Completion pneumonectomy: experience in eighty patients

Completion Pneumonectomy for Non-Small-Cell Lung Cancer: Does Induction Treatment Influence Postoperative Outcomes?

Simple Summary

In recent years there have been important improvements in surgical and adjuvant therapy for lung cancer which have led to an increasing number of patients with non-small-cell lung cancer (NSCLC) which had been previously cured by surgery being identified as having a second primary NSCLC or a recurrence of the previous tumor. In these cases, a completion pneumonectomy (CP), defined as the complete removal of the remaining lung after an ipsilateral pulmonary resection, may be performed. Although this procedure has a higher morbidity and mortality than standard pneumonectomy due to the high degree of surgical difficulty strongly associated with the previous surgery, the number of patients undergoing CP is increasing with improvement in morbidity and mortality. To the best of our knowledge, there is no study evaluating the role of induction therapy (IT) on the outcomes of patients who have undergone CP. We reviewed our single-center experience in patients receiving CP for recurrent/second NSCLC after IT and analyzed perioperative results and long-term outcomes. Our results revealed that postoperative complications were not influenced by IT, and long-term survival was adversely influenced by the absence of IT, the presence of squamous cell carcinoma, and cancers at advanced stages. Correct patient selection is crucial to evaluating possible contraindications and adopting technical details to reduce the complication rate.

Abstract

Background: Completion pneumonectomy (CP) is associated with high morbidity and mortality. We reviewed our experience to evaluate whether induction treatment (IT) may affect postoperative outcomes and analyzed factors influencing long-term results. Methods: Between 1998 and 2020, 69 patients with lung cancer underwent CP (50 males, median age 63 years, right CP in 47 patients). A total of 23 patients (33.3%) received IT (chemotherapy in 15, chemoradiotherapy in 7, and radiation in 1). Surgery included 25 (36.2%) extended resections and five (7.2%) tracheal sleeve CP. Results: The 30-day mortality rate was 7.2% (5/69), and overall morbidity was 37.6%. Major complications occurred in five patients (7.2%): one cardiac dislocation, one diaphragmatic hernia, one transient ischemic attack (TIA), and two bronchopleural fistulas. Minor complications occurred in 21 cases (30.4%): pulmonary in 12, cardiac in 7, and neurological in 2. The median hospital stay was 8 days (range, 5–56 days). IT did not influence postoperative morbidity and mortality. Pathological staging included 19 (27.5%) stage I, 36 (52.2%) stage II, and 14 (20.3%) stage III. Overall 5-year survival was 51.7%. Factors influencing survival were IT (p = 0.01), extension of resection (p = 0.04), histology (p = 0.01), pathological stage (p = 0.03), and T and N factors (p = 0.2, respectively). Factors affecting survival in multivariate analysis included IT (p = 0.02) and histology (p = 0.03). Conclusions: In our experience, CP had a low mortality, acceptable morbidity, and good long-term survival, which justifies this surgical procedure. Postoperative complications were not influenced by IT. Long-term survival was adversely influenced by the absence of IT, the presence of extended resection, the presence of squamous cell carcinoma, and cancers at advanced stages.

Completion Pneumonectomy for Second Primary/Primary Lung Cancer and Local Recurrence Lung Cancer

BACKGROUND

Completion pneumonectomy (CP) for second primary/primary lung cancer (SPLC) and local recurrence lung cancer (LRLC) is still controversial. Although several case series on such a practice exist, the oncological benefit is under debate. The purpose of this study was to review available literatures on CP for SPLC and LRLC and evaluate postoperative and long-term outcomes.

METHODS

MEDLINE, SCOPUS and Web of Science were reviewed for eligible studies in January 2021. Studies were included if they indicated outcomes of patients with lung cancer undergoing CP. Overall survival (OS) was defined as the primary end point; secondary end points included operative morbidity and 30-day mortality. Random-effects meta-analysis based on a binomial distribution was used to create pooled estimates.

RESULTS

Thirty-two eligible studies including 1,157 patients were identified. These studies were uniformly retrospective reports. Pooled estimates for 3- and 5-year OS were 50.6% [95% confidence interval (CI) 34.7-66.5] and 38.9% [95% CI 32.2-46.1] in SPLC patients. When the SPLC was a stage I tumor, pooled 5-year OS was favorable with 60.7% [95% CI 43.2-75.9]. In LRLC, pooled 3- and 5-year OS were 47.6% [95% CI 36.1-59.4] and 33.8% (95% CI 26.8-41.5). Pooled morbidity and 30-day mortality was reported in 38.2% (95% CI 32.0-44.9), and 10.0% (95% CI 8.1-12.3).

CONCLUSIONS

CP for SPLC and LRLC is a challenging procedure with significant perioperative morbimortality. However, published evidence indicates good long-term survival for selected patients. Further studies are needed to identify patient subgroups which benefit most from CP.

Long-term outcomes of completion pneumonectomy for non-small cell lung cancer

Background: Completion pneumonectomy (CP) is the removal of remaining lung tissue after initial resection. Our aim in this study was to investigate the factors affecting mortality, morbidity, and survival after CP. Methods: Patients who underwent CP in our clinic between January 2000 and December 2015 were evaluated retrospectively. The patients' demographic information, morbidity, mortality, histopathological characteristics, and 2-, 5-, and 10-year survival were evaluated. Results: Of the 32 non-small cell lung cancer patients in the study, 31 (96.9%) were male and one (3.1%) was female. The postoperative mortality rate was 9.4% and the morbidity rate was 46.9%. The most common complication was atrial fibrillation (31.3%). Median survival time was 67 ± 10.3 months; 5- and 10-year survival rates were 50.3 and 31.2%, respectively. Conclusion: Completion pneumonectomy involves an acceptable mortality rate but high morbidity rate. Based on the results of this study, the interval between initial resection and CP does not affect survival time.

Analysis of Pneumonectomy for Benign Disease: A Single Institution Retrospective Study on 59 Patients

INTRODUCTION

Pneumonectomy is the only curative treatment for some benign diseases but the operation is a challenging procedure. Herein, we present our experiences of pneumonectomy for 59 patients.

METHODS

The medical records of 59 patients who undergone pneumonectomy for benign lung diseases from 2008 to 2013 at the Division of Thoracic Surgery in Beijing Chest Hospital were retrospectively reviewed.

RESULTS

There were 23 male and 36 female patients. Three procedures including pneumonectomy, pleuropneumonectomy and completion pneumonectomy were used. The operative time and intraoperative blood loss were statistically different in the patients who undergone different operations. The operative time of the patients with and without tuberculosis had no difference but the intraoperative blood loss was more in the patients with tuberculosis (P = 0.035). The operative type, age and operative blood loss were relevant with the morbidity, the P value were 0.024, 0.042 and 0.027 respectively.

CONCLUSIONS

Pneumonectomy for patients with benign disease may be more difficult than for patients with lung cancer, mean while pleuropneumonectomy and completion pneumonectomy may be greater challenges. But with careful patient selection and operative technique, it is a satisfactory treatment method for benign lung disease. The morbidity is acceptable and associated with operative type, age and operative blood loss.

[Lung cancer surgery in a single-lung]

INTRODUCTION

The diagnosis of a second lung cancer in a patient with a previous medical history of lung cancer is no longer a rarity. Also, it is possible to observe a new location in a patient who underwent pneumonectomy in the past. Surgery remains the best treatment. Our objective was to overview this subject.

PATIENTS AND METHODS

Among 5611 patients operated in our institution, 186 (3.3%) had metachronous cancer and 17 had previous pneumonectomy (0.7% of pneumonectomies and 0.2% of NSCLC treated in our department). The procedure was diagnostic and therapeutic in 88% of cases (n=15).

RESULTS

There were 16 males and 1 female, mean age was 62.5-years. All were smokers (11 were former smokers) and 6 had other medical history. Mean FEV was 52% (range 35-95%). Types of resection were 2 lobectomies, 4 segmentectomies, and 11 wedge resections. There were no postoperative deaths, but two complications. Histological subtype of the first and second cancer was the same in 11 patients. All patients were pN0 after second surgery. The long-term survival (median 33 months) was 35.3% at 5-years and 14.1% at 10-years. Two patients treated with pneumonectomy for their first cancer were pN2. Patients who underwent upper right lobectomy for treatment of their second cancer survived longer than 5-years.

CONCLUSION

Surgical resection for lung cancer on single-lung is associated with acceptable morbidity and mortality. Prolonged survival can be achieved in selected patients.

The early and long-term outcomes of completion pneumonectomy: report of 56 cases

OBJECTIVES

The aim of this study was to analyse the early and long-term results of completion pneumonectomy (CP).

METHODS

A retrospective review of consecutive patients who underwent CP in the Shanghai Chest Hospital.

RESULTS

Fifty-six CP were performed between January 2003 and July 2013. There were 45 conventional CP (CCP) and 11 rescue CP (RCP) cases. CCP was defined as resection of the remaining lung because of the occurrence of new lesions in patients with previous lung resection. RCP was defined as resection of the remaining lung because of severe complication after primary lung surgery. The mortality and morbidity rates of CCP were 4.4 and 33.3%, respectively. For CCP, the morbidity was significantly higher in benign cases than in malignant cases (80.0 vs 27.5%, P = 0.04). The mortality and morbidity rates of RCP were 27.3 and 90.9%, respectively. For RCP, advanced age (P = 0.046) and preoperative mechanical ventilation (P = 0.03) were related to higher postoperative mortality. The overall 5-year survival rate was 80% for benign cases, whereas for lung malignancy cases, it was 30%. Survival varied (median 60.0 vs 35.0 vs 10.0 months, I vs II vs III, P < 0.01) for different TNM stages and was better for a time interval (between primary surgery and occurrence of lesion) of >2 years (median 60.0 vs 18.0 months, P < 0.01).

CONCLUSIONS

CP was an operation with high risk, especially for RCP. Advanced age and mechanical ventilation before the operation were related to higher mortality in RCP. CCP of benign cases was related to higher postoperative risk, but with good survival. For lung malignancy, survival was better for a time interval (between primary surgery and occurrence of lesion) of >2 years.

Salvage stereotactic ablative irradiation for isolated postsurgical local recurrence of lung cancer

BACKGROUND

For isolated postsurgical local recurrences (IPSLR) of lung cancer, salvage resection is often unfeasible due to a high risk of morbidity and death. Stereotactic ablative body radiotherapy (SABR) provides excellent therapeutic effects, with mild toxicities, for patients with medically inoperable lung cancer. However, the outcomes of SABR for IPSLR have not been reported.

METHODS

Patients with IPSLR who were treated with SABR between 2005 and 2012 were retrospectively identified. The prescribed doses were 40 to 60 Gy per 5 to 10 fractions. Treatment outcomes and toxicities were evaluated.

RESULTS

We identified 23 patients with IPSLR, including 21 with bronchial stump or staple line recurrences and 2 with chest wall recurrences. During follow-up, IPSLR occurred at a median of 36.7 months (range, 5.0 to 190 months) after resection. All patients were N0 M0, and the T stages at recurrence were T1a, T1b, T2a, and T4 in 6, 5, 3, and 9 patients, respectively. The initial pathologic diagnoses were adenocarcinoma in 17 patients and squamous cell carcinoma in 6. At a median follow-up duration of 17.0 months (range, 6.0 to 89.6 months) after SABR, there were 2 local recurrences. Local control and overall survival rates at 1 and 2 years were 94.7% and 86.8% and 84.0% and 76.4%, respectively. Grade 3 to 5 radiation pneumonitis occurred in 1 patient each. Grade 3 temporary but repeated obstructive pneumonia occurred in 2 patients.

CONCLUSIONS

SABR for IPSLR achieved high local control with limited toxicities. SABR may lead to a potential cure and should be considered as a salvage treatment option for IPSLR.

Completion pneumonectomy: outcomes for benign and malignant indications

BACKGROUND

Past series have identified completion pneumonectomy (CP) as a high-risk operation. We evaluated factors affecting outcomes of CP with a selective approach to offering this operation.

METHODS

We analyzed a prospective institutional database and abstracted information on patients undergoing pneumonectomy. Patients undergoing CP were compared with those undergoing primary pneumonectomy (PP).

RESULTS

Between January 2000 and February 2011, 211 patients underwent pneumonectomy, of which 35 (17%) were CPs. Ten of 35 (29%) CPs were for benign disease and 25 of 35 (71%) for cancer. Major perioperative morbidity was seen in 21 of 35 (60%) with 4 (11%) perioperative deaths. In univariate analysis, postoperative bronchopleural fistula (p = 0.05) and benign diagnosis (p = 0.07) tended to be associated with perioperative mortality. All 10 patients undergoing CP for benign disease developed a major complication compared with 11 of 25 (44%) with malignancy, p = 0.002. A bronchopleural fistula (4 of 35, 11%) was more likely to occur in patients undergoing CP shortly after the primary operation (interval between lobectomy and CP; 0.28 vs 4.5 years; p = 0.018) with a trend toward a benign indication for operation (p = 0.07). Median survival after CP for benign and malignant indications was 24.3 months and 36.5 months, respectively. Comparing CP patients to those undergoing PP (n = 176), CP patients were more likely to undergo an operation for benign disease (10 of 35, 29% vs 14 of 176, 8%, p = 0.001). Perioperative mortality for PP was 10 of 176 (5.7%), and was statistically similar to CP (11%).

CONCLUSIONS

Despite a selective approach, CP remains a morbid operation, particularly for benign indications. Rigorous preoperative optimization, ruling out contraindications to operation and attention to technical detail, are recommended.

Completion pneumonectomy in patients with cancer: postoperative survival and mortality factors

OBJECTIVE

To describe postoperative complications and long-term outcomes of completion pneumonectomy and highlight prognostic factors.

METHOD

We retrospectively reviewed the records of 46 patients (38 men, 8 women) who underwent completion pneumonectomy for lung cancer between 1995 and 2009 in one of two thoracic surgery departments. Most were current or former smokers (n = 41; 89%) and did not undergo chemotherapy (n = 38; 83%) or radiotherapy (83%) before surgery.

RESULTS

Complications after surgery were respiratory failure (n = 11; 24.4%), bronchopleural fistula (n = 6; 13%, with no side preference), and empyema (n = 6; 13%). Blood transfusion was necessary for 43% of the cases (n = 20). The day 90 death rate was 15.2% (n = 7). Postoperative staging showed mostly limited disease. Ten patients (21.7%) underwent operation for a second primary cancer, 25 for local recurrence (54.3%), five for microscopically incomplete resection, and six for other reasons. Median overall survival after completion surgery was 30 months (median follow-up: 46.5 months). Among the 15 living patients (33%), 11 are free of disease (24%). In a Cox regression model, factors negatively influencing overall survival were: age older than 65 years (odds ratio [OR] = 2.47; p = 0.012), current smoker status (OR = 2.285; p = 0.033), postoperative pulmonary (OR = 5.144; p = 0.004), cardiac (OR = 3.404; p = 0.033), or parietal wound complications (OR = 5.439; p = 0.016).

CONCLUSION

Despite its increased postoperative complications and mortality compared with standard pneumonectomy, completion pneumonectomy offers encouraging long-term results. Five main factors seem predictive of shorter overall survival.

Completion pneumonectomy for lung cancer treatment: early and long term outcomes

Background

To analyze the experience of completion pneumonectomy for lung cancer at a single institution in China.

Methods

From January 1988 to December 2007, 92 patients underwent completion pneumonectomy for the treatment of lung cancer. The indications were second primary lung cancer (n = 51), Local metastasis (n = 37) and Lung metastasis (n = 4). The median interval between the primary operation and CP was 24.4 months (1.5-145 m).

Results

There was no intraoperative deaths. The CP procedure lasted 4.3 h (1.5-8 h). Blood loss in the CP performance was 1854.5 ml (200-9100 ml) 9 (9.78%) patients died in the postoperative period: pulmonary embolism (n = 2), disseminated intravascular coagulation (DIC) after the multisystem failure (n = 1), respiratory failure after contralateral pneumonia (n = 5), bronchopleural fistula (BPF) with acute respiratory distress syndrome (ARDS) (n = 1) 31(33.7%) patients had at least one major nonfatal complication. The 1, 3 and 5 year survival rates were 81%, 26% and 14% respectively.

Conclusions

Completion pneumonectomy for lung cancer is a safe surgical procedure for the skilled surgeon though it has a relatively higher complications and the long-term survival is acceptable.

Surgical Management of Late Postpneumonectomy Bronchopleural Fistula: The Transsternal, Transpericardial Route

BACKGROUND

Late postpneumonectomy bronchopleural fistula (LBPF) is a serious complication. Surgical repair of the bronchial stump through a lateral thoracotomy is a dangerous attempt due to mediastinal fibrothorax and the risk of pulmonary artery stump damage.

OBJECTIVES

The goal of this study was to estimate the effectiveness of the transsternal, transpericardial approach for bronchial stump repair in case of LBPF.

METHODS

From 1996 to 2002, 1,294 lung resections for non-small cell lung cancer were performed at our department. Out of 412 pneumonectomies, 16 patients (3.8%) presented with LBPF after right pneumonectomy for non-small cell lung cancer. Thirteen of these patients were subjected to transsternal, transpericardial bronchial stump repair. They were followed postoperatively, and morbidity and mortality rates were recorded.

RESULTS

The interval between pneumonectomy and fistula diagnosis lasted from 12 to 85 months. The estimated sizes of the fistulae ranged from 5 to 21 mm, and the length of the bronchial stump was >1 cm only in 2 patients (15.3%).Due to persistent empyema, open-window thoracostomy was performed for definite treatment immediately after the operation for bronchial stump reamputation in 6 cases (46.1%). One patient (7.6%) died 3 months postoperatively due to bronchopleural fistula recurrence. This was also the only case of fistula recurrence.

CONCLUSION

LBPF usually needs definite management to save the patient's life. The transsternal, transpericardial approach is a safe and effective method.

Surgical resection of recurrent lung cancer in patients following curative resection

We reviewed our experience with resection of recurrent lung cancer to evaluate the benefit and risk of the procedure. From December 1994 to December 2003, 29 consecutive patients underwent pulmonary resections for recurrent lung cancer. The mean duration from the first resection to second surgery was 25.4+/-15.1 months for the definite 2nd primary lung cancer (n=20) and 8.9+/-5.7 months for metastatic lung cancer (n=9). The procedures at the second operations were completion-pneumonectomy in 11 patients, lobectomy in 5 patients, wedge resection in 12 patients and resection and anastomosis of trachea in 1 patient. Morbidity was observed in 6 (21%) of the patients and the in-hospital mortality was two patients (7%) after the repeated lung resection. Tumor recurrence after reoperation was observed in 14 patients (48%). The actuarial 5-yr survival rate was 69% and the 5-yr disease free rate following reoperation was 44%. No significant difference was found in overall survival and disease free survival between the 2nd primary lung cancer group and the metastatic lung cancer group. The recurrence rate following reoperation was significantly different between the wedge resection group and lobectomy/completion pneumonectomy group (p=0.008), but the survival rate was not significantly different (p=0.41). Surgical intervention for recurrent lung cancers can be performed with acceptable mortality and morbidity. If tolerable, completion pneumonectomy or lobectomy is recommended for resection of recurrent lung cancer.

Sekund�re Pneumonektomien

Completion pneumonectomy (CP) is widely known to be associated with high morbidity and lethality. However, in certain instances, it offers the only chance for cure. The results of the following CPs (N=86) were investigated: progressive or recurrent benign disease (N=6, group I), recurrence of a malignant tumor (N=41, group II), and complication after lung resection (N=39, group III). Right completion pneumonectomy was carried out in 48 cases and left completion pneumonectomy in 38. The overall 30-day lethality of CP was 20.2%, 0% in group I, 10% n group II, and 33.3% n group III. This lethality was significantly higher on the right side (29.8%) than on the left (7.7%; P=0.014). Differentiation between emergency and urgent indications resulted in 30-day lethalities of 54% and 23%, respectively. This difference is significant (P=0.002). The 30-day lethality for patients with anastomotic or stump insufficiency was 41% (P=0.002). Five-year survival was 26% in the group of patients with malignant disease and 32% in those with complications after lung resection. The results show: the lethality of CP remains high, especially after complications from operating in emergency conditions. However, considering the long-term survival, CP is certainly justified.

Treatment of recurrent disease in lung cancer

Recurrence is a common event after treatment of lung cancer. Retreatment options depend on previous therapies, location of recurrence, and physical condition of the patient. Locoregional relapse can be treated the same way as initial lung cancer, including surgery, radiotherapy (RT), and chemotherapy (CHT), or combined treatment. Approximately 1% to 2% of all recurrent lung cancer is treated with curative reoperation, with somewhat dismal results. RT has been used for either postsurgical or post-RT locoregional recurrences. In the former case, external beam RT was particularly effective in isolated bronchial stump recurrences, with median survival time of approximately 28.5 months and a 5-year survival of approximately 31.5%. In the latter case, reirradiation, generally with endobronchial brachytherapy, was successful in palliation of intrathoracic symptoms (in at least two-thirds of cases), carrying a low incidence of radiation pneumonitis (up to 5%) although cumulative doses went up to 120-150 Gy. Besides external beam RT, endobronchial RT was used to treat symptomatic intraluminal recurrences, with the vast majority of studies using high-dose rate brachytherapy. Finally, CHT has been used in relapsed/refractory advanced or metastatic non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) with the major emphasis on the third-generation drugs that show good response after previously used platinum-based CHT.

Completion pneumonectomy: factors affecting operative mortality and cardiopulmonary morbidity

BACKGROUND

The purpose of this report is to analyze preoperative and perioperative factors affecting operative mortality and cardiopulmonary morbidity after a completion pneumonectomy.

METHODS

We retrospectively reviewed all patients who underwent completion pneumonectomy from January 1985 through September 1998 at the Mayo Clinic in Rochester, MN. Factors affecting operative mortality and postoperative morbidity and were analyzed using univariate and multivariate analysis.

RESULTS

There were 115 patients (73 men and 42 women), with a median age of 64 years (range, 12 to 83 years). Indication for pneumonectomy was benign disease in 57 patients (49.6%), lung cancer in 51 (44.3%) and metastatic disease in 7 (6.1%). There were 24 deaths (mortality 20.9%, 95% CI 13.9% to 29.4%). Mortality for patients undergoing completion pneumonectomy for benign disease, lung cancer, and metastatic cancer was 26.3%, 17.6%, and 0%, respectively (p = 0.24). Factors adversely affecting mortality with univariate analysis included advanced age (p = 0.004), preoperative corticosteriod use (p = 0.01), decreased preoperative diffusion capacity of lung to carbon monoxide (p = 0.01), intraoperative blood transfusion (p = 0.04), and excessive crystalloid infusion within the first 12 hours (p = 0.01) and 24 hours (0.03) postoperatively, respectively. Factors adversely affecting mortality with multivariate analysis included advanced age (p = 0.001), preoperative corticosteriod use (p = 0.002), and low preoperative hemoglobin (p = 0.02). Cardiopulmonary complications occurred in 72 patients (63.7%). Factors adversely affecting morbidity with univariate analysis included benign disease (p = 0.002), decreased preoperative diffusion capacity of lung to carbon monoxide (p = 0.04), bronchial stump reinforcement (p = 0.0001), and excessive crystalloid infusion within the first 12 hours (p = 0.006) and 24 hours (p = 0.02) postoperatively, respectively. Factors adversely affecting morbidity with multivariate analysis included advanced age (p = 0.005) and bronchial stump reinforcement (p = 0.001).

CONCLUSIONS

Multiple factors adversely affect operative mortality and cardiopulmonary morbidity after completion pneumonectomy. Although completion pneumonectomy remains a high-risk procedure, especially for benign disease, it still should be considered a treatment option in selected patients.

Completion pneumonectomy for non-small cell lung cancer: experience with 59 cases

OBJECTIVE

The objective of this study was to assess the results of completion pneumonectomy performed for non-small cell lung cancer, classified as second primary or recurrence/metastasis.

METHODS

From 1982 to 2000, 59 patients underwent completion pneumonectomy for lung cancer, classified second primary or recurrence/metastasis according to a modified form of Martini's criteria, after a mean interval from first resection of 60 months for second primary lung cancers and 19 months for recurrences/metastases.

RESULTS

Operative mortality was 3.4% and complications occurred in 30% of patients. Five-year survival rate for completely resected patients was 25% (median 20 months). No significant difference in long-term survival was detected between second primary and recurrent tumors; survival was not adversely affected by a resection interval of less than 2 years or less than 12 months.

CONCLUSIONS

Completion pneumonectomy for non-small cell lung cancer is a safe surgical procedure in experienced hands; long-term survival is acceptable and the best results are obtained for stage I lung cancer. Distinction between second primary lung cancer and recurrence failed to demonstrate a prognostic value.

Completion pneumonectomy for recurrent or second primary lung cancer

OBJECTIVE

We studied 8 patients undergoing completion pneumonectomy for recurrent or second primary lung cancer.

METHODS

Subjects were men who averaged 62 years of age. Of these 6 had p-stage I, and 2 p-stage II disease at initial operation. At the second operation, we diagnosed 3 with second primary lung cancer and 5 with recurrent lung cancer. We predicted postoperative pulmonary function by calculating the predicted forced expiratory volume in 1.0 second (FEV1.0) from residual numbers of subsegments after completion pneumonectomy. All predicted FEV1.0 in our 8 cases ranged from 544 to 926 (773 +/- 144) ml/m2.

RESULTS

Six patients experienced postoperative complications and morbidity was 75%. One patient undergoing completion sleeve pneumonectomy after radiation therapy for local carina recurrence died on 7th postoperative day due to anastomotic dehiscence and pneumonia. Overall operative mortality was 12.5% (1/8). Four remain alive and actuarial 5-year survival was 37.5%.

CONCLUSIONS

Careful consideration is needed in determining operative indications for completion pneumonectomy for patients after radiation therapy. Patients with recurrent squamous cell carcinoma who have p-stage I disease at initial operation and those with second primary lung cancer and p-stage I or II disease can expect relatively a long-term survival, and we concluded that completion pneumonectomy could be conducted in these cases with a satisfactory prognosis.

Completion pneumonectomy: current indications, complications, and results

OBJECTIVE

Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when done in patients with benign disease. We review our 9 years of experience with this operation to evaluate the postoperative outcome and long-term results of various indications.

METHODS

Between January 1990 and December 1998, 66 consecutive patients underwent completion pneumonectomy (6.8% of all pneumonectomies), and their cases were retrospectively reviewed. The indication was benign disease in 17 patients and malignant disease in 49 patients. In patients with malignant indications there were 14 local recurrences, 4 second primary tumors, 5 metastatic diseases, and 26 indications because of incomplete initial resection.

RESULTS

There were no intraoperative deaths, and the postoperative mortality rate was 7.6%. Complications were encountered in 32 (53%) patients, without any significant difference between benign indication (71%) and malignant indication (47%; P =.0923). Bronchopleural fistula was encountered in 5 (7.6%) patients, and empyema was encountered in 7 (11%) patients. The actuarial 5-year survival was 57% for all patients, 65% for those with benign indications, and 54% for those with malignant indications (60% for local recurrence, 50% for second primary tumor, and 56% for incomplete resection), without any difference between benign and malignant indications (P =.9478).

CONCLUSIONS

Completion pneumonectomy can be performed with acceptable mortality and morbidity, even in patients with benign disease. Patients with preoperative infection can be managed with bronchial stump covering and adequate postoperative drainage. Although complications are common, they can successfully be managed with a proper understanding of them.

Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer

OBJECTIVES

Despite the advances in surgical technology, bronchopleural fistulas (BPFs) still occur and are often fatal. We studied the risk factors for BPF formation after lung cancer operation to clarify the indication of preventive bronchial stump coverage. In addition, the reliability of our methods of bronchial closure was evaluated.

METHODS

We reviewed 557 consecutive bronchial stumps, corresponding to 547 patients without any coverage in pulmonary resection for lung cancer between 1989 and 1998. According to nine variables, stumps that made dehiscence were compared with uneventful ones using contingency table analysis. The incidence of BPFs according to each method of bronchial closure was calculated.

RESULTS

BPFs developed in ten patients (1.8%). Compared with the lobar bronchus (LB), the main bronchus (MB; P<0.01; odds ratio, 23.0) and the intermediate bronchus (IB; P=0.03; odds ratio, 10.7) carried a high risk. Previous ipsilateral thoracotomy (P<0.01; odds ratio, 37.9) and preoperative chemotherapy and/or radiotherapy (P=0.02; odds ratio, 13.2) increased the risk. The incidence of BPFs with manual suture, stapling devices only, reinforcement suture at the distal side of staplers, or reinforcement suture at the proximal side of staplers was 1.8, 5.0, 1.9 and 1.0%, respectively.

CONCLUSIONS

The main and intermediate bronchial stumps, and the stumps in cases with previous ipsilateral thoracotomy or receiving induction therapy are prone to BPFs. Preventive coverage should be considered for these stumps. Our methods for reinforcement of stapled stumps are thought to be reliable.

Pathogenesis and management of respiratory insufficiency following pulmonary resection

The underlying principle of the surgical treatment of non-small-cell lung cancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without compromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patient, the pathologic process requiring resection, the physiologic impact of the procedure, and the addition of pre-operative or postoperative adjuvant therapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 to 2 days after pulmonary resection forewarns of respiratory distress; however, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and advanced critical care often unfolds. Management of patients with severe respiratory failure remains primarily supportive. "Good critical care" is the mainstay of therapy: this includes gentle mechanical ventilation to avoid ventilator-induced barotrauma and over-extension of remaining functional alveoli, diuresis, infection identification and management, and nutritional support. New therapeutic strategies that may impact on outcomes in the adult population include pressure-limited ventilation (permissive hypercapnia), inverse ratio ventilation, high-frequency jet ventilation, high-frequency oscillatory ventilation, intratracheal pulmonary ventilation, and prone position ventilation. In addition, alternative therapies such as partial liquid ventilation, inhaled nitric oxide, and extracorporeal techniques including extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO(2)R), intravascular oxygenation (IVOX), and arteriovenous carbon dioxide removal (AVCO(2)R), provide additional modalities. A component of some or all of these strategies is finding a role in clinical practice.