Lung Resection Surgery

Overview

What are the indications for lung resection surgery?

Malignant Conditions
  • Non-Small Cell Lung Cancer:
    • Those well enough and where curative surgery is possible
    • May be combined with extrapleural or en-bloc chest wall resection
  • Small Cell Lung Cancer:
    • Early-stage disease (T1–2a, N0, M0)
Non-Malignant Conditions
  • Large lung bullae
  • Infectious disorders:
    • Lung abscess
    • Tuberculosis
  • Trauma
  • Congenital disorders:
    • A-V fistula
    • Sequestrated lobe
    • Lobar emphysema

What are the different forms of lung resection surgery?

Wedge Resection

Segment Resection

Lobectomy

Pneumonectomy

  • Surgical removal of a small wedge shaped portion of the lung containing malignant tissue and a rim of healthy tissue surrounding
  • Performed to remove small tumours or for diagnosis
  • Can be performed when there is a danger of decreased pulmonary function if a lobectomy is performed
  • Can be performed by VATS or open thoracotomy
  • Surgical removal of a bronchopulmonary segment along with segmental artery and vein
  • Removes a larger portion of the lung than a wedge resection but less tissue than a lobectomy
  • Now rarely performed
  • Surgical removal of any of the five lobes
  • Right middle and lower are often removed together due to shared lymphatic drainage
  • Can be performed by VATS or anterolateral / posterolateral thoracotomy
  • Surgical removal of the entire ling
  • Radical pneumonectomy include excision of mediastinal glands and dissection of chest wall or pericardium
  • Incision is usually posterior lateral thoracotomy

How can lung resection surgery be performed?

Approach

Open Thoracotomy

Video-Assisted Minimal Approach (VATS)

Robotic-Assisted Minimal Approach (RATS)

Description
  • Uses a large single incision (10-15cm) and rib spreading to gain entry to the chest
  • Provides good vision and access to the lungs and mediastinum
  • Forcible spreading of the ribs to permit the surgeons hands to enter results in great surgical access trauma and associated morbidity
  • Significant risk of rib fractures and costovertebral joint damage
  • Uses a main incision (4-6cm), usually with multiple additional incisions, though single port entry is practiced
  • Compared to open thoracotomy associated with significantly
  • less postoperative pain, less intraoperative blood loss, shorter hospital stays and improved postoperative quality of life
  • May offer more limited ability to perform extensive lymph node dissection though 5 years survival outcomes are non-inferior to open surgery
  • Uses 3-4 small incisions to access the chest with robotic instruments
  • Offers the theoretical advantage of 3-dimensional vision and instruments with 360-degree dexterity allowing increased ability to perform complicated proceduresAt present has comparable outcomes to VATS
UK Frequency
43.2%
55.8
(10.6% conversion from open)

What are the outcomes of lung resection surgery?

Mortality varies according to the degree of lung resection performed:

  • Pneumonectomy: 4.5% 30-day mortality
  • Lobectomy 1.7% 30-day mortality

Patient Selection

How do you assess fitness for lung resection?

  • BTS recommends a tripartite risk assessment model when assessing fitness for lung resection surgery including:
    • Risk of operative mortality
    • Risk of perioperative myocardial events
    • Risk of postoperative dyspnoea
  • These can be used to discuss individual risks with the patient and MDT

How is cardiovascular risk assessed?

  • BTS guidance suggests the use of the ACC/ AHA risk stratification tool
    • Necessitates careful history, physical examination and resting ECG
    • All patients with an audible murmur or unexplained dyspnoea should have an echocardiogram
  • Patients identified as having an active cardiac condition should be referred for evaluation and optimisation by a cardiologist

What is the thoracascore?

  • Thoracoscore is a global risk score used for estimating perioperative death in thoracic surgery
  • Uses nine variables (age, sex, ASA score, performance status, dyspnoea score, priority of surgery, extent of surgery, malignant diagnosis and a comorbidity score)

How is pulmonary function assessed to help determine suitability for lung resection surgery?

  • Important in determining risk of:
    • Operative mortality
    • Postoperative complications
    • Postoperative dyspnoea and unacceptable quality of life
  • Assessment includes the use:
    • Routine lung function tests:
      • Spirometry values (FEV1 / FVC)
      • Diffusing capacity for carbon monoxide (TLCO)
    • Calculated postoperative predicted values using ventilation/perfusion scans or CT evaluation
    • Functional assessments (CPET or shuttle walk test)
  • In changes from previous guidance, specific cut-offs are no longer recommended but used to risk-stratify patients for shared decision making

Which values of pulmonary function are used to determine risk associated with lung resection surgery?

Management Summary

Concerns
  • Potentially difficult airway, particularly in the setting of large or retrosternal goitre
  • Anaesthetic implications of thyroid disease
  • Concerns of head and neck surgery including limited access to the airway
  • Potential for bleeding associated with a large goitre
  • Risk of postoperative complications which can lead to significant airway or respiratory compromise
History & Examination
  • Full anaesthetic, medical and surgical history
  • Assess for symptoms and signs of thyroid disease
  • Assess for presence of associated endocrine disorders as part of MEN
  • Assess for symptoms of airway compromise:
    • Dyspnoea
    • Dysphagia
    • Stridor
    • Exacerbation of symptoms on lying flat
  • Examine the goitre:
    • Size and degree of tethering
    • Inability to feel bottom of goitre suggests retrosternal spread
    • Evidence of tracheal deviation
  • Examine for complications:
    • Superior vena cava (SVC) obstruction
    • Horner’s syndrome
    • Pericardial or pleural effusions
 
 
Investigations
  • Laboratory investigations:
    • Thyroid function tests – ensure patient is euthyroid prior to surgery
    • Full blood count – serious adverse haematological effects of concurrent antithyroid medications
    • Two group and save samples –  potential for blood loss
    • Calcium levels – provides baseline as levels may fall post-operatively
  • Clinical investigations:
    • Nasendoscopy: document vocal cord function
    • Respiratory flow volume loops (spirometry) – can help characterize fixed obstruction but rarely used
    • ECG – to determine arrhythmias associated with thyroid disease
  • Imaging investigations:
    • Ultrasound – first-line diagnostic imaging of thyroid nodule to determine size, location and suspicious features
    • CXR – may demonstrate tracheal deviation / retrosternal goitre
    • CT scan – performed if concerns regarding tracheal narrowing or deviation
 
 
Optimisation
  • Primary goal of optimization is to render the patient euthyroid:
    • Usually achieved with carbimazole or propylthiouracil
    • Lugol’s iodine may be given for 10 days to reduce vascularity of the gland
  • Multidisciplinary approach usually key: endocrinologist, surgeon, cardiologist, radiologist and anesthesiologist
  • In emergency surgery may not be possible to achieve euthyroid state:
    • Cardiac symptoms should be controlled with beta-blockade
    • Temperature management may be necessary

On the day of surgery, usual antithyroid medications should be administered except for Carbimazole

 
 
Premedication
  • Glycopyrrolate has been advocated to dry secretions and test adequacy of anti-thyroid treatment
Technique
  • Performed under general anaesthesia
 
 
Airway Management
  • Direct laryngoscopy and oral intubation most frequently performed:
    • Muscle relaxation generally used
    • Ensure smaller tube available if tracheal compression
  • If difficult intubation predicted:
    • Awake fibre optic may be used – risks ‘cork in bottle’ phenomenon in setting of external compression
    • Gas induction previously described but limited data
    • Ensure rigid bronchoscope available in case of ‘can’t intubate, can’t ventilate’ (CICO) situation – cricothyroidotomy may not bypass obstruction
  • Options for tracheal tube include:
    • Nerve Integrity Monitoring tube (NIM):
      • Allows intraoperative monitoring of recurrent laryngeal nerve
      • Recommend by NICE
    • Reinforced (flexi) tube
  • Consider head-up tilt during induction to avoid possibility of tracheal compression on lying flat

  • Ensure adequate pre-oxygenation given risk of slower than usual intubation:
    • Consider use of high-flow nasal oxygenation
  • Tracheal tube should be positioned away from surgical field

  • Consider spraying cords with lidocaine to reduce coughing
  • Cuff should not be overinflated to avoid laryngeal oedema
  • Be aware of the presence of a ‘shared-airway’
    • Tracheal tube should be positioned away from surgical field
    • Ensure tube securely taped
 
 
Induction & Maintenance
  • Total intravenous anaesthesia (TIVA) has become increasingly popular:
    • Provides fast and gentle recovery
  • Use of remifentanil reduces stimulation and motion in the absence or neuromuscular blockade
 
 
Extubation
  • Leak test should be performed prior to extubation
  • Aim is to minimize coughing and straining to reduce the potential for bleeding
  • Options for extubation include:
    • Deep extubation on to OPA or LMA
    • Awake extubation using techniques to prevent coughing:
      • Remifentanil
      • Intravenous lidocaine
Monitoring
  • Standard AAGBI monitoring
  • Continuous temperature monitoring:
    • Risk of hyperthermia or hypothermia in patients with thyroid disease
  • Recurrent laryngeal nerve neuromonitoring:
    • Specialist NIM tube required
    • May reduce incidence of RLN palsy
 
 
Positioning
  • Supine with head fully extended:
    • Padded ring under head
    • Padded roll under shoulders
  • Slight head up favourable to promote venous drainage
  • Vigilance needs to be taken to pad and cover eyes if thyroid eye disease
 
 
Conduct
  • Following intubation neuromuscular blockade is avoided if RLN neuromonitoring is being performed
  • High risk of nausea and vomiting – ensure anti-emetics given
  • Dexamethasone useful in reducing postoperative airway oedema
  • Prior to closing checks for haemostasis may be requested:
    • ‘Passive’ valsalva maneuver
    • Period of normotension / hypertension
Location & Review
  • Can generally be managed on the ward post-operatively unless co-morbidities or complications warrant HDU admission
 
 
Monitoring & Investigations
  • Observation of wound to monitor for haematoma
  • Vocal cord function assessment to assess for palsy:
    • Assessment of voice
    • Fibreoptic nasendoscopy
  • Serum calcium levels to exclude hypocalcaemia
 
 
Supportive Care
  • Thyroxine commenced following total thyroidectomy

Complications

What are the complications that can occur following lung resection surgery?

Pulmonary
  • Pulmonary oedema (9%)
  • Post-pneumonectomy syndrome
  • Orthodeoxia–platypnoea syndrome
  • Lobar torsion (<0.5%)
  • Pneumonia
  • Atelectasis
  • Haemorrhage
  • Chronic respiratory failure
Pleural
  • Prolonged air leak and persistent pleural space
  • Bronchopleural fistula
  • Empyema
  • Chylothorax
Cardiovascular
  • Arrhythmias (AF most common)
  • Thromboembolic disease
Other
  • Wound infection
  • Phrenic nerve injury
  • Recurrent laryngeal nerve injury
  • Chronic pain
  • Death (2%)

What are the risk factors for developing post-operative complications after lung resection surgery?

Patient Factors
  • Preoperative PFTs:
    • FEV1 <60%
    • ppo-FEV1 <30%
    • ppo-DLCO <30%
  • Age ≥75 years
  • BMI ≥30 kg/m2
  • Current smoking status
  • ASA 3-5
  • Disease factors:
    • Anaemia:
    • COPD
    • Liver dysfunction
Procedural Factors
  • Major procedure:
    • Pneumonectomy
    • Extended resection
    • Diaphragm or mediastinal resection
  • Right sided procedure
  • Emergency procedure
  • Low level of operator or surgical expertise
  • Intraoperative complication

What is post-lung resection pulmonary oedema and how common is it?

  • Post-lung resection pulmonary oedema is the occurrence of post-operative pulmonary oedema in the absence of left ventricular dysfunction or infection
  • Oedema can occur in either lung though classically affects the contralateral lung
  • It is associated with the degree of lung resection with pneumonectomy carrying the highest risk
  • The overall incidence is reported as 5.1%
  • It is a serious complication associated with a mortality of up to 50%

Why does pulmonary oedema occur after lung resection surgery?

  • Post-lung resection pulmonary oedema is non-cardiogenic in origin
    • Characterised by increased permeability, oedema and diffuse alveolar damage.
  • Mechanisms behind the development are not clearly understand
  • Factors believed to contribute include:
    • Increase blood perfusion volume through remaining lung
    • Intraoperative fluid overload
    • Barotrauma / volutrauma from intraoperative mechanical ventilation
    • Oxygen toxicity from high intraoperative oxygen concentrations
    • Reperfusion injury
    • Mediastinal lymphatic interruption

What is post-pneumonectomy syndrome?

  • Post-lung resection pulmonary oedema is non-cardiogenic in origin
    • Characterised by increased permeability, oedema and diffuse alveolar damage.
  • Mechanisms behind the development are not clearly understand
  • Factors believed to contribute include:
    • Increase blood perfusion volume through remaining lung
    • Intraoperative fluid overload
    • Barotrauma / volutrauma from intraoperative mechanical ventilation
    • Oxygen toxicity from high intraoperative oxygen concentrations
    • Reperfusion injury
    • Mediastinal lymphatic interruption

What is orthodeoxia–platypnoea syndrome?

  • Post-lung resection pulmonary oedema is non-cardiogenic in origin
    • Characterised by increased permeability, oedema and diffuse alveolar damage.
  • Mechanisms behind the development are not clearly understand
  • Factors believed to contribute include:
    • Increase blood perfusion volume through remaining lung
    • Intraoperative fluid overload
    • Barotrauma / volutrauma from intraoperative mechanical ventilation
    • Oxygen toxicity from high intraoperative oxygen concentrations
    • Reperfusion injury
    • Mediastinal lymphatic interruption

What is lobar torsion?

  • Post-lung resection pulmonary oedema is non-cardiogenic in origin
    • Characterised by increased permeability, oedema and diffuse alveolar damage.
  • Mechanisms behind the development are not clearly understand
  • Factors believed to contribute include:
    • Increase blood perfusion volume through remaining lung
    • Intraoperative fluid overload
    • Barotrauma / volutrauma from intraoperative mechanical ventilation
    • Oxygen toxicity from high intraoperative oxygen concentrations
    • Reperfusion injury
    • Mediastinal lymphatic interruption

What is a bronchopleural fistula?

  • Post-lung resection pulmonary oedema is non-cardiogenic in origin
    • Characterised by increased permeability, oedema and diffuse alveolar damage.
  • Mechanisms behind the development are not clearly understand
  • Factors believed to contribute include:
    • Increase blood perfusion volume through remaining lung
    • Intraoperative fluid overload
    • Barotrauma / volutrauma from intraoperative mechanical ventilation
    • Oxygen toxicity from high intraoperative oxygen concentrations
    • Reperfusion injury
    • Mediastinal lymphatic interruption

Management

What are the complications after lung resection surgery?

What are the risk factors for developing post-operative complications after lung resection surgery?

  • Bleeding requiring repeat surgery is uncommon (0.36% in one large study)

Why does pulmonary oedema occur after lung resection surgery?

  • ABC assessment
  • Manoeuvres to relieve dyspnoea:
    • Administer high flow oxygen
    • Sit the patient up
  • Remove surgical clips/sutures:
    • Allows decompression of the haematoma
  • Ensure G&S performed and blood available
  • Ensure appropriate support:
    • ENT surgeon
    • Senior anaesthetist
  • Arrange prompt return to theatre:
    • Secure airway at earliest possible opportunity

What are the key considerations in managing the airway in a post thyroidectomy haematoma?

  • Ensure appropriate support:
    • ENT surgeon on standby
    • Experienced anaesthetist
  • Anticipate and prepare for difficult airway:
    • Ensure smaller ETT than previously used
    • Have difficult airway trolley in close proximity
  • Consider options for securing the airway:

RSI with Direct / Videolaryngoscopy

Awake Tracheostomy

Awake Fibreoptic intubation

Inhalational Induction

Generally considered best option in most situations
Often impractical with patient in extremis
Often impractical with patient in extremis
Risks aspiration in patients that are not starved

Author

The Guidewire
Trainee in ICM & Anaesthesia

Reviewer

The Guidewire
Trainee in ICM & Anaesthesia