immediate complications following thoracic surgery

IMMEDIATE COMPLICATIONS FOLLOWING PULMONARY ANATOMIC

RESECTIONS – THE EXPERIENCE OF AN ONCOLOGIC THORACIC SURGERY

DEPARTMENT

S.-T. Makkai-Popa, Luminița Ionescu, C. Sandu, M. Bosînceanu

Second Surgical Clinic, Regional Institute for Oncology, Iași

Introduction

Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol. 2015;33(5):455-64.

Introduction

PE Van Schil, JM Hendriks, P Lauwers. Focus on treatment complications and optimal management surgery. Transl Lung Cancer Res. 2014;3(3):181-6.

Material and method• Retrospective study – January 2013 – August 2015 (32

months)• Patients undergoing anatomic lung resections• 172 resections analysed

• 31 (18,02%) pneumonectomies• 5 (2,91%) bilobectomies• 136 (79,06%) lobectomies

Results• 36 (20,93%) patients with complications • 3 (1,74%) postoperative deaths due to complications• General complications:

• 3 (1,74%) postoperative arrythmias• 1 (0,58%) postoperative stroke

• Pleuro-pulmonary complications:• 7 (4,06%) bronchial stump fistulas• 8 (4,65%) pneumonias on the remaining parenchyma• 1 (0,58%) empyema without fistula• 1 (0,58%) chylothorax• 11 (6,38%) persistent air leaks requiring hospital stays longer than

14 days• 3 (1,74%) haemothorax requiring an iterative surgical procedure

Results• 31 male patients and 5 female patients

Initial cohort Complications group

Age (years) 62,52 ± 9,29 62,7 ± 9,46Length of hospital stay (days) 14,54 ± 8,16 20,27 ± 13,39Duration of the surgical (min) 154,1 ± 43,94 163,46 ± 42,95

Results

Number of cases Histologic type17 adenocarcinoma9 squamous cell carcinoma2 small cell carcinoma1 neuroendocrine carcinoma1 pleomorphic sarcomatoid carcinoma1 adenomatoid cystic malformation1 bronchogenic cyst1 aspergilloma

Results

Number of cases Surgical procedure

28 lobectomy7 pneumonectomy1 bilobectomy

Discussion• 30 days postoperative mortality:

• 6-20% after pneumonectomies1

• 3-8 % after lebectomies1

• our experience - 1,74%

• Postoperative morbidity – up to 60%1

• our experience – 20,93%• neoadjuvant therapy?

• Morbidity and mortality prediction scores2

1. S. Renaud, C. Renaud, A. Seguin, L. Brouchet, J. Berjaud, M. Dahan, P.-E. Falcoz. Principes de la chirurgie d'exérèse pulmonaire. Techniques chirurgicales – thorax. Mise a jour 2013, vol. 8, no. 2, [42-230]

2. Brunelli A., Morgan-Hughes N.J., Refai M., Salati M., Sabbatini A., Rocco G. Risk-adjusted morbidity and mortality models to compare the performance of two units after major lung resections. J Thorac Cardiovasc Surg. 2007;133(1):88-96.

Discussion• Bleeding complications:

• 0,1 – 3% following thoracotomies• less than 2% following thoracoscopies• our experience – 1,74% - haemothorax – iterative surgery

• Cardiac complications:• arrhythmias – 35%• myocardial infarction - 3,8%• cardiac herniation – immediately after surgery - 50% mortality• our experience – 1,74% arrhythmias, no myocardial infarction

• Phrenic and recurrential lessions – 1% - none in our experience• In our experience – 1 stroke

S. Renaud, C. Renaud, A. Seguin, L. Brouchet, J. Berjaud, M. Dahan, P.-E. Falcoz. Principes de la chirurgie d'exérèse pulmonaire. Techniques chirurgicales – thorax. Mise a jour 2013, vol. 8, no. 2, [42-230]

Discussion• Postpneumonectomy pulmonary edema – 2-5%• Prolonged air leak, severe subcutaneous emphysema – 50% - if

severe “Michelin syndrome”• our experience - 11 (6,38%) persistent air leaks requiring hospital stays

longer than 14 days• intra-operative control of bronchial stump• early extubation – intra-alveolar pressure

• Lobar torsion – less than 0,5%• none in our experience – regular preventive fixation of the remaining lobes• reintervention indicated – emboli spread after untwisting – intrapericardic

clamping of pulmonary veins recommended

PE Van Schil, JM Hendriks, P Lauwers. Focus on treatment complications and optimal management surgery. Transl Lung Cancer Res. 2014;3(3):181-6.

Discussion• Empyema – 2-12% in the literature

• our experience – 1 (0,58%) empyema without fistula on control bronchoscopy

• culture of pleural fluid before antibiotics• adequate chest tube drainage required

• Bronchial stump fistulas – incidence varies across literature• our experience – 7 (4,06%) bronchial stump fistulas

• 3 surgical revisions of the bronchial stump:• 1 pneumonectomy• 1 resection and closure of the bronchial stump• 1 bronchial stump plasty with serratus muscle

• 4 bronchoscopically sealed bronchial stump fistulas

PE Van Schil, JM Hendriks, P Lauwers. Focus on treatment complications and optimal management surgery. Transl Lung Cancer Res. 2014;3(3):181-6.

Discussion

• Particular pleuro-pulmonary complications we encoutered:• 1 (0,58%) chylothorax after the surgical treatment of a Stocker type

II adenomatoid cystic malformation in an adult (41 years old)

Discussion

Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol. 2015;33(5):455-64.

Discussion

Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol. 2015;33(5):455-64.

Discussion

Stitzenberg KB, Chang Y, Smith AB, Nielsen ME. Exploring the burden of inpatient readmissions after major cancer surgery. J Clin Oncol. 2015;33(5):455-64.

Conclusion

• Our experience so far is comparable to the data provided in the current literature

• Postoperative complications – survival differences• Deficiencies in healing

• Neoadjuvant therapy• Age