72: Pneumonectomy

Introduction

As long as surgery remains the best curative treatment for lung cancer, patients will continue to require pneumonectomy to treat lung cancer and for other occasional problems.¹ Arguably, no other surgery carries as high a risk for perioperative mortality as pneumonectomy. Operative mortality from pneumonectomy has been reported to be between 5% and 20%.^2–8 In a meta-analysis of 27 studies, 90-day mortality for right pneumonectomy was 20% and left pneumonectomy was 9%, for an overall mortality of 11%.⁹ For this reason, appropriate selection, operative technique, and postoperative management of patients who potentially may undergo pneumonectomy is crucial. We say potentially because patients scheduled for pneumonectomy ultimately may undergo a sleeve resection or exploration without resection depending on the findings at surgery.

Surprisingly, low preoperative lung function has not been demonstrated consistently to increase the perioperative risk of pneumonectomy, although some authors have found preoperative lung function to be an important factor.^10–12 This finding may result from diligent efforts to identify and eliminate patients with poor pulmonary function from the surgical pool. Some have found poor preoperative lung function to increase the preoperative risk.^13–15 Other factors have included increased age,^{7,8,11,14,16,17} right-sided procedures,^{8,9,12,14–19} preoperative chemo/radiation,^12,14,20 large intraoperative fluid volumes,^12,20,21 perioperative cardiac dysrhythmias,¹⁶ and immediate preoperative smoking history.^12,22

This chapter includes discussion of the preoperative evaluation and management of pneumonectomy patients, the decision to perform pneumonectomy rather than sleeve resection, the technical aspects of the operation, and the postoperative management, all with the goal of decreasing perioperative mortality.

Preoperative Evaluation and Management

Staging, Surgical, or PET?

All patients with lung cancer, especially those who may undergo pneumonectomy, should first undergo preoperative staging (Table 72-1). At this time, a complete history and a physical examination that focuses on the identification of lymph nodes and liver masses, followed by a chest CT scan and a PET scan, are appropriate. This evaluation will rule out distant metastases other than brain metastases. Patients without symptoms of headache and with PET-negative mediastinum are unlikely to have brain metastases, so that brain CT scans or MRIs are not obligatory. However, the risk of the procedure supports appropriate evaluation to rule out brain metastases if the surgeon desires.

Candidates for pneumonectomy typically have large or hilar masses and thus a high likelihood of mediastinal metastases. ...