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.
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.
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
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
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.
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:
- relieving pain
- 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.
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
Between 40% and 60% of pneumonectomy patients experience such short-term postoperative difficulties as:
- prolonged need for a mechanical respirator
- abnormal heart rate (cardiac arrhythmia), heart attack (myocardial infarction), or other heart problems
- infection at the site of the incision
- a blood clot in the remaining lung (pulmonary embolism)
- 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.
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 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.
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.
ACS Cancer Resource Center. 18 April 2000. 17 July 2001 <http://www3.cancer.org/cancerinfo>.
Pneumonectomy 3 February 2000. 17 July 2001 <http://www.intelihealth.com>
—An abnormal connection between an air passage and the membrane that covers the lungs.
—Accumulation of pus in the lung cavity, usually as a result of infection.
—A small space between the two layers of the membrane that covers the lungs and lines the inner surface of the chest.
—Blockage of a pulmonary artery by a blood clot or foreign matter.