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• Improving outcome and quality of life after pneumonectomy.
  Richard G Fiddian-Green
  Published on: 9 March 2005

• Published on: 9 March 2005

  Improving outcome and quality of life after pneumonectomy.

  • Richard G Fiddian-Green, Former chairma general surgery Unmassachusetts.

  Dear Editor,

  As Professor Treasure observed in his editorial written in the BMJ this week pneumonectomy for cancer still has a postoperative mortality of 10% to 15% despite patients being rejected if their respiratory function is limited.

  Patients who cannot climb stairs before a pneumonectomy had "similar morbidity rates (31.1 vs. 35.6%, respectively, P=0.7), but higher mortality rates (15.6 vs. 4....

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  Dear Editor,

  As Professor Treasure observed in his editorial written in the BMJ this week pneumonectomy for cancer still has a postoperative mortality of 10% to 15% despite patients being rejected if their respiratory function is limited.

  Patients who cannot climb stairs before a pneumonectomy had "similar morbidity rates (31.1 vs. 35.6%, respectively, P=0.7), but higher mortality rates (15.6 vs. 4.4%, respectively, P=0.08) and deaths among complicated patients (50 vs. 12.5%, respectively, P=0.025)", [occur] compared to matched controls who could perform a stair climbing test bfore pneumonectomy [1]. These data might be interpreted as support for even more stringent selection criteria. That would be a pity for radiotherapy is not as effective as definitive surgery.

  Half the postoperative deaths after a pneumonectomy are attributable to bronchopleural fistulae and its subsequent complications. This complication is more likely to occur on the right than the left. There are technical reasons for this notably the increased need for a hand-sewn anastomosis. Smoking remains an important risk factor [2].

  It is a long time since I spent 6 months as Mr Bromley's houseman at St Mary's but recall well the technical challenges, postoperative fears and the hazards of postoperative care. May I offer some observations and suggestions. My thoracic credentias are that I do not recall ever having had a death within 30 days of an oesophagectomy regardless of the approach, mostly transhiatal for lower third lesions, or manner of construction.

  The break down of a broncheal stump closure may have technical origins but almost certainly also have a metabolic origin, namely an energy supply/demand imbalance imposed by local, regional, and/or systemeic causes. Regional causes might include cytokine release which can iinhibt oxygen consumption, convert xanthine dehydrogenase into xanthine oxidase, deplete adenine nucleotide pools, and promote free radical release. Blood products administered intravenously and especially those from incomplete haemostasis in the viscinity of the bronchial stump might be the most important early causes of cytokine release and sepsis a later cause.

  Whilst cytokines may increase net ATP yield by uncoupling and increasing metabolic rate they might only be able to do so if blood flow can be greatly increased to acccommodate the increased demand for nutrient delivery and uptake to compensate for the accmpanying decline in efficiency of ATP resynthesis. The adequucy of hepatic oxygenation appears to be critical for this to be sustained in hyperperfused healing wounds. ATP resynthesis in a healing wound appears to be almost solely dependent upon anaerobic glycolysis, rather than oxidative phosphorylation, and the ability to wash tissue metabolites out of the wound and recycle them in the liver. The perceived need for positive pressure ventilation and especially PEEP might aid in the generation of the pressure ultimately responsible for blowing a stump whose tissue energeticss have been compromsied.

  Several stragegies might be conveniently adopted. Meticulous attention to haemostasis. The avoidance of transfusion with blood products at any stage even if the haemoglobin falls. The avoidance of increasing the FiO2 for this might increase the risk of pulmonary damage by increasing free radical release. Supplementary oxygenation delivered transenteraly and/or transperitoneally to achieve adequate hepatic oxygenation, increase arterial oxygen daturation, decrease myocardial workload, and avoid the ned for positive pressure ventilation and especially PEEP [3]. ECMO might even be of supplementary benefit in this regard.

  Dead spaces are notorious for their propensity to become secondarily infected especially if needles are inserted into them as was done routinely and repetitively to prevent mediastinal drift after pneumonetomy when I was a houseman. Might the dead space be effectively closed by incising or even excising the diaphragm, rotatng the liver and allowing the abdominal contents to enter the thorax? The diaphragm is no longer needed and any continued contractions permitted might even increase the risk of cytokine release. Mediastnal drift could not occur if the right lobe of the liver was ocupying the space. If in addition the omentum were mobilized, making sure not to devasculrize a part of it [easy to do and difficult to recognize because it may not turn blue], it might even be used to buttress the stump and alllow it to benefit from its unique properties. Havimg said that I never did that for my intestinal anastomoses and never had a fatal leak even one I had in the chest.

  Drains, other than closed suction drains, appar to have an adverse effect inthe abdomen by increasing the risks of infection. I adandoned the practice of placng a drain next to a colonic or rectal anastmosis and closing the floor of the pelvis very early in my career and never had a reason to regreet the practice. I even dispensed with the prctive of placng a chest drain after a Sigura I did through the left chst. I would give serious consideration, therefore, to avoiding the use of any forms of drains after a pneumonectomy.

  The major added risks might be kinking the cava and intestinal obstruction but with full mobilization of the liver these should be easy to avoid. The liver and heart transplant surgeons might have the best technical advice to offer in this regard. My two cents would be to cleanse the gut before surgery with a lavage, and make sure that al intraabdominal adhesions are feed from DJ flexure to ileocaeca valve and that the small bowel is placed in its proper anatomic position prefrable with an intact omentum placed over it under the wound.

  The potential for increasing the number of patients who might withstand a pneumonectomy in additon to reducing the risks of surgery by supplementary oxygenation via transenteral and/or peritoneal routes would seem huge. In our animal study we were able to able to completely abolish the compensatory increase in cardiac output induced by very severe hypoxaema. We did this by tranenteral oxygenation of juat some 60% of the small bowel. The obvious concern would be perforation but that risk would be small if a transperitoneal route were employed as exprience with peritoneal dilaysis has shown.

  There is one other intervention that might increase the efficiency of ATP resynthesis by oxidarive phosporylation and limit myocardial workload and hence risk of MI during and afrer surgery. Clamping actual gastic intramucosal pH at abnormaly low levels wiht a Radiometer pH-stat system whilst keeping the standard intramucosal pH at 7.40 [4].

  I see no reason why resection rates might not be increased and 30-day mortality from pneumonectomy reduced to less than 1% by experimenting with these strategies.

  The possibility that transenteral oxygenation might also be safely achieved on a chronic basis and increase the quality of life after pkeumonectomy, or indeed in anyone with limited pulmonar function, would seem very real [5].

  References:

  1. Brunelli A, Sabbatini A, Xiume' F, Borri A, Salati M, Marasco RD, Fianchini A. Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome. Eur J Cardiothorac Surg. 2005 Mar;27(3):367-372.

  2. Darling GE, Abdurahman A, Yi QL, Johnston M, Waddell TK, Pierre A, Keshavjee S, Ginsberg R. Risk of a right pneumonectomy: role of bronchopleural fistula. Ann Thorac Surg. 2005 Feb;79(2):433-7.

  3. Gross BD, Sacristan E, Peura RA, Shahnarian A, Devereaux D, Wang HL, Fiddian-Green R Supplemental systemic oxygen support using an intestinal intraluminal membrane oxygenator. Artif Organs. 2000 Nov;24(11):864-9.

  4. Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and acid-base balance. Br J Anaesth. 1995 May;74(5):591-606.

  5. T Win, L Sharples, F C Wells, A J Ritchie, H Munday, and C M Laroche Effect of lung cancer surgery on quality of life Thorax 2005; 60: 234-238

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  Conflict of Interest:
  None declared.

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