiogenic pulmonary edema following lung resection was first discussed by Gibbon and
Gibbon31,32 in 1942. At that time, they reported on two patients who had undergone bilateral
lobectomies and succumbed within 12 hours of surgery. This clinical experience as well as
experimental studies conducted in a feline model led the authors to conclude that edema
occurs because of increased capillary blood pressure following acute reduction of the
pulmonary vascular bed. More recently Zeldin and associates33 compiled ten cases from
several institutions and retrospectively compared them with controls. After comparison, the
authors identified three significant risk factors for postresection pulmonary edema (PPE); right
pneumonectomy, increased administration of perioperative fluid, and high urine output as a
sign of relative overhydration. In conclusion, it was recommended that "the anesthesiologist
must not boldly load the patients up with fluids prior to induction." Since then, several more
recent studies have confirmed and expanded upon this earlier work. Verheijen-Breemhaar34
and associates reviewed 243 pneumonectomy patients in the Netherlands and found that
postoperative pulmonary edema occurred in 4.5% of patients, with a mortality rate of 27% in
affected patients. As in Zeldin's33 report, the authors found an increased incidence of PPE in
right versus left pneumonectomy patients and in those who had a more positive fluid balance
as well as in patients who required reoperation for bleeding. Patel and associates35
retrospectively studied 197 pneumonectomy patients in England and found a 15% incidence
of postoperative pulmonary edema and a mortality rate of 43%.

A larger series involving 402 lung resection patients from Leeds, England, was reported by
Waller and associates.36 In this series, PPE occurred in 5.1% of right pneumonectomies,
4.0% of left pneumonectomies, and 1% of all lobectomies. The mortality rate was 55% in
patients who developed this complication. Interestingly, these authors did not observe a
correlation between perioperative fluid administration and postresection pulmonary edema,
which prompted discussion regarding other possible mechanisms. Turnage and Lunn37
retrospectively reviewed charts on 806 pneumonectomy patients at the Mayo Clinic and found
21 cases (2.6%) who experienced postresection pulmonary edema. Affected patients had a
100% mortality rate and histologic evidence of adult respiratory distress syndrome (ARDS) at
autopsy. Patients who had a right-sided resection had a threefold higher incidence of PPE as
compared to left pneumonectomy patients. Interestingly, no significant difference was found
between the affected patients and age- and sex-matched control groups with regard to
administration of perioperative fluids. The authors concluded that while postresection
pulmonary edema is more common following right pneumonectomy, the etiology was still
uncertain. Shapira and Shahian38 reviewed the literature in their report and confirmed that
pulmonary edema developed in approximately 4% of patients following a major lung
resection. They further concluded that several factors were involved in the pathogenesis of
interstitial pulmonary edema. Finally, in a recent review by Deslauriers and colleagues,39
current understanding of factors associated with the development of postresection pulmonary
edema was presented and summarized in Table 41.2.

Table 41.2: Postpneumonectomy Edema

Incidence of 2% to 5% after pneumonectomy
Appears two to three days after otherwise uncomplicated postoperative period
Radiologic onset may precede symptoms by 12 to 24 hours
Radiologic image of interstitial pulmonary edema
Unresponsive to conventional therapies
Mortality of 50% to 100%
Histology compatible with ARDS
Occurs despite a normal pulmonary wedge pressure
From Deslauriers J, Aucoin A, Gregoire J. Postpneumonectomy pulmonary edema. Chest
Surg Clin N Am 1998;8(3):611, with permission.

Pathogenesis

Slinger 40 pointed out in his review that the cause of PPE was probably multifactorial since no
single factor could adequately explain the clinical experience. He further characterized the
causes of PPE into probable, possible or of questionable influence (Table 41.3).

Table 41.3: Causes of the Postpneumonectomy Pulmonary Edema

Probable: Fluid overload
Interrupted lung lymphatics
Increased pulmonary capillary pressure
Pulmonary endothelial damage
Possible: Hyperinflation
Right ventricular dysfunction
Cytokine release
Oxygen toxicity

From Slinger PD. Perioperative fluid management for thoracic surgery: the puzzle of
postpneumonectomy pulmonary edema. J Cardiothorac Vasc Anesth 1995;9:442, with
permission.

Fluid overload has been implicated in the pathogenesis of PPE since the early work of Gibbon
and Gibbon,31,32 and almost certainly plays a major role. Forty years later, Zeldin and
associates33 confirmed the role of overhydration in the canine model. In their study, dogs
were randomized to receive lactated Ringers at 100 mL per kg before or during a right
pneumonectomy, and compared to a control group that received lactated Ringers but no
resection. Six of the 12 pneumonectomy dogs developed PPE, while none of the controls did
[p = less than 0.05]. The authors concluded that following pneumonectomy, the entire cardiac
output is directed to the remaining lung with resultant increase in the intracapillary pressure,
which predisposes to edema formation. Increased cardiac output from catecholamine release
secondary to pain or from excessive fluid administration will exacerbate this situation.

Interruption of mediastinal lymphatics probably also plays a role in the formation of PPE. In
normal lungs, it has been estimated that lymph flow can increase seven- to tenfold without
leading to pulmonary edema. Following pneumonectomy, a proportional amount of lymphatic
channels is removed with the specimen. In addition, mediastinal and subcarinal dissection
can effectively compromise the lymphatic drainage from the remaining lung. Little and
colleagues41 studied the effect of pneumonectomy and mediastinal lymphatic interruption in a
canine model. Their findings suggested that following pneumonectomy, the contralateral lung
was more prone to extravascular fluid development secondary to the loss of parenchymal and
hilar lymphatic drainage routes. Nohl-Oser42 has further described the lymphatic drainage of
the lung and mediastinum and reported that the lymphatics from the right and left lungs are
notably different. The majority of lymphatic channels from the left lung cross the midline.
Therefore a right pneumonectomy is more likely also to disrupt lymphatic drainage from the
remaining left lung, possibly contributing to edema formation.

Other possible factors implicated in the formation of PPE include increased capillary pressure
and endothelial cell damage producing a "leaky capillary" situation. This is consistent with an
ARDS histology previously described in these patients.

Preventative Maneuvers
As previously described, following pneumonectomy the entire cardiac output is directed to the
remaining lung, with resultant elevation in pulmonary capillary pressure. Because of this,
efforts should be made to restrict fluid administration during the intraoperative and early
postoperative periods. Total positive fluid balance in the first 24 hours perioperatively should
not exceed 20 mL per kg, typically, less than 2 liters intraoperatively followed by less than 50
mL per hour postoperatively for an average adult. Urine output greater than 0.5 mL per kg is
unnecessary in the early postoperative period unless renal insufficiency exists. Placement of
a central venous pressure monitoring line is often useful in assessing intravascular volume
and will aid in the decision to administer diuretic or inotropic therapy.

Adequate pain control is essential to minimize catecholamine release with resultant increase
in cardiac output. Recently, lumbar or thoracic epidural anesthesia has proved extremely
useful in this situation by providing adequate pain control without oversedation of the patient.

Avoidance of mediastinal shift and overdistention of the remaining lung is also essential.
Experimental work by Raffensperger and colleagues43 in dogs confirmed that overdistention
of the contralateral lung following pneumonectomy led to deterioration in lung function. These
changes were reflected by an increase in the alveolar-arterial gradient. It is now believed that
acute hyperinflation of the remaining lung is probably a significant factor in the development
of PPE.

Treatment

As previously stated, the development of PPE is associated with a mortality rate in excess of
50%. Current therapy advocated is supportive and essentially the same as for ARDS. This
generally consists of fluid restriction, diuretic therapy, and maintenance of adequate
oxygenation and nutritional support. Most patients will require intubation and mechanical
ventilation. Unfortunately, prolonged ventilation may increase barotrauma and bronchial
stump dehiscence. Inspired oxygen concentrations of 80% to 100% may be required to
maintain adequate arterial saturation. Peak inspiratory pressures greater than 30 mm of
mercury should be avoided if possible. Empiric administration of antibiotics is probably of little
benefit because the underlying process is not infectious in nature.

Mathisen and colleagues44 have recently reported on the use of inhaled nitric oxide in a series
of ten PPE patients with reasonable success. In their series affected patients were treated
with standard supportive measures plus inhaled nitric oxide at 10 to 20 parts per million.
Overall mortality for this limited series was 30%. Finally, in refractory cases, extracorporeal
membrane oxygenation (ECMO) may improve survival, but its role is not yet fully defined.

Cardiac Herniation

Cardiac herniation is a rare but potentially lethal complication that can occur after pulmonary
resection when a pericardial defect is created. The mechanism is simply anatomic
displacement of the heart through the pericardial defect, which results in entrapment of the
heart, thereby effectively obstructing both venous inflow and arterial outflow. This results in
elevation of central venous pressure and resultant diminished cardiac output.45 This
complication was first reported in 1948 after a left intrapericardial pneumonectomy with
resultant pericardial defect.46 Since then, about 30 additional cases of cardiac herniation have
been reported after both left and right pneumonectomies. Patients who develop cardiac
herniation typically experience cardiovascular collapse, and if not promptly reoperated to
reposition the heart within the pericardial space, death ensues. Most series in the literature
have reported about a 50% mortality rate with this complication.47,48 Physical findings include
cardiovascular collapse with tachycardia, hypotension, and jugular venous distention. This
complication usually occurs either during the procedure or in the immediate postoperative
period. Beyond that time, intrapericardial adhesions usually form, thereby preventing gross
displacement of the heart. The precipitating event is often a change in the patient's position,
coughing, positive pressure ventilation, or excessive negative pressure in a pneumonectomy
space. A chest radiograph often diagnoses right-sided herniation (Figure 41.1), but left-sided
herniation can be somewhat more difficult to appreciate on a standard posteroanterior film. A
lateral chest radiograph may help to demonstrate posterior displacement of the heart.
Fluoroscopy has also been suggested as a diagnostic aid in this condition, but this may
needlessly postpone timely reexploration to reduce the herniation. Any patient suspected of
having cardiac herniation should undergo prompt reexploration and repositioning of the heart
into the pericardial space. The pericardial defect should then be closed to prevent
reoccurrence.
Figure 41.1: A: Cardiac herniation after radical right pneumonectomy. B: Chest radiograph
after repair with prosthetic patch to close the defect in the pericardium.

To prevent cardiac herniation, some authors have advocated wide excision of the pericardium
to prevent entrapment and strangulation of the heart through a small defect. Others have
documented the inability of partial pericardiectomy to prevent hemodynamic embarrassment
when cardiac displacement does occur.49 Closure of the pericardial defect after a resection is
the more widely held method of prevention. Many authors have advocated closure of
pericardial defects with a variety of materials, including pleura, Vicryl mesh,24 fascia, and even
a latticework of catgut.48 Dippel and Ehrenhaft50 have advocated a technique of suturing the
pericardial defect edge to the adjacent atrial and ventricular myocardium.

We believe that all small pericardial defects should be closed. On the right side, large
pericardial defects must be closed, owing to the fact that right-sided displacement of the
heart, even without entrapment, causes hemodynamic compromise. In contrast, large left-
sided defects do not necessarily have to be patched because the heart normally resides in
the left thorax, and further displacement will not result in hemodynamic compromise unless
the heart is strangulated through a small defect. We generally do not attempt primary closure
of pericardial defects but rather place a material such as Gore-Tex, which is durable and easy
to suture. Suturing of the edge of the pericardial defect directly to the myocardium should be
discouraged because of unwarranted risk to the coronary vessels.51

Lobar Torsion
Postresection lobar torsion has been most commonly described involving the right middle
lobe after a right upper lobectomy.52 If the middle lobe is not secured by either an incomplete
transverse fissure or by direct suturing to the remaining lower lobe, the middle lobe can rotate
on its bronchovascular pedicle, with resultant circulatory embarrassment of the involved lung
parenchyma. Schuler53 reviewed this complication and reported a 16% mortality rate in a
series of 31 patients. Less commonly, lobar torsion can occur on the left side, either in the left
upper lobe after lower lobectomy (Figure 41.2) or in the lower lobe after upper
lobectomy.54,55,56 Pulmonary lobar torsion involves rotation of the lung parenchyma on its
bronchovascular pedicle. This results in occlusion of the pulmonary veins, with resultant
infarction and eventual gangrene of the parenchyma involved. Angulation of the bronchus
also compromises the bronchial circulation, which further endangers remaining lung
parenchyma. Pulmonary infarction can also occur postoperatively in the absence of lobar
torsion. Pulmonary vein thrombosis, pulmonary artery occlusion, and intraoperative damage
to the bronchial circulation have all been implicated in postoperative pulmonary infarction.57
Figure 41.2: A: Torsion of the left upper lobe after left lower lobectomy. B: Chest
radiograph after repositioning of the left upper lobe and fixation with a pleural flap.
Early recognition of this complication is essential to prevent irreversible damage to the
involved lobe. A baseline chest radiograph should be obtained shortly after the completion of
any pulmonary resection. This is done to ascertain that all remaining lung tissue is fully
expanded, with proper positioning of chest tubes. Radiographic findings consistent with
torsion include hilar displacement, bronchial cutoff, and lobar consolidation. Nuclear perfusion
scans and pulmonary angiography can support the diagnosis by demonstrating lack of arterial
blood flow to the affected lobe. However, pulmonary artery blood flow is also decreased in
patients with large areas of atelectasis or postoperative parenchymal hematomas. Urgent
flexible bronchoscopy should be considered to examine the bronchus and remove any
retained secretions, thereby facilitating reexpansion of the pulmonary parenchyma. A
bronchus with a "fish-mouth" occlusion generally indicates that torsion has taken place. The
bronchoscope can be manipulated through the narrowed area, only to have the bronchus
reobstruct after removal of the bronchoscope, which is a diagnostic finding. Clinically, the
patient may lack any significant symptoms early in the postoperative period. However, once
the parenchyma has infarcted with ensuing gangrene, patients commonly develop foul-
smelling or blood-tinged sputum, fever, and malodorous chest drainage.58,59 If left untreated,
these patients can progress to frank sepsis with hemodynamic instability and even death.
Treatment consists of early recognition of this condition in the postoperative period and a low
threshold for performing flexible bronchoscopy in any patient suspected of having this
condition. Reexploration is required with repositioning of the affected lobe, securing it to the
adjacent lobe to prevent recurrence. If the affected lobe is clearly infarcted at the time of
reexploration, resection is mandatory.

Prevention of lobar torsion is essential and begins in the operating room after pulmonary
resection. Careful inspection of the remaining lung tissue should be performed while the lung
is carefully reexpanded. Complete interlobar fissures permit rotation of a remaining lobe and
should be prevented by placement of sutures to the adjacent lobe. Avoidance of unnecessary
dissection of a fissure also minimizes this complication. Finally, any inadvertent compromise
of lobar venous drainage results in pulmonary infarction (Figure 41.3). When recognized
intraoperatively, the affected lobe should be resected if the venous injury is not easily
repaired. Accidental ligation of the middle lobe vein requires middle lobectomy.
Figure 41.3: Pulmonary infarction caused by obstructive venous drainage of the right
upper lobe.

Atelectasis

Atelectasis after thoracotomy is probably the most common postoperative complication. The
reported incidence varies widely in the literature as a result of an inability adequately to define
significant atelectasis. An incidence as high as 70% has been reported, but other large series
of patients generally agree on an overall incidence of 20% to 30% after thoracotomy.2,60,61

Atelectasis was previously believed to result from mucus plugging of small airways, with
resultant distal gas absorption and alveolar collapse.62 Although airway occlusion from
retained secretions, blood, foreign bodies, or bronchospasm can lead to atelectasis, the
etiology is far more complex. Other causes of atelectasis include prolonged shallow breathing
or splinting secondary to pain, absorption atelectasis with high inspired oxygen concentration,
and parenchymal compression from retraction, hemothorax, pneumothorax, or other space-
occupying lesions.

At least two mechanisms normally prevent alveolar collapse. The first is a periodic sigh
breath, which is generally twice the usual resting tidal volume and serves to recruit collapsed
alveolar. Patients who have shallow breathing secondary to pain and ventilated patients with
inadequate tidal volumes may experience progressive alveolar closure with resultant
atelectasis.63,64
The second preventive physiologic mechanism involves surfactant, a normally occurring
wetting agent in the alveoli. LaPlace's theorem states that the surface tension of a distensible
sphere increases proportionately as the radius decreases. This relation alone would favor
collapse of smaller alveoli into larger units. Surfactant, however, acts to reduce the surface
tension within alveoli and thereby prevent preferential collapse of smaller alveoli. Conditions
such as malnutrition, sepsis, parenchymal injury, and prolonged collapse can adversely affect
production of surfactant and predispose to alveolar collapse.

A condition known as absorption atelectasis merits comment. Normally, the sum of the partial
pressures of gases in the alveoli exceeds the partial pressure in mixed venous blood. It
follows that, with proximal airway occlusion, distal gases in the alveoli are absorbed, resulting
in alveolar collapse. In addition, a higher concentration of oxygen in the trapped or anesthetic
gases is more readily absorbed, thereby hastening the process.

Physiologically significant atelectasis results in decreased lung compliance, functional

residual capacity, and vital capacity. This results clinically in increased work of breathing and
impaired gas exchange.65,66 Patients typically manifest with varying degrees of fever,
tachycardia, tachypnea, and impaired gas exchange. Atelectasis may also render the lung
more susceptible to infection.67 Physical findings usually include crackles over the affected
area. More extensive atelectasis results in tubular breath sounds, indicating involvement of
entire segments or lobes. Sudden stoppage of an air leak frequently occurs with atelectasis.
The radiologic appearance of atelectasis varies depending on the extent of involvement.
Linear horizontal densities in the basilar segments are typical of small areas of atelectasis
and usually occur near the diaphragm. Larger areas can usually be visualized if entire
segments are involved, and this can progress to collapse of an entire lobe.

Several maneuvers can be extremely valuable in the prevention of postoperative atelectasis.

Patients must refrain from smoking for as long as possible before thoracotomy. In addition,
any bronchospasm detected either clinically or on preoperative pulmonary function testing
should be minimized with medical therapy. Patient training and use of incentive spirometry
should be initiated in the preoperative period and continued postoperatively. Adequate
analgesia is essential to prevent splinting and to allow adequate pulmonary hygiene. We
continue to use epidural analgesics routinely for three to five days postoperatively because
they provide excellent pain relief with minimal adverse effects.68

Treatment of postoperative atelectasis involves many of the principles used in its prevention.
Airways must remain free of retained secretions, and collapsed lung tissue must be
reexpanded. Adequate postoperative analgesia is essential to allow for deep breathing,
effective cough, and therapeutic physiotherapy. Epidural analgesia is an effective means of
obtaining adequate analgesia without significant sedation. Local analgesics or opiates are
injected into the epidural space continuously to achieve the proper level of analgesia.
Contraindications to placement of an epidural catheter include bleeding diathesis, spinal
deformity, neurologic deficit, or local infection in the area of catheter placement. Side effects
and symptoms of overdosing include respiratory depression, nausea, pruritus, urinary
retention, and hypotension secondary to peripheral vasodilatation. We routinely leave epidural
catheters in place for 72 hours postoperatively but have maintained selected patients for up to
five days.

Patient positioning in the early postoperative period is also important. Functional residual
capacity declines by about 40% in the supine position as compared with upright. Routine
elevation of the head of the bed to 45 degrees and early ambulation promote effective
inspiration. Incentive spirometry is inexpensive and effective in preventing atelectasis.
Patients are best trained in this technique preoperatively.

Intermittent positive-pressure breathing may be of some benefit in selected patients but has
generally not been effective in treating postoperative atelectasis.60,65 These results, along with
increased cost, have persuaded many to abandon this technique.
Patients with thick or copious secretions require a more aggressive approach. Nasotracheal
aspiration is effective when performed by personnel experienced in passing the catheter into
the trachea. Passing a catheter through a nasal trumpet may facilitate the process while
decreasing patient discomfort. Caution should be exercised when passing the catheter blindly
into a patient's airway after pneumonectomy or a bronchoplastic procedure. Also, prolonged
suctioning can precipitate hypoxia and should therefore be performed only intermittently for
short periods following administration of supplemental oxygen.

A technique of percutaneous cricothyroidotomy, or "minitracheostomy," has been developed.

A 20F tracheostomy tube is inserted into the trachea through the cricothyroid membrane
under local anesthesia. Au and colleagues69 reported using this technique in 144
postthoracotomy patients. The minitracheostomy tract was found to be a relatively safe and
effective means to prevent postoperative sputum retention. Others70,71,72 have confirmed the
efficacy of this technique for pulmonary hygiene and treatment of atelectasis secondary to
retained secretions. Complications with this technique are uncommon and consist mostly of
bleeding at the insertion site. Catheter aspiration, pneumothorax, and vocal cord dysfunction
from hematoma have also been reported.73,74

Patients who require more aggressive treatment of secretions should undergo flexible
bronchoscopy (Figure 41.4). Routine use of flexible bronchoscopy for the prevention of
postoperative atelectasis has been studied prospectively and found to offer no advantage
over other less invasive techniques.63,75 However, in the setting of significant pulmonary
collapse or after bronchoplastic procedures, fiber-optic bronchoscopy is a safe and effective
method to aspirate secretions under direct vision. Bronchoscopy can be easily performed at
the bedside using local analgesia and, if necessary, can be repeated often.76 Treatment of
postoperative atelectasis should be graded according to the patient's clinical status and risk
factors as described by Massard.77
Figure 41.4: A: Atelectasis of the residual right middle and lower lobes after right upper
lobectomy and chest wall resection. B: Full expansion after aspiration of retained
secretions by flexible fiberoptic bronchoscopy.

Bronchial Fistula
The incidence of bronchopleural fistula after pulmonary resection is reported to be under
5%.78,79,80 Both systemic and local factors are associated with the development of a
bronchopleural fistula, and a lung cancer patient may be particularly prone to this
complication. Systemic factors include the patient's general nutrition status and the presence
of sepsis. Lung cancer patients frequently lose weight, and the ability of tissues to heal is
decreased. Sepsis can also retard bronchial healing, and many patients with an obstructive
endobronchial neoplasm have distal pneumonitis producing chronic low-grade infection.
Neoadjuvant protocols for the treatment of clinically advanced lung cancer include
chemotherapy and radiation. Effects of chemotherapy can be debilitating to the patient, and
depleted nutritional status can be a significant factor in the development of a bronchial fistula.
Radiation destroys small blood vessels, creates fibrous tissue, and is associated with an
increased incidence of bronchial fistula.81 Vester and colleagues78 reported that, of 33
patients who developed a bronchopleural fistula after resection for bronchogenic carcinoma,
20 had received radiation or chemoradiation. It is mandatory that special care be given to the
bronchial stump in all patients who have received neoadjuvant therapy.

Numerous studies indicate that the causes of bronchial fistula include devitalization and
devascularization by excessive dissection, parabronchial infection related to nonabsorbable
suture, residual bronchial disease, poor approximation of the mucosa, the length of the
stump, and the surgeon's lack of experience.82 The avoidance of the complication of a
bronchial fistula implies prevention, and several technical factors can minimize this
complication.

Preoperative bronchoscopy is an important step in evaluating the status of the bronchial

mucosa at the site of the planned resection. If inflammation is present, specific attention is
made to the stump closure along with coverage by flaps of tissue for reinforcement and added
blood supply. If surgery for the cancer is semielective, then it can be delayed for additional
supportive therapy and antibiotics.

In a patient with lung cancer, the bronchial tissues must be cleared with care and precise
sharp dissection. It is important for the surgeon to have knowledge of the anatomic location of
the bronchial arteries and to preserve as many as possible despite the necessity for a radical
procedure. This is particularly true when carrying out mediastinal lymphadenectomy in the
lung cancer patient. The subcarinal area is traversed by feeding bronchial arteries, and this
dissection must be done as carefully as possible to preserve some of these nutrient vessels.
The right mainstem bronchus receives its blood supply from vessels posterior to the trachea
and bronchus, and it is appropriate to not dissect this area if at all possible. The
lymphadenectomy between the vena cava and trachea is done carefully to minimize damage
to the blood supply to the lateral walls of the trachea. On the left side, a large bronchial artery
has its origin from the distal transverse aorta and, on occasion, can be preserved despite
removal of lymph nodes in the aorticopulmonary window. An excessively long bronchial
stump accumulates excessive secretions, and its distal margin has a limited blood supply;
both factors predisposing to poor healing. The bronchus should always be divided as
proximally as possible, but closure must not compromise the adjacent trachea or bronchial
lumen.

The method of bronchial stump closure is generally the surgeon's preference. In 1980,
Forrester-Wood83 reported results of 450 pneumonectomies. Bronchial closure was carried
out by using stapling techniques in half of the patients, and the other half had bronchial
closure with nonabsorbable suture or stainless steel. The incidence of fistula formation was
11% in the suture group and 2.6% in the staple group. Vester and colleagues78 reported on
30 bronchial fistulas in 1773 pulmonary resections (1.7%) after staple closure of the
bronchus. There were 23 fistulas in 506 pneumonectomy patients (4.5%). Al-Kattan and
associates84 reviewed the incidence of bronchopleural fistula in 530 consecutive
pneumonectomies after hand-suture closure of the bronchus. Polypropylene suture was used
for the closure, and there were seven fistulas (1.3%). In 1982, Lawrence and colleagues79
studied 378 patients undergoing pulmonary resection and found no significant difference
between the hand-sewn and stapled bronchial closure. The surgeon must be aware of
contraindications to close the bronchus by stapling techniques. If the cancer is close to the
bronchial orifice, as observed by bronchoscopy or identified during hilar dissection, the
stapling techniques should not be used. In this instance, the bronchus is transected by a
knife, and both the proximal and distal margins are inspected. Whenever there is a question
about the proximal extent of the cancer, the bronchus is transected by knife dissection, and
suture closure of the bronchus is carried out. After neoadjuvant therapy, the bronchial tissues
can be particularly thick and fibrotic. In this instance, careful judgment is required to
determine the appropriate type of bronchial closure. A thickened bronchus does not hold the
staples, and excessive tension permits edges of the bronchus to separate. In this instance, it
is recommended that the hand-suture technique be carried out with either nonabsorbable or
absorbable monofilament suture (see also Chapter 38).

The same principles used in dissecting and closing the bronchus for a pneumonectomy apply
to the bronchus after lobectomy. If the tissues are too thick or the cancer is too close to the
margin of resection, stapling techniques are not used. We prefer to use a 4.8-leg-length
staple for the lobar bronchus because there is less compression of the tissue and distal blood
supply is preserved through the B shape of the staple. Special attention must be given to the
bronchial stump of a bilobectomy. Vester and colleagues78 reported ten bronchial fistulas in
965 patients receiving either bilobectomy or lobectomy, and there were nine fistulas after
bilobectomy for primary cancer of the lung (right upper lobe and right middle lobe, four; right
middle lobe and right lower lobe, five). The increased incidence of fistula after a bilobectomy
undoubtedly relates to the extensive dissection of the bronchus, with a probable decrease in
blood supply to the surrounding tissues. It is important to consider tissue coverage of the
bronchial stump after bilobectomy to minimize this complication. This is particularly true if the
patient has received neoadjuvant therapy.

Tissue coverage of the pneumonectomy stump can minimize the complication of a small
bronchial fistula and can also bring additional blood supply to the bronchus to promote
healing. All right pneumonectomy stumps should be covered with some form of tissue. The
left pneumonectomy stump, if done correctly, retracts deeply into the mediastinum, and the
decision for tissue coverage requires careful judgment. All pneumonectomy patients who
have received neoadjuvant therapy should have both the right and left pneumonectomy
stumps covered with tissue.

Several methods are available for tissue coverage of a pneumonectomy stump. Al-Kattan and
colleagues84 recommend burying the bronchial stump beneath the mediastinal tissues.
Azygos vein, adjacent pleura, pericardium, and esophageal wall can all be used for this
technique. It was noted that this maneuver is important to decrease the incidence of bronchial
fistula in patients older than 60 years and in those who underwent resection for lung cancer. A
broad-based pleural flap can also be used to cover the bronchial stump. The pleura is tacked
to both sides of the bronchus with a 40 absorbable suture. Only the parabronchial tissues
are sutured to the pleura, and every attempt is made to avoid placing the needle through the
entire thickness of the bronchial wall. This only distorts the bronchus and decreases its blood
supply. However, the pleura contains few blood vessels and does not enhance the healing
process with additional blood supply. For this reason, other tissue coverage is generally
recommended. The intercostal muscle pedicle flap provides good reinforcement of a bronchial
closure. It has also been demonstrated to deliver increased blood supply to the bronchial
tissue.85 It is helpful to have made the decision to use the intercostal muscle flap before
opening the chest, because the flap can be developed with a portion of parietal pleura,
ensuring its viability and blood supply. This flap is best created through a posterolateral
thoracotomy. When the flap is used after completion of the resection, it is not as suitable. The
rib spreader can traumatize the intercostal muscle, and the vessel can be damaged by
retraction or extension of the thoracotomy incision posteriorly. Rendina and associates85
clearly described the construction of the intercostal pedicle flap. It was used in 59 patients,
and postoperative angiographic studies of the intercostal artery in 14 patients demonstrated
full patency of this vessel.

The serratus anterior muscle provides excellent coverage to the bronchial stump and is the
muscle flap of choice for some thoracic surgeons.86,87 The serratus anterior muscle is
mobilized at the time of the posterolateral thoracotomy, and its insertion is detached from the
ribs with a cautery technique. The lateral thoracic artery is preserved, and the muscle is not
separated from its scapular attachments until a final decision is made to use it as a tissue
flap. Muscle is easily brought through the incised third intercostal space or through a defect
made by a subperiosteal excision of a small portion of the third rib. The muscle is then
sutured in place with 40 absorbable sutures and amply covers the stump and areas of
mediastinal dissection. Care must be taken that the muscle flap is not under tension and that
its vascularity is not compromised by compression of tissues in the intercostal space.
Regnard and colleagues87 used this technique in seven patients who underwent
pneumonectomy after 6,000 to 6,500 cGy of radiation. There were four empyemas in this
group of patients, but only one recurrent fistula, which was successfully treated by antibiotics
and additional tissue placed into the pneumonectomy space.

The use of this flap for bronchial coverage is reserved for patients who have received an
excessive amount of radiation or when there is concern about the viability of the bronchial
stump closure. In patients who have received neoadjuvant therapy, the serratus anterior
muscle can be preserved during a posterolateral thoracotomy. Added exposure is obtained by
detaching it from several ribs. If the surgeon decides to use this muscle flap to cover the
bronchus, the construction of the flap can be completed at the end of the procedure. If this
muscle flap is not used to cover the bronchus, then it can be resutured to the tissue adjacent
to the ribs, with the incision closed in the standard fashion. One problem associated with the
serratus flap is that the patient may complain of a winged scapula due to detachment of the
fibers from the inferior portion of the scapula. We use a broad-based mediastinal fat pad for
coverage of both the right and left pneumonectomy stumps (Figure 41.5). Most patients have
an adequate amount of fat that extends down to the cardiophrenic angle, and dissection
frequently encompasses the lateral wall of the thymus gland. The fat pad is sharply dissected
from the pericardium and freed to the upper mediastinum; it is easily brought over to the
bronchial stump. Its blood supply is not as generous as that of a serratus anterior muscle or
intercostal muscle flap, but secure tissue coverage is obtained (see Figure 41.5). Again, it is
important to place fixation sutures in the peribronchial wall, both anteriorly and posteriorly, to
secure the coverage. It is not appropriate just to place the fat pad over the bronchus and
suture to the adjacent pleura, because this does not provide an adequate seal.
Figure 41.5: Large mediastinal fat pad covers the right pneumonectomy stump. Arrows
depict the superior vena cava, and the head of the patient is to the left.

Use of the omentum is not recommended for routine coverage of pneumonectomy stump. It
requires the placement of additional incision in the abdomen and a longer operating time than
the flaps described earlier. The omentum is reserved for closure of a bronchial fistula if the
complication does develop.88

Patients who develop a bronchial fistula three to four weeks after pneumonectomy
expectorate varying amounts of serosanguineous fluid, may become dyspneic, and frequently
develop subcutaneous emphysema. Chest radiograph illustrates a decreasing amount of fluid
in the pneumonectomy space and the presence of subcutaneous air. In the hospital, the
patient should be positioned with the operated side down to prevent spillage of the pleural
fluid into the contralateral lung. Without delay or diagnostic studies, a chest tube is inserted
into the pleural space to remove all of the fluid. Balanced pleural drainage is preferable, but a
standard underwater-seal drainage system can also be adequate. The drainage system must
not be connected to suction, because detrimental physiologic mediastinal shift can occur.
Flexible fiber-optic bronchoscopy should be done to evaluate the status of the
pneumonectomy stump and clear the airway of any secretions or fluid. With the development
of vascular tissue flaps for stump coverage, new antibiotics, and the success of antibiotic
irrigation in combating empyema, reoperation and bronchial stump reclosure can be
considered up to 14 days after the initial operation.

If the patient undergoes reoperation, a long single-lumen endotracheal tube is placed into the
contralateral bronchus with the aid of the flexible fiber-optic bronchoscope under local
anesthesia. Precise placement of the endotracheal tube is achieved under direct
bronchoscopic visualization and eliminates any possibility of contamination of the dependent
lung during positioning of the patient. A double-lumen catheter can be used, but it can be
difficult to position in the presence of a mainstem bronchial fistula, and excessive
manipulation of the tube may only make the fistula larger. Proper position of the double-lumen
tube must be documented with the small-diameter flexible bronchoscope.

The necrotic edges of the bronchial stump are carefully debrided back to viable tissue, and
the stump is closed with an interrupted suture technique using nonabsorbable monofilament
suture. Omentum provides excellent coverage and blood supply to a dehisced bronchial
stump, and the pedicle would have been prepared before opening the chest.88 If the serratus
anterior muscle was preserved at the time of the original thoracotomy, it is also an excellent
flap to provide coverage for the bronchial fistula. Intercostal muscle and mediastinal fat can
also be used, but their blood supply is not as generous as the previously mentioned flaps.

The pleural space is cultured to determine whether infection is present and also to obtain
antibiotic sensitivities for postoperative antibiotic irrigation. Antibiotic irrigations are begun in
the first postoperative 48 hours through a previously placed intercostal catheter, and the
pleural space is filled twice daily with an appropriate concentration of antibiotics and 1,000 mL
of sterile saline. The tube is clamped, and the chest is emptied every ten hours. Serum levels
of the antibiotics are obtained to be certain that toxic blood levels are not present. After ten
days of antibiotic irrigation, cultures of the draining fluid are obtained to be certain that the
effluent fluid is sterile, and the chest tube is then removed. Before removal, the space is filled
with the antibiotic solution. If an empyema develops at a later date, it is treated by adequate
dependent drainage, and the space eventually closed by thoracoplasty or myoplasty or both.
The antibiotic sterilization can again be attempted if a fistula is not present, as described by
Claggett and Gerace.89

A two-stage procedure is advocated by Deschamps et al.90 for fistula closure and sterilization
of the empyema space. The first stage consists of opening of the thoracotomy incision with
debridement and closure of the bronchial fistula and coverage with viable tissue. The
empyema cavity is thoroughly debrided and the cavity is packed open with gauze soaked in
povidone-iodine solution diluted 20 to 1. The packing is changed daily, and when healthy
granulation tissue appears in the pleural space, the cavity is filled with antibiotic solution and
a watertight chest wall closure is obtained.

The management of a bronchopleural fistula that occurs several weeks or months after
pneumonectomy requires that the space be clean and dependently drained. This is best
accomplished with the open-window thoracostomy or Eloesser flap.91 The presence of a
chronic bronchopleural fistula requires direct closure because it will not heal on its own, and
the pneumonectomy space cannot be closed or sterilized until the fistula has healed. Puskas
and colleagues91 described successful closure of chronic bronchopleural fistulas in 40 of 47
patients (85%) using direct suture closure of the bronchial stump in 37 patients and suturing
of omental or tissue flaps over the fistula in ten patients. All of these closures were buttressed
with vascularized pedicle flaps of omentum, muscle, or pleura. At the time of the bronchial
fistula closure, the empyema cavity can be obliterated using myoplasty and thoracoplasty
techniques. Any residual cavity that remains can be successfully sterilized using the
Claggett89 technique.

Failure of sterilization of the residual space can be successfully managed with packing and
daily dressing change, with expected obliteration of the space by granulation tissue over
several months. Pairolero and colleagues86 used muscle grafts of pectoralis, serratus anterior,
latissimus dorsi, and rectus abdominis, along with the omentum, and achieved an 88%
success rate in closing fistulas and controlling intrathoracic sepsis. Extrathoracic muscle
transpositions, along with omentum, are now the accepted standard of therapy for treatment
of the chronic bronchopleural fistula and empyema. These techniques have significantly
decreased the need for a disfiguring thoracoplasty, which is the alternative method of treating
postpneumonectomy empyema and fistula.

If a pneumonectomy fistula occurs in a long bronchial stump, consideration can be given to

the transsternal approach for reamputation of the stump. This is a technically demanding
procedure, and the surgeon must thoroughly review the literature before embarking on this
repair.93 After successful transsternal closure of the fistula, antibiotic sterilization of the
pneumonectomy space is done.

Fibrin glue can successfully close a small fistula up to 4 mm in size, and its use should be
considered when a small fistula has been identified. Tissue glue in the United States can be
made from cryoprecipitate and thrombin, and the European version with a stronger tensile
strength is now available. Closure of small fistulas in both pneumonectomy and lobar stumps
has been achieved. The cryoprecipitate and thrombin are instilled through catheters passed
through the channel of a fiber-optic bronchoscope. This technique is associated with low
morbidity and can be the initial therapeutic maneuver if the fistula is small.94,95

Bronchial fistula after lobectomy is a rare occurrence, and it is more common for a lobar
bronchial fistula to occur after a bilobectomy than a standard lobectomy. A cancer resection
requires an extensive dissection when carrying out a bilobectomy, and bronchial blood supply
is jeopardized. The surgeon must pay particular attention to closure and coverage of
bilobectomy stumps.

Early dehiscence of a bronchial stump after lobectomy is evidenced by a persistent and

moderate air leak, a sudden increase in the size of an air leak, or the development of a space
after chest tubes have been removed. Other symptoms include fever and a cough productive
of serosanguineous fluid or purulent material from a developing empyema. If a fistula is
suspected, bronchoscopy should be carried out. Complete separation of a bronchial closure is
obvious, but small defects in a lobar bronchus may be difficult to identify. A to-and-fro motion
of secretions at the stump, necrotic tissue, and granulations are all indicators of a fistula. If the
chest tubes have been removed, a new chest tube must be inserted into the developing
space as soon as the diagnosis of a lobar stump fistula is made. A decision is then made
about appropriate therapy.

In general, it is better to treat lobar bronchial fistula in a long-term conservative manner, for
several reasons. First, acute debridement of a dehisced lobar stump may result in little
remaining bronchus to reapproximate, and closure would compromise a mainstem bronchus.
Second, to achieve closure of viable bronchial tissue, a completion pneumonectomy may be
required, with increased morbidity and mortality. Third, the probable infected space may
predispose the fistula closure to failure, resulting in an increase in morbidity and mortality.

If reoperation for a lobar fistula is decided on, the surgeon has several options. The bronchus
can be resected to obtain more healthy tissue, and the stump is reapproximated with a fine,
nonabsorbable, monofilament suture. If the bronchial tissues are necrotic, the amputation of
the bronchus at a higher level must be considered. This technique is applicable when a right
lower lobectomy stump has developed a fistula, and the middle lobe can be resected with
bronchial closure at the proximal bronchus intermedius. Sleeve lobectomy can be considered
after an upper-lobe bronchial fistula, but the surgeon must be aware of possible anastomotic
failure along with probable difficulty in reexpansion of the residual lung tissue. All reoperative
bronchial closures must be covered by a viable tissue flap.

Despite the fact that adequate tube drainage after lobar bronchial fistula may result in a more
protracted course, a successful long-term result can usually be achieved. Myoplasty or
thoracoplasty, or both, may be necessary to close the fistula and obliterate the associated
space, but they are accomplished at less risk when the patient's condition is able to withstand
a second operation. Tube drainage is maintained until the residual lung tissue is adherent to
the parietal pleura, and the fistula is then treated as a chronic problem. A small fistula may
eventually close with fibrotic resolution of the space, but most remain open. Basic criteria to
be carried out include control of the underlying disease process and a clean, dependently
drained space.96

Spaces and Air Leaks

A decrease in the incidence of the development of the postoperative space and prolonged air
leak directly results in a decreased incidence of postoperative complications. The lung cancer
patient is particularly prone to the development of these complications. The normal
mechanisms of compensation for the loss of lung tissue are (a) expansion of the residual
lung, (b) mediastinal shift, (c) narrowing of the intercostal spaces, and (d) elevation of the
diaphragm. Frequently, lung cancer patients have had neoadjuvant irradiation and
chemotherapy, and there is fibrosis in the mediastinum that limits its ability to shift its position.
The lung tissue, if fibrotic from irradiation, does not fully expand, and parenchymal air leaks
fail to heal. The elderly lung cancer patient is prone to prolonged air leaks from
emphysematous lung tissue.

Most persistent air leaks originate from small bronchi or disrupted alveoli and can be termed
alveolo-pleural fistulas. Most air leaks close within seven days of the operative procedure, but
some require special maneuvers in an attempt to stop the leak. Alveolo-pleural fistulas
originate from lung tissue that has been denuded of its visceral pleura, incomplete lung
fissures, the raw surface of a segmentectomy, and nonanatomic resections for neoplasms.
These leaks can be minimized at the time of resection by careful attention to technical detail,
and prevention is the best method of treatment.

The use of the stapler can minimize air leaks from a divided minor or major fissure and helps
to separate the upper lobe from the middle lobe. The stapling device can also minimize air
leaks when carrying out wedge resection or segmental resection, depending on the surgeon's
technique. The staple line should be reinforced with a bovine pericardium or Gore-Tex when
the lung tissue is emphysematous. At the close of the operation, the anesthetist fully expands
the lung to 20 to 25 cm of airway pressure with the lung and bronchus submerged in saline,
and the bronchial stump and lung parenchyma are carefully observed. Air leaks from staple
lines and disrupted parenchyma are closed with fine, interrupted absorbable sutures. Small
air leaks near the hilum can be approximated with carefully placed sutures to avoid damage
to major arteries or veins. A defect in the bronchial stump is repaired.
A pedicle flap of pleura can be used to cover air leaks from tissue just as well as it can cover
a bronchial stump. Absorbable sutures can be placed through the pleura and then through the
lung tissue to anchor the pleura flap securely over the leaking area of lung. On occasion, a
free graft of pleura can be used to reinforce sutures. If a segmentectomy has not been done
by the stapling technique, the residual segmental lung surface can be approximated to the
adjacent lobe. This technique is particularly applicable to posterior, superior, anterior, and
medial basal and lingular segmentectomies.

If an air leak persists at seven days, there are several therapeutic maneuvers that can be
attempted. Suction can be discontinued, because it is possible that the increased negative
intrapleural pressure is maintaining the air leak, and discontinuing the suction will cause the
leak to close. A chest radiograph is obtained in 24 hours, and if a space is developing, the
suction is restarted. Chest-tube suction is maintained for the initial postoperative seven days
because it has been our experience that if the lung collapses in the early postoperative
period, reexpansion can be difficult, with a resultant residual space. A second maneuver is to
withdraw the anterior chest tube by 1 or 2 inches. A chest-tube hole may be directly adjacent
to a small air leak; repositioning the tube allows the lung to expand, and the leaking lung
surface adheres to the parietal pleura. Suction is never increased if the residual lung is fully
expanded because increased suction may potentiate the air leak.

If the lung remains expanded after discontinuation of suction, consideration can be given to
removing the chest tubes, despite the presence of a small air leak. This technique can be
successful, but if a space does develop, a chest tube must be reinserted. Suction is
maintained until the air leak stops or the patient is discharged with a Heimlich valve attached
to the leaking chest tube. The patient is seen at weekly intervals in the office. The leak usually
stops by the time of the first office visit, and the tube is then removed. It may be necessary to
leave the tube in place for an additional two to three weeks until the air leak stops. If the air
leak persists four weeks after hospital discharge, the patient is considered to have an
empyema, and open drainage is instituted. The tube is then shortened by 1 or 2 inches at
weekly intervals until it is removed. This method of tube management is predicated on the fact
that the patient does not have an infected space and the lung is expanded.

There are no specific guidelines for the indications of reoperation of a patient with a persistent
air leak at seven to 14 days. Factors that play a role in this decision include the general
condition of the patient, the emphysematous nature of the remaining lung, the speculated
cause of the persistent air leak, and the presence and magnitude of an intrapleural space.
Reoperation and necessary decortication can create new air leaks, and careful judgment is
required to reoperate for a persistent air leak. A large and increasing air leak may make
reoperation necessary. The management of a persistent air leak is noted in Figure 41.6.

The development of a postoperative space is commonly related to a persistent and large air
leak, but other causes include resection of two lobes on the right side, only the basal
segments of either lobe remaining, fibrosis in the remaining lung that limits expansion, and
incomplete decortication from prior pleural effusion or infection. Postoperative atelectasis and
a fixed mediastinum due to irradiation or prior inflammation also contribute to the
development of a space. All of these factors are seen in patients undergoing resection for
lung cancer. Kirsch and colleagues97 reported on the natural history of the pleural space and
noted that 74% undergo spontaneous resolution, 13% require temporary drainage, 7% are
persistently sterile, and only 6% become infected. Despite the relatively low incidence of
major complications associated with a persistent space, the thoracic surgeon must make
every attempt to minimize it because an infected space is a problem for both the patient and
the thoracic surgeon.
Figure 41.6: Suggested management of prolonged air leak. (From Piccione W Jr, Faber
LP. Management of complications related to pulmonary resection. In: Waldhausen JA,
Orringer MB, eds. Complications in cardiothoracic surgery. St. Louis: Mosby Year Book,
1991:336, with permission.)

Practical steps can be carried out in the management of a postoperative space. The first is to
be certain that the residual lung tissue is clear of all secretions and that postoperative
atelectasis is aggressively treated. Early postoperative consideration must be given to
increasing the amount of chest-tube suction. We routinely start with 20 cm of water suction
immediately after the operation and recommend increasing suction to 30 or 40 cm of water
pressure if there is a space in association with an air leak. Evacuation of the air permits the
raw lung surface to reach the parietal pleura, and small air leaks close. The patient can be
dyspneic owing to a decrease in tidal volume as inspired air is removed by increasing suction.
Significant pleural pain can also be troublesome. Suction should be increased in increments
of only 10 cm of water to evaluate the patient's ability to tolerate it. We do not use suction set
at more than 40 cm of water pressure because of patient discomfort.

Certain intraoperaive maneuvers can also minimize the possible complications of the
postoperative space. One method is to use a pleural tent (Figure 41.7). If an extrapleural
dissection was required to resect an upper-lobe lesion, then a pleural tent is obviously not
available. Even if a constructed pleural tent is not airtight, the large pleural flap can cover
residual lung tissue and expedite the closure of parenchymal air leaks, which effectively
eliminates a space problem. Transplantation of the diaphragm and crushing of the phrenic
nerve have been advocated to minimize the postoperative space, but have not been used in
our experience. Disadvantages include the time involved to transplant the diaphragm and the
loss of diaphragmatic motion, which decreases the patient's ability to cough as well as long-
term pulmonary function. The most extensive intraoperative procedure is to bring the chest
wall to the lung tissue. This is accomplished by either a tailoring or an osteoplastic
thoracoplasty. A tailoring thoracoplasty entails subperiosteal resection of the first and second
ribs along with a portion of the third rib to decrease the size of the apex. An osteoplastic
thoracoplasty is a subperiosteal resection of the posterior portions of ribs 2, 3, 4, and 5, with
wire fixation of these ribs to the posterior sixth rib. A standard five- or seven-rib thoracoplasty
in association with an extended pulmonary resection is not recommended, because it will
result in inadequate postoperative ventilation owing to paradoxical chest wall motion.
Figure 41.7: A: Pleural tent constructed to minimize air leak and pleural space after left
upper lobectomy and resection of a portion of the superior segment of the left lower lobe.
Arrows depict the location of the pleural tent. One chest tube drains the space above the
pleural tent, and two chest tubes drain the normal pleural space. B: Chest radiograph six
months later in the same patient.

If the air leak stops and there is a persistent space, the chest tube is removed, and the space
is treated as if it were sterile. The patient can be safely discharged without antibiotic therapy
and is followed with periodic chest radiographs (Figure 41.8). The sterile space obliterates
with fibrous tissue over time.
Figure 41.8: Frontal (A) and lateral (B) views of a sterile space after left upper lobectomy.
Space will obliterate in several weeks with no postoperative sequela.

If an empyema does develop in a postoperative space, tube drainage is mandatory. If the

space is small, it is managed with open-tube drainage, and the tube is slowly backed out as
the space obliterates. If closure of an infected space does not occur after several weeks, or if
the space is large, there remain two surgical options. The first is thoracoplasty, and the space
must be located so that the appropriate type of thoracoplasty obliterates it. A large space
necessitates a standard posterior seven-rib thoracoplasty.

The pedicle muscle flap is the most effective method of obliterating almost any infected
residual space, and the muscle can be used to close any residual bronchial fistula.98 The
pectoralis major is particularly well suited for placement into the apex of the chest and avoids
the deformity of a thoracoplasty. Other tissues that can be used include the omentum,
serratus anterior muscle, and latissimus dorsi muscle if it has not been transected by the
previous thoracotomy.

Careful attention to all the preoperative and postoperative details in managing the lung cancer
patient minimizes the complications of the postoperative space. Space management is
detailed in Figure 41.9.
Figure 41.9: Suggested management of the postoperative space. (From Piccione W Jr,
Faber LP. Management of complications related to pulmonary resection. In: Waldhausen
JA, Orringer MB, eds. Complications in cardiothoracic surgery. St. Louis: Mosby Year
Book, 1991:336, with permission.)

Intraoperative Hemorrhage

Hilar dissection can be extremely difficult when central lung cancers are removed, because
they often invade major vascular structures, and the avoidance of damage to these vessels is
difficult. Neoadjuvant therapy for a clinically advanced lung cancer frequently obliterates
tissue planes and makes the hilar dissection extremely difficult. The normal tissue plane of
the pulmonary artery and its branches can be totally obliterated, and meticulous sharp
dissection is necessary to remove the cancer from these structures. Neoadjuvant therapy,
coupled with prior mediastinoscopy, also renders the paratracheal tissues fibrotic and further
complicates mediastinal lymphadenectomy. The thoracic surgeon must be prepared to handle
intraoperative hemorrhage, and there are various technical maneuvers that can be
undertaken to minimize its occurrence.

Right Hilum

The primary cancer or involved regional lymph nodes may render approach to the pulmonary
artery or its branches technically difficult. In this instance, it is appropriate to obtain provisional
control of the more proximal pulmonary artery. Also, in many instances, the cancer obliterates
the standard approach to the main pulmonary artery, and other maneuvers must be
undertaken to ligate it more proximally.99
An approach to the right main pulmonary artery is to open the pericardium at the level of the
superior pulmonary vein and extend this opening to a level onto the superior vena cava above
the azygos vein. If the azygos vein can be encircled, it is ligated proximally and distally and
transected to provide added exposure. The right main pulmonary artery can then be isolated
medial to the superior vena cava (Figure 41.10). If a difficult lobectomy is to be attempted, a
provisional Rumel tourniquet can be applied to control the main pulmonary artery if bleeding
does occur during the dissection. This approach can also be used to transect the pulmonary
artery either by using the stapling technique with vascular staples or by placing a vascular
clamp proximal and then suturing the transected pulmonary artery stump.

Figure 41.10: The right main pulmonary artery is isolated medial to the superior vena cava
after the pericardium is widely opened.

A second approach to the right pulmonary artery is more medial, and it is necessary to open
the pericardium widely to provide exposure to the pulmonary artery between the ascending
aorta and superior vena cava (Figure 41.11). A significant portion of this dissection must be
done by blunt finger dissection, and care must taken not to disrupt the main artery with this
maneuver. It is rare that a tumor extends to this level of the main pulmonary artery, and
provisional proximal control can usually be obtained by this technique. If a pneumonectomy is
being done, the artery is usually ligated at this level with a heavy permanent suture.
Transection of the main artery is then done on the other side of the superior vena cava. The
vascular stapling technique can also be used to divide the main artery, but the instrument can
be difficult to position.

Figure 41.11: The proximal right main pulmonary artery is isolated between the aortic arch
to the right and the superior vena cava. The pericardium has been widely opened, and the
technique of isolation is by both sharp and blunt finger dissection.

An upper-lobe tumor may totally occlude the anterior approach to the pulmonary artery, but
the mainstem bronchus remains free of cancer involvement. In this instance, the posterior
aspect of the pulmonary artery is readily accessible and it can be isolated by initially
dissecting the right mainstem bronchus so that it can be transected. The pneumonectomy
stump is closed by the staple technique (Figure 41.12). To avoid contamination of the space
during continued aspects of the dissection, the stapler can also be used to close the distal
bronchus. After transection of the bronchus, the posterior aspect of the pulmonary artery
becomes readily available, and a more proximal dissection with ligation and transection of the
right main pulmonary artery can be carried out. This approach is predicated on the finding that
the proximal right mainstem bronchus can be freed for transection and closure. Despite
proximal control of the main pulmonary artery, a defect in a large lobar branch can bleed
profusely from atrial back bleeding and large bronchial arteries supplying the tumor. In this
instance, distal control of the pulmonary artery must be obtained, or vascular clamps can be
placed on both the superior and inferior pulmonary veins to minimize blood loss while the
arterial defect is closed.
Figure 41.12: The right main pulmonary artery is approached posteriorly after transection
and closure of the right mainstem bronchus. Tumor obliterates the customary anterior
approach to the right main pulmonary artery.

Involvement of either the superior or inferior pulmonary vein by the cancer necessitates
opening of the pericardium to obtain more proximal control. The vascular stapling device can
be placed on the atrium to obtain an adequate margin of resection beyond the tumor, and
proximal control is achieved. On occasion, both the superior and inferior pulmonary veins are
involved by the tumor, and the stapling instrument is not long enough to close a single atrial
cuff. In this situation, a large vascular clamp is placed to occlude the atrium, and it is
transected. The atrial tissues are then reapproximated by a running monofilament suture.

The primary tumor or involved lymph nodes may invade the superior vena cava. If the
invasion is minimal, a partially occluding vascular clamp can be placed, and a portion of the
vena cava wall is transected. The defect is closed with a running monofilament suture. In
other instances, a portion of the wall of the vena cava may require resection to remove all of
the tumor. The right and left innominate veins must be isolated, and provisional ligatures are
placed. The pericardium is opened, and a provisional tourniquet is placed at the level of the
caval-atrial junction. The vena cava can be bypassed by a catheter technique, as described
by Piccione and colleagues,100 and the defect in the vena cava is repaired by a patch graft of
pericardium. The vena cava can also be replaced or bypassed by Gore-Tex grafts, as
described by Dartevelle and associates.101 For more on these techniques, see Chapter 62.

Left Hilum
Left-sided lung cancer frequently invades the aorticopulmonary window, and the pulmonary
artery cannot be dissected safely outside the pericardium. The pericardium is then opened
medial or lateral to the phrenic nerve, and this opening is extended up above the aortic arch.
The main pulmonary artery is identified, and the proximal left main pulmonary artery is
dissected free (Figure 41.13). It is usually necessary to isolate and transect the ligamentum
arteriosum to provide exposure for proximal transection and closure. It is also necessary to
identify the proximal portion of the right pulmonary artery to ensure that the main pulmonary
artery is not ligated or compromised. Staple closure of the artery with the vascular stapling
technique is effective in this instance. Provisional proximal left pulmonary artery control can
also be obtained with a Rumel tourniquet after the pericardium is opened during a difficult
lobar dissection.

Figure 41.13: The left main pulmonary artery is isolated after the pericardium is opened.
The right main pulmonary artery must be clearly identified before transection.

The left main pulmonary artery can also be approached posteriorly after dissection and
transection of the left mainstem bronchus. This approach provides additional exposure if the
anterior, intrapericardial approach is particularly difficult. The atrium is handled in similar
fashion as described for the right side.

The primary tumor or involved lymph nodes frequently are densely adherent to the transverse
aortic arch. This is particularly true when a large hilar tumor has been treated with
neoadjuvant therapy and the fibrotic tissues are difficult to dissect. In this instance, careful
sharp dissection is necessary to free the tumor from the aorta. It is important to avoid
development of a plane of dissection between the adventitia of the aorta, because this defect
can rupture during the dissection or in the postoperative course. It is rarely indicated to resect
a portion of the transverse or descending thoracic aorta en bloc with a primary lung cancer.
This type of invasion usually precludes long-term survival of the patient, and aortic graft
replacement with its attendant morbidity is not indicated.

Postoperative Hemorrhage

Postoperative bleeding usually occurs from the site of the pulmonary resection or from an
intercostal vessel in the thoracic incision. Lung cancers invade the mediastinum, chest wall,
and diaphragm, and blood vessels, both large and small, are transected during the resection.
Frequently, it is necessary to carry out an extrapleural dissection, and the persistent oozing of
blood from the chest wall can be difficult to control. A ligature can roll off a previously tied
branch of the pulmonary artery or pulmonary vein, and blood loss in the recovery unit can be
sudden and precipitous. The second major cause of postoperative bleeding is a coagulation
defect related to transfusion of several units of stored bank blood during the operative
procedure.

Many elderly patients who undergo resection for lung cancer take aspirin as a prophylactic
measure to avoid vascular problems. This is particularly true in patients who have had either
transient ischemic attacks or coronary bypass surgery for atherosclerotic heart disease.
Others may take aspirin for chest pain, arthritis, or prophylaxis to avoid a stroke because of a
prior family history. This information should be obtained in the patient's history, and all aspirin-
related products must be stopped before the surgical procedure. It is appropriate to stop
aspirin two weeks before the operation. Aspirin affects platelet function, and if generalized
oozing persists during an extended difficult dissection for lung cancer, then platelets can be
administered to the patient who did not stop aspirin before the thoracotomy.

Symptoms of postoperative hemorrhage include tachycardia and hypotension. The usual

evidence of significant postoperative bleeding is the drainage of about 200 mL or more of
blood per hour through the chest tubes into the drainage system. A portable chest radiograph
should be obtained to ensure that blood is not accumulating in the thorax, because the
quantity of chest-tube drainage is not a reliable indicator. It is important to obtain the chest
radiograph in the upright position to quantitate better the amount of retained blood in the
chest cavity.

Blood replacement is carried out dependent on measured blood loss during the operative
procedure, the patient's physiologic status, and the measured blood loss through the chest
tubes. Continued blood loss at a rate of 200 mL per hour for four hours is generally an
indication for reoperation to identify and control the source of bleeding. In this situation,
continued observation can be carried out if the surgeon thinks that the trend of blood loss is
slowing and the patient's condition is stable. This decision must be carefully correlated with
the operative findings and the speculative cause for the postoperative bleeding. Coagulation
studies are obtained, and when defects are identified, they are corrected. Agents used
include fresh frozen plasma, cryoprecipitate, or platelets as indicated.

A sudden rush of blood into the chest drainage system approximating several hundred
milliliters mandates immediate reexploration. A ligature may have slipped from a large vessel,
or a vascular repair may have partially separated.

Prevention is the key to the avoidance of the postoperative complication of bleeding.

Meticulous hemostasis is carried out during and after the resection. Cautery is used
generously on the chest wall or pleural surface to stop the ooze from the many disrupted
small vessels after pleurectomy. The mediastinum is carefully explored for a large bronchial
artery that may have clotted off but that will start bleeding after the clot moves or the patient
has an episode of postoperative hypertension. The main pulmonary artery and veins are
carefully inspected for any defects in the closure, and persistent bleeding is controlled with
fine interrupted sutures. Lobar branches from the pulmonary artery must be securely tied, and
the operator can feel a break in the intima as the initial knot is placed. Large vessels require
suture ligation, including the more proximal ligature, to prevent slippage. The anterior and
posterior portions of a thoracotomy are always carefully inspected to ensure that there is no
bleeding from a traumatized intercostal artery.

Postoperative Chylothorax

Chylothorax after pulmonary resection is a rare complication and occurs more frequently after
pneumonectomy than after lobectomy or segmentectomy. The thoracic duct enters the chest
through the aortic hiatus at the level of T-12 and is adjacent to the aorta. It remains on the
right side of the vertebral bodies until it crosses to the left at the level of the fifth or sixth
thoracic vertebra. It then passes behind the aortic arch to an area adjacent to the esophagus
and exits the mediastinum to drain into the left subclavian vein. The duct can be
multichanneled and have many tributaries in the area of the subcarinal space. Damage to the
main duct or tributaries can occur anywhere along the mediastinum. Subcarinal
lymphadenectomy requires exposure of the esophagus, and the removal of these lymph
nodes may result in unrecognized thoracic duct injury. Damage can also occur on the left side
when the proximal left mainstem bronchus is freed for transection, and lymph nodes involved
by a tumor are removed along the descending thoracic esophagus.

Frequently, damage to the duct or its tributaries is clearly identified during the dissection.
Whenever a small flow of milky fluid is identified, it is mandatory that the defect in the main
duct or one of its branches be closed with interrupted permanent sutures. If the patient has
not eaten for several hours before the surgical procedure, the chyle can appear more golden-
yellow than milky, and this is a clue to the fact that a defect has been created.

Often, patients do not eat solid food after a major pulmonary resection, and the chest-tube
drainage is not the characteristic milky color. However, the continued drainage of serous fluid
measuring more than 1,000 mL in 24 hours alerts the surgeon to the possibility of a thoracic
duct fistula. As soon as the patient begins to eat solid food, the classic milky appearance of
the fluid appears. Analysis of the pleural fluid shows chylomicrons with lipoprotein
electrophoresis, and the triglyceride level is more than 100 mg per dL if the fluid is chyle.

After pneumonectomy, the development of a chylothorax is indicated by rapid filling of the

pneumonectomy space with deviation of the mediastinum away from the operated side.102
The initial treatment of a postresection chylothorax is conservative. Chest-tube drainage is
maintained to provide expansion of the remaining lung or mediastinum stabilization, and total
parental nutrition is carried out. All oral feedings are discontinued, and meticulous observation
of the amount of daily drainage is recorded. Miller103 reported that spontaneous closure after
an operative injury may be expected in only about half of patients. The maximal amount of
time for observation is two weeks, but if fluid loss is persistent at seven days, operation for
closure of the fistula is undertaken. Sarsam and colleagues102 reported postpneumonectomy
chylothorax in nine patients; in five patients, conservative therapy managed the problem, and
in four, reoperation was required. The pneumonectomy space must be drained by tube
thoracostomy, and central hyperalimentation is carried out. Although two weeks can again be
used as a time limit for conservative management, a persistent loss of fluid at seven days
indicates the need for reoperation in our experience.

At reoperation, the chest should be opened on the side of the fistula. The patient can be given
cream or olive oil two to three hours before the thoracotomy, and this will enhance recognition
of the site of the fistula. Frequently, the area of the fistula is edematous, and tissues do not
hold sutures well. Further dissection to visualize the fistula better can result in bleeding, and
secure closure of the boggy tissues is not obtained. We recommend that in reoperation for a
thoracic duct fistula after pulmonary resection, supradiaphragmatic ligation of the main duct
should be carried out, as reported by Lampson.104 Just above the diaphragm, the tissue
between the aorta and the azygos vein is bluntly freed with an angled clamp, and mass
ligation of this tissue is carried out with a heavy silk suture. Clips should be avoided because
they damage the duct and a new fistula will occur where the duct is clipped. This ligation can
be accomplished through either a right or left thoracotomy. However, it is more easily
accomplished through a limited lower right thoracotomy, and on occasion, this approach has
been used despite a left-sided chylous fistula.

Other surgical options include pleurectomy, placement of a pleural peritoneal shunt,

application of fibrin glue, and thorascopic ligation of the thoracic duct. However, the gold
standard to which all other techniques must be compared is direct ligation of the duct.

Long-term conservative management of the postoperative chylous fistula is to be avoided,

because the patient's condition will only deteriorate and nutritional depletion will cause further
complications and possible mortality.

Esophagopleural Fistula

The anatomic pathway of the esophagus is in close proximity to the lower trachea and right
mainstem bronchus, and its muscular wall can be directly invaded by a large hilar cancer.
Pneumonectomy and resection of the neoplasm may result in an unrecognized defect in the
wall of the esophagus, with a resultant esophagopleural fistula. The esophagus is also directly
posterior to the subcarinal space, and it can be damaged during subcarinal lymphadenectomy
from either the right or left side. The performance of a left pneumonectomy requires exposure
of the carina and the medial aspect of the proximal right mainstem bronchus, and during this
aspect of the dissection, the esophagus must be freed from the adjacent tissues to permit a
high amputation of the left mainstem bronchus. Damage to the esophagus can also occur
during this phase of the dissection.

A careful review of the preoperative computed tomographic scan usually reveals the presence
of the tumor in close proximity to the esophageal wall. This finding alerts the surgeon to the
need for clear anatomic definition of the esophageal wall during the dissection, and the
placement of a nasogastric tube before the procedure assists in early definition of the entire
thoracic esophagus. If a defect is made in both the muscular and mucosal layers of the
esophagus, a two-layer repair is accomplished with a fine absorbable monofilament suture.
Interrupted sutures are evenly placed to achieve a watertight seal. An adjacent pleural flap is
easily constructed to buttress the repair. If it is determined during the resection that only the
muscularis of the esophagus has been removed and that the mucosa is intact, the muscularis
is reapproximated with similar suture material.

Several bronchial arteries traverse the subcarinal space and are in close proximity to the
esophageal wall because they originate from the aorta. These arteries can be large because
they have nourished the cancer or involved subcarinal lymph nodes. These vessels should be
individually ligated as they are encountered; on occasion, bleeding can be significant if the
vessels are not seen and cut. In this instance, vigorous cautery should be avoided because
unrecognized damage and subsequent necrosis of the esophageal wall can occur. Cautious
use of cautery in the subcarinal space is directly applicable to subcarinal lymphadenectomy
from both the right and left sides.

An esophagopleural fistula after a pulmonary resection can occur either in the early or late
postoperative period. The signs and symptoms are those of an empyema, with fever, chest
discomfort, loss of appetite, a falling air fluid level in the pneumonectomy space, and the
appearance of an air fluid level in a previously opacified hemithorax. The placement of a
chest tube may reveal food particles, but a diagnosis of empyema is obvious. Bronchoscopy
is usually carried out to detect the presence of a bronchial fistula, and an immediate
esophagogram confirms the presence of the clinically suspected esophageal fistula (Figure
41.14). Massard and associates105 recommend the routine use of a barium swallow whenever
a postpneumonectomy empyema develops. This diagnostic study is particularly important
after the development of a late empyema.
Figure 41.14: Bronchoscopy is usually carried out to detect the presence of a bronchial
fistula, and an immediate esophagogram confirms the presence of the clinically suspected
esophageal fistula.

In the early postoperative period, therapy is directed toward direct repair of the fistula. The
previous thoracotomy space is opened, and careful debridement of the pneumonectomy
space is carried out. The esophageal fistula is identified and repaired in two layers. It must be
buttressed with a vascularized tissue flap that includes intercostal muscle, serratus anterior
muscle, and omentum. A gastrostomy for drainage and jejunostomy for feeding and
postoperative alimentation are also recommended. The pneumonectomy space is lavaged
with antibiotic solution, and if sterilized, the chest tube can be removed. However, this is a
difficult empyema to sterilize, and it may be necessary to provide long-term open drainage
with attempted later sterilization by the Claggett technique. An alternative approach is to
exclude the esophagus by a proximal cutaneous fistula and perform a distal ligation with a
second-stage reconstruction. However, the one-stage repair is generally recommended.106
The development of an esophagopleural fistula in the late postoperative period requires rib
resection and adequate drainage of the pleural space. Gastrostomy and jejunostomy are
required for alimentation and drainage of gastric contents. When the patient's condition is
stabilized and the pleural space is clean, thoracotomy and direct repair of the esophageal
defect are carried out. The fistula must be buttressed with tissue, and in this instance,
omentum is an excellent choice because of its vascularity and adhesive qualities. The
pneumonectomy space must be obliterated; this is accomplished by thoracoplasty in
association with thoracoplasty and myoplasty. A small pneumonectomy space can be
obliterated by myoplasty alone. The development of an esophageal pleural fistula after
pulmonary resection is associated with high mortality and morbidity. The fistula must be
treated aggressively because it will not close spontaneously.

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