Pneumonectomy

A pneumonectomy is the surgical removal of a lung, usually as a treatment for cancer. It can be performed in one of two ways:

· Traditional pneumonectomy - Only the diseased lung is removed.

· Extrapleural pneumonectom - The diseased lung is removed, together with a portion of the pericardium (the membrane covering the heart), part of the diaphragm and the parietal pleura (the membrane lining the chest cavity) on the same side of the chest.

Pneumonectomy removes half of a patient's breathing capacity. Because of this, surgeons usually opt for a less extreme form of lung surgery in cancer patients if possible. For example, in some people, the surgeon may perform some other lung-sparing procedure. However, a pneumonectomy is probably the best option when a tumor is located in the middle of the lung and involves a significant portion of the pulmonary artery or veins.

Currently, less-invasive treatments are being developed as alternatives to traditional pneumonectomy. These include:

· The use of video - assisted thoracic surgery, which has reduced the hospital stay to an average of seven days.

· A minimally - invasive approach (without video-assisted thoracic surgery), which has dramatically shortened the hospital stay to one day.

These innovative techniques are exciting, but they are not yet accepted as standard procedures that can be performed on the majority of pneumonectomy patients.

What It's Used For?

Most often, a traditional pneumonectomy is performed to remove an area of lung cancer. A traditional pneumonectomy also may be necessary when a patient has suffered a severe chest wound and there is irreparable damage to major blood vessels or the lung's main bronchial tube, which carries air into the lungs.

An extrapleural pneumonectomy often is performed to treat certain patients with malignant mesothelioma. Malignant mesothelioma is a cancer of the pleura (the membrane lining the chest cavity and covering the lungs) that typically is related to asbestos exposure.

Preparation 

If you need a pneumonectomy to treat lung cancer or malignant mesothelioma, your doctor will order extensive pulmonary testing before your surgery to confirm that your remaining lung is healthy enough to take over the entire workload of breathing for your body. You also will have careful cardiac screening to make sure your heart will be strong enough to withstand the stress of surgery.

Before your surgery is scheduled, you will have a series of scans and blood tests to confirm that the cancer has not metastasized (spread) to areas of your body outside your lungs. These scans may include a bone scan, a computed tomography (CT) scan of your abdomen and a CT scan of your head. Your doctor also will review your allergies and your medical and surgical histories.

About one week before surgery, you will be told to stop taking aspirin and other blood-thinning medications. Beginning at midnight on the night before your pneumonectomy, you must not eat or drink anything. This reduces the risk of vomiting during surgery.

How It's Done? 

An intravenous (IV) line will be inserted into your arm to deliver fluids and medications, and you will be given general anesthesia. An incision will be made in your chest on the side of the diseased lung. In most cases, the surgical cut is an incision that extends from below your shoulder blade, around your side, along the curvature of the ribs, to the front of your chest. The surgeon also may remove a portion of one rib to help to expose the lung and to give him or her sufficient working space.

Next, in a traditional pneumonectomy, the surgeon collapses the diseased lung and ties off its major blood vessels. Then the surgeon clamps the lung's main bronchial tube, cuts through this tube as close to the trachea (windpipe) as possible and removes the lung. The cut end of the bronchial tube either is closed with staples or tied off with sutures (stitches). After confirming that the closed stump of the bronchial tube is not leaking air, the surgeon closes the chest incision with sutures, leaving a temporary drain in the pleural space, the space between the two membranes that surround the lung.

  If you are having an extrapleural pneumonectomy, the surgeon not only will remove your diseased lung, but also will carefully dissect away the pleura from your chest wall. Parts of your pericardium and diaphragm will be cut away on the affected side, and these will be replaced with patches made of Gore-Tex (a safe, synthetic material).

   After your surgery, you will be taken to the surgical intensive care unit (ICU). For the first 24 hours, your breathing will be assisted with a respirator, and your chest drainage tube will remain in place. Once your condition is considered stable, you will leave the surgical ICU within a few days and be transferred to a regular hospital room. Most patients who have had a traditional pneumonectomy will be able to go home within seven to 10 days after their surgery. The hospital stay for an extrapleural pneumonectomy may be one or two days longer.

Follow-Up 

Before you are discharged from the hospital, your surgeon will tell you when you should schedule your first follow-up visit. As you gradually resume your normal daily activities, your remaining lung will slowly compensate for the loss of its partner. If all goes well, you may be able to return to a non-strenuous job within two months.

Overall, recovery tends to be slow for most patients. Even at six months after surgery, about 60 percent of pneumonectomy patients find that their exercise tolerance is still significantly limited by shortness of breath.

Risks 

Pneumonectomy carries significant short- and long-term surgical risk. However, this major operation is considered appropriate for some patients because complete removal of a lung cancer and malignant mesothelioma offer the best chance of a cure. Your thoracic surgeon will explain your personal risk. Short-term postoperative complications affect 40 percent to 60 percent of patients who have had a pneumonectomy. Some of these complications include:

· The need for prolonged mechanical ventilation (being connected to a mechanical respirator that will "breathe" for you) because of poor air exchange.

· Heart problems, including cardiac arrhythmias and myocardial infarction (heart attack)

· Pneumonia 

· Wound infection  

· Pulmonary embolism — a blood clot lodged in the lungs  

· Bronchopleural fistula — an abnormal connection between the stump of the cut bronchus and the pleural space.

· Empyema — pus accumulation in the pleural space  

· Pulmonary edema — fluid accumulation in the lungs  

· Kidney failure 

A long-term risk is that some patients will remain very short of breath after the surgery and require home oxygen therapy.  

Source: Intelihealth