Pneumonectomy is most often used to treat lung cancer when less radical surgery cannot achieve satisfactory results. It also may be the most appropriate treatment for a tumor that is located near the center of the lung and that affects the pulmonary artery or veins, which transport blood between the heart and lungs. For the treatment of cancer, pneumonectomy may be combined with chemotherapy or radiation therapy. Pneumonectomy may also be the treatment of choice when traumatic chest injury has damaged the main air passage (bronchus) or the lung's major blood vessels so severely that they cannot be repaired. A form of this procedure known as extrapleural pneumonectomy is often used to treat malignant mesothelioma.
Precautions
Before scheduling a pneumonectomy, the surgeon reviews the patient's medical and surgical history and orders a number of tests to determine how successful the surgery is likely to be.
Blood tests, a bone scan, and computed tomography (CT) scans of the head and abdomen reveal whether the cancer has spread beyond the lungs. Positron emission tomography scanning (PET) is also used to help "stage" the disease. Cardiac screening indicates how well the patient's heart will tolerate the procedure, and extensive pulmonary testing (breathing tests and quantitative ventilation/perfusion scans) predicts whether the remaining lung will be able to compensate for the body's diminished breathing capacity.
Because extrapleural pneumonectomy is such an invasive operation, the patient must have no serious illness other than the cancer the surgery is designed to treat.
Description
Traditional pneumonectomy removes only the diseased lung. A more complex surgery generally performed in specialized medical centers, extrapleural pneumonectomy also removes:
a section of the membrane (pericardium) covering the heart
a portion of the muscular partition (diaphragm) that separates the chest and abdomen
the membrane (parietal pleura) that lines the affected side of the chest cavity
General anesthesia is given to a patient undergoing either of these procedures. An intravenous (IV) line inserted into one arm supplies fluids and medication throughout the
operation, which usually lasts between one and three hours; extrapleural pneumonectomies may last up to six hours.
The surgeon begins the operation by cutting a large opening on the side of the chest where the diseased lung is located. This posterolateral thoracotomy incision extends from below the shoulder blade, around the side of the patient's body, and along the curvature of the ribs at the front of the chest. Sometimes removing part of the fifth rib gives the surgeon a clearer view of the lung and makes it easier to remove the diseased organ.
A surgeon performing a traditional pneumonectomy then:
deflates (collapses) the diseased lung
ties off the lung's major blood vessels to prevent bleeding into the chest cavity
clamps the main bronchus to prevent fluid from entering the air passage
cuts through the bronchus
removes the lung
staples or sutures the end of the bronchus that has been cut
makes sure that air is not escaping from the bronchus
inserts a temporary drainage tube between the layers of the pleura (pleural space) to draw air, fluid, and blood from the surgical cavity
closes the chest incision
Besides removing the diseased lung, a surgeon performing an extrapleural pneumonectomy:
cuts the pleura away from the chest wall
removes parts of the pericardium and diaphragm on the affected side of the chest
substitutes sterile synthetic patches for the tissue that has been removed
closes the incision
Preparation
A patient who smokes must stop as soon as the disease is diagnosed.
A patient who takes aspirin or any other other blood-thinning medication must stop taking the medication about a week before the scheduled surgery, and patients may not eat or drink anything after midnight on the day of the operation.
Aftercare
Chest tubes drain fluid from the incision and a respirator helps the patient breathe for at least 24 hours after the operation. The patient may be fed and medicated
intravenously. If no complications arise, the patient is transferred from the surgical intensive care unit (ICU) to a regular hospital room within one to two days.
A traditional pneumonectomy patient will probably be discharged within 10 days. A patient who has had an extrapleural pneumonectomy is likely to remain in the hospital between 10 and 12 days after the operation. While the patient is hospitalized, care focuses on:
monitoring to ensure that concentrations of oxygen in the blood do not become dangerously low (hypoexemia)
encouraging the patient to walk in order to prevent formation of blood clots
encouraging the patient to cough productively in order to clear accumulated lung secretions.
If the patient cannot cough productively, the doctor uses a flexible tube (bronchoscope) to remove lung secretions and fluids (bronchoscopy).
Recovery is usually a slow process, with the remaining lung gradually taking on the tasks of the lung that has been removed and the patient gradually resuming normal, non-strenuous activities. Within eight weeks, a pneumonectomy patient who does not experience postoperative problems may be well enough to return to a job that is not physically demanding, but 60% of all pneumonectomy patients continue to experience marked shortness of breath six months after having surgery.
Risks
In the United States, the immediate survival rate from the surgery for patients who have had the left lung removed is between 96% and 98%. Due to the greater risk of complications involving the stump of the cut
bronchus in the right lung, between 88% and 90% of patients survive removal of this organ.
Between 40% and 60% of pneumonectomy patients experience such short-term postoperative difficulties as:
an abnormal connection between the stump of the cut bronchus and the pleural space due to a leak in the bronchus stump (bronchopleural fistula)
accumulation of pus in the pleural space (empyema)
kidney or other organ failure
Over time, the chest's remaining organs may move toward the space created by the surgery. This condition is called postpneumonectomy syndrome, and a surgeon can correct it by inserting a fluid-filled prosthesis into the space the diseased lung occupied.
Normal results
The doctor will probably advise the patient to refrain from strenuous activities for a few weeks after the operation. Ribs that were cut during surgery will remain sore for some time.
A patient whose lungs have been weakened by non-cancerous diseases like emphysema or chronic bronchitis may experience long-term shortness of breath as a result of this surgery.
Abnormal results
A patient who experiences a fever, chest pain, persistent cough, or shortness of breath, or whose incision bleeds or becomes inflamed, should notify his or her doctor immediately.
Resources
BOOKS
DeVita, Vincent T. Jr., Samuel Hellman, and Steven A. Rosen berg, eds. Cancer:Principles & Practice of Oncology, 5th ed. Philadelphia: Lippincott-Raven Publishers, 1997.
Pass, H., D. Johnson, et al. Lung Cancer: Principles and Prac tice, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
