Complications of Pulmonary Resection: Postpneumonectomy Pulmonary Edema and Postpneumonectomy Syndrome

Indications, contributing factors, and short-term outcomes of pneumonectomy: an 8-year retrospective study in a resource-limited setting

BACKGROUND

Pneumonectomy, the surgical removal of an entire lung, was first performed in 1933 by Evarts A. Graham for lung carcinoma. Today, pneumonectomy is primarily indicated for non-small cell lung cancer (NSCLC) worldwide. However, it carries a higher risk of morbidity and mortality compared to less extensive lung resections.

OBJECTIVES

This study aims to investigate the indications for pneumonectomy and its short-term outcomes among patients who underwent the procedure between 2016 and 2023.

METHODS AND MATERIALS

A retrospective study was conducted on 112 patients who underwent pneumonectomy. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25. Univariate, bivariate, and multivariate analyses were performed to address the study's objectives. The Pearson chi-square test, crude odds ratio (COR), and adjusted odds ratio (AOR) were calculated for categorical variables where appropriate. To identify factors associated with pneumonectomy, a binary logistic regression model was used, and odds ratios with 95% confidence intervals were calculated. A p-value of < 0.25 was used as a threshold for including variables in the multivariate analysis, while a p-value of < 0.05 was considered statistically significant in the final model.

RESULTS

The majority of patients were aged between 20 and 30 years, with 54 patients (48.2%) in this age group, and a male-to-female ratio of 1.6:1. The primary indication for pneumonectomy was inflammatory conditions, accounting for 62.5% (70 patients), followed by carcinoid tumors at 32.1% (36 patients). Lung cancer was the diagnosis in 5.4% (6 patients) of cases. Factors significantly associated with pneumonectomy included a history of tuberculosis treatment (AOR 40.3; 95% CI: 3.01, 540.2), intraoperative blood loss > 500 mL (AOR 9.07; 95% CI: 1.04, 79.13), and surgical duration > 180 min (AOR 37.9; 95% CI: 1.82, 792.3). The morbidity rate was 25%, while the mortality rate was 5.4%.

CONCLUSION AND RECOMMENDATIONS

In our setting, pneumonectomy is most commonly performed for inflammatory conditions. Significant factors associated with the procedure include a history of tuberculosis treatment, intraoperative blood loss > 500 mL, and surgical duration > 180 min. To reduce the need for pneumonectomy, strategies should focus on tuberculosis prevention, screening, and proper patient evaluation and diagnosis before treatment, to prevent extensive lung damage that often necessitates this procedure.

Stress-induced eosinophil activation contributes to postoperative morbidity and mortality after lung resection

Respiratory failure occurs more frequently after thoracic surgery than abdominal surgery. Although the etiology for this complication is frequently attributed to underlying lung disease present in patients undergoing thoracic surgery, this notion is often unfounded because many patients with normal preoperative pulmonary function often require prolonged oxygen supplementation even after minimal resection of lung tissue. Using a murine model of pulmonary resection and peripheral blood samples from patients undergoing resection of the lung or abdominal organs, we demonstrated that lung surgery initiates a proinflammatory loop that results in damage to the remaining lung tissue, noncardiogenic pulmonary edema, hypoxia, and even death. Specifically, we demonstrated that resection of murine lung tissue increased concentrations of the homeostatic cytokine interleukin-7, which led to local and systemic activation of type 2 innate lymphoid cells. This process activated lung-resident eosinophils and facilitated stress-induced eosinophil maturation in the bone marrow in a granulocyte-macrophage colony-stimulating factor-dependent manner, resulting in systemic eosinophilia in both mice and humans. Up-regulation of inducible nitric oxide synthase in lung-resident eosinophils led to tissue nitrosylation, pulmonary edema, hypoxia, and, at times, death. Disrupting this activation cascade at any stage ameliorated deleterious outcomes and improved survival after lung resection in the mouse model. Our data suggest that repurposing US Food and Drug Administration-approved eosinophil-targeting strategies may potentially offer a therapeutic intervention to improve outcomes for patients who require lung resection for benign or malignant etiology.

Research Progress on the Mechanism of Right Heart-Related Pulmonary Edema

Objective. To investigate the mechanisms underlying the development of right heart-associated PE. Background. Right heart-related pulmonary edema (PE) refers to PE resulting from impaired right heart function caused by primary or secondary factors, which is common in critically ill patients. Although the clinical manifestations of different types of right heart-related PE are similar, the pathophysiological changes and treatment methods are significantly different. According to the hemodynamic mechanism, right heart-related PE is primarily classified into two types. One is the increase of right heart flow, including extravascular compression, intravascular compression, cardiac compression, and cardiac decompression. The other type is the abnormal distribution of pulmonary circulation, including obstruction, resistance, pleural decompression, or negative pressure. With the development of hemodynamic monitoring, hemodynamic data not only help us understand the specific pathogenesis of right heart-related PE but also assist us in determining the direction of therapy and enabling individualized treatment. Summary. This article presents a review on right heart-associated PE, with a perspective of hemodynamic analysis, and emphasizes the importance of right heart function in the management of circulation. Understanding the mechanism of right heart-associated PE will not only aid in better monitoring right heart function but also help intensivists make a more accurate identification of various types of PE in the clinic.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

Early corticosteroid treatment for postoperative acute lung injury after lung cancer surgery

Background:

Acute lung injury (ALI) is the most serious pulmonary complication after lung resection. Although the beneficial effects of low-dose corticosteroids have been demonstrated in patients with postoperative ALI, there are limited data on optimal corticosteroid treatment.

Methods:

We retrospectively analyzed 58 patients who were diagnosed with ALI among 7593 patients who underwent lung cancer surgery between January 2009 and December 2016.

Results:

Of the 58 patients, 42 (72%) received corticosteroid treatment within 72 h (early treatment group) and 16 (28%) received corticosteroid treatment more than 72 h after ALI occurred (late treatment group). The early treatment group demonstrated a higher response to corticosteroid treatment compared with the late treatment group (95% versus 69%, respectively, p = 0.014), had an improved lung injury score (86% versus 63%, p = 0.072), and were more likely to be successfully weaned from the ventilator within 7 days (57% versus 39%, p = 0.332). During corticosteroid treatment, the early treatment group had a lower rate of delirium (24% versus 63%, p = 0.012) compared with the late treatment group. No significant differences in length of stay (30 versus 37 days, p = 0.254) or in-hospital mortality (43% versus 38%, p = 0.773) were observed; however, the early treatment group tended to have a higher rate of successful weaning than the late treatment group (p = 0.098, log-rank test).

Conclusions:

Early initiation of corticosteroid treatment improved lung injury and promoted ventilator weaning in patients with ALI following lung resection for lung cancer.

Intensive care in thoracic oncology

The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.

Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.

For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.

Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.

Focus on treatment complications and optimal management surgery

Thoracic surgery comprises major procedures which may be challenging, not only from a technical point of view but also regarding anesthetic and postoperative management. Complications are common occurrences which are also related to the comorbidity of the patients. After major lung resections pulmonary and pleural complications are often encountered. In this overview more surgically related complications are discussed, focusing on postpneumonectomy pulmonary edema, thromboembolic disease including pulmonary embolism, prolonged air leak, lobar torsion, persistent pleural space, empyema and bronchopleural fistula. Prevention, timely recognition, and early adequate treatment are key points as complications initially considered to be minor, may suddenly turn into life-threatening events. To this end multidisciplinary cooperation is necessary. Preoperative smoking cessation, adequate pain control, attention to nutritional status, incentive spirometry and early mobilization are important factors to reduce the incidence of postoperative complications.

Prevention of late postpneumonectomy complications using a 3D printed lung in dog models

OBJECTIVES

Repositioning of the mediastinum with implantation of a prosthesis seems the favoured approach to treat late complications of pneumonectomy caused by mediastinal shift. However, the traditional prostheses are not designed specifically for use in the thoracic cavity, sometimes resulting in failure of treatment for many reasons. The aim of our study was to develop a novel prosthesis to promote prevention or treatment of late postpneumonectomy complications.

METHODS

Using 3D printing technology, we created a novel mimetic lung model replicating the native one and then transplanted it into the thoracic cavity of postpneumonectomy dogs to maintain the original position of the mediastinum. Postoperative morbidity and mortality of late complications were compared between transplanted and non-transplanted groups. The safety and feasibility of implanting a 3D printed prosthesis were also evaluated by chest computed tomography (CT) scan and pathological examination.

RESULTS

At the 1-year follow-up, pneumonectomy dogs with 3D printed lungs showed less morbidity and mortality of late complications. CT images indicated dynamic mediastinal shift in pneumonectomy-only dogs with enlarged contralateral lungs. Nevertheless, there was no obvious change in the position of the mediastinum in 3D printed lung transplanted individuals. Moreover, the 3D printed lungs did not cause any additional side effects and revealed good histocompatibility and tolerance of recipients.

CONCLUSIONS

Our experiences indicated the safety, feasibility and efficacy of transplantation with 3D printed lungs for prevention of late postpneumonectomy complications and provided a practical and possibly unique clinical application of 3D printing technology for surgical therapy.