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Post-operative complications following thoracic oncology procedures

Oncology
Surgery

Introduction

Post-operative complications are unfortunately frequent following thoracic surgical procedures. Careful patient selection with appropriate assessment of cardiopulmonary reserve and co-morbidities is necessary. Additionally, efforts at prehabilitation such as pulmonary rehab enrollment, smoking cessation, nutrition optimization and patient education are beneficial. Intraoperatively, attention to meticulous technique is complementary to patient selection. Despite these efforts, major morbidity is encountered in 30-40% of cases [1].
Complications can be grouped into early and late categories, and further by procedure (e.g. pulmonary, mediastinal, esophageal, and chest wall. This chapter will focus on complications of pulmonary resections.

Early Complications

The most common early complications are alveolar-pleural fistula (e.g. air-leak) and arrhythmia, typically atrial fibrillation. Additional early complications include pneumonia, aspiration, high chest tube output, pulmonary edema, bronchopleural fistula, pulmonary insufficiency, and empyema.
Alveolar-pleural fistula is typically defined as a detectable air-leak beyond seven days post operatively, though some surgeons argue any air-leak that delays discharge should be classified as a complication [2].
An air-leak is best defined by when it occurs in the respiratory cycle and qualitatively by the drainage chamber’s air-leak meter. This leads to labels of continuous (occurring with both inspiration as well as expiration), inspiratory, expiratory, and forced expiratory, with grades between 1 and 5-7 chambers dependent on the drainage system used (Pleur-Evac Traditional Chest Drainage System or Atrium Ocean, Teleflex, Morrisville, NC, USA), with 1 chamber being least severe.
Patients at risk for air leak include those with preoperative emphysema, those undergoing bilobectomy (compared with lobectomy) and operative technique. For example, fissureless surgery [3] reduces the likelihood of this complication.
Patients are rarely symptomatic from an alveolar-pleural fistula, though they can develop dyspnea or subcutaneous emphysema from an expanding pneumothorax. Treatment is best aimed at prevention, otherwise early water seal of the chest tube [4] is beneficial.
Atrial fibrillation is reported to occur in up to 20% of patients undergoing pulmonary resection. Patients at risk include those older than 70, patients undergoing a greater extent of resection (pneumonectomy more likely than lobectomy), and history of cardiac disease.
Unfortunately, there are no proven preventative strategies, though fastidious attention to maintaining normal electrolytes – especially magnesium and potassium – is recommended.
Treatment in the stable patient is aimed at restoring normal sinus rhythm and can typically be accomplished with IV administration of β-blockers (e.g. metoprolol) or calcium channel blockers (e.g. diltiazem). Providers must be attentive towards hypotension with these agents; in stable, hypotensive patients, amiodarone, administered as a bolus followed by a drip, is effective at restoring sinus rhythm with less impact to blood pressure [5]. In the unstable patient, emergent electrical cardioversion is required.
Respiratory insufficiency and infectious complications are less frequent but associated with significant morbidity [6,7]. Respiratory insufficiency can manifest regardless of preoperative evaluation and patient selection. Pain from thoracic incisions can decrease inspiratory effort and reduce the ability to cough. This combination can lead to atelectasis with subsequent ventilation/perfusion mismatch, hypoxemia, and pneumonia. Prevention is the best treatment; aggressive multi-modal pain control which combines systemic and regional methods is optimal for analgesia following thoracic surgery [8].
Early ambulation and frequent respiratory hygiene measures – chest physiotherapy and percussion are useful adjuncts at rehabilitating the patient post pulmonary resection. Bronchoscopy should be used liberally – it can aid in secretion clearance and to obtain respiratory cultures to guide antibiotic therapy.
Despite preventative strategies, pneumonia can still develop. A constellation of fever, productive cough and leukocytosis should prompt immediate therapy with broad spectrum antibiotics. An infiltrate may not be present on chest film as radiographic signs often lag behind the clinical picture. Empyema is less frequent – most commonly seen in the post-pneumonectomy patient. Despite the rarity, empyema represents the most common cause of readmission following resection [9]. In addition to pneumonectomy, advanced cancer stage, an immunosuppressed state, and prolonged air leak are risk factors for empyema [10].
Treatment is directed at controlling the pleural space, typically with a tube thoracostomy. The goal is to drain the infection and re-expand the lung. In select circumstances, lytic therapy using tissue plasminogen activator and DNAse (dornase) can be used to address loculated collections and drain the space without re-operation [11].
However, if lung expansion is not achieved with drainage, reoperation to decorticate the lung and any additional interventions, such as muscle or omental flap coverage, aimed at the source of empyema, e.g. bronchopleural fistula, are necessary. In the unstable patient, a thoracostomy window should be performed to control the space and decorticate the lung over time with serial dressing changes [12].
The true incidence of high chest tube output is unknown, as the definition of high chest tube output is vague. Enhanced recovery pathways have determined daily chest tube outputs as high as 500 mL are safe for removal [13].
The caveat to this recommendation is the assurance of no air leak and no evidence of post-operative hemorrhage/hemothorax or chylothorax. In cases involving the posterior mediastinum, high chest tube output should prompt the evaluation for subarachnoid-pleural fistula. The incidence of post-operative hemorrhage is low and can occur from the pulmonary artery, bronchial arteries, chest wall, inferior ligament, or pulmonary parenchyma.
As always, prevention is the best method of treatment – meticulous dissection and handling of the pulmonary artery can prevent occult injury to this fragile vessel.
Careful assessment of all lymphatic beds for hemostasis is necessary. Bronchial artery bleeding is most common in the subcarinal space, and any visible vessels should be controlled prior to chest closure. Hemostatic agents are useful, though not a substitute for appropriate surgical technique. Bloody output greater than 200 mL/hour for 3 consecutive hours should be further evaluated with a coagulation profile and early re-exploration. Care must be taken if tube output suddenly stops, as this often represents a clotted chest tube rather than cessation of hemorrhage. Retained clot can activate the fibrinolytic system and worsen coagulopathy, and as such should be addressed by prompt evacuation.
Chylothorax occurs less than 2% of the time and should be considered when chest tube output appears milky, especially after the patient begins alimentation [14]. Triglyceride levels greater than 110 mg/dL in the pleural fluid confirms the diagnosis [15].
Following pulmonary resection, this complication is typically caused by injury to lymphatic tributaries, rather than a thoracic duct injury. Patients who have undergone neoadjuvant therapy, have N2 disease, and those with complete lymphadenectomy are at highest risk. Initial treatment options include nil per os (NPO) to decrease chest tube output. A medium chain fatty acid diet can then be started.
We prefer to maintain patients on this diet for at least 2 weeks before adding full fats to the diet. If this fails, defined as persistent output of greater than 500 mL, returning the patient to NPO and starting total parental nutrition (TPN) are the next steps in the treatment. Failure on TPN should prompt intervention on the duct either by surgical ligation or lymphoscintigraphy with coil placement. Control of the duct is successful in at least 85% of cases using surgery or interventional radiology techniques [16].
We recommend aggressive management of patients with chyle leak as persistent output can lead to rapid lymphopenia, immunosuppression, and malnutrition. Subarachnoid-pleural fistula occurs after disruption of the dura during resections involving the posterior mediastinum.
The detection of beta-trace protein confirms the diagnosis [17]. Conservative measures such as lumbar drainage and blood patch can be effective, however, surgical closure with vascularized tissue is the standard treatment [18].
Judicious fluid management is critical in the care of the post pulmonary resection patient. Fluid shifts tend to be less severe than intra-abdominal surgery, and the lymphatic dissection coupled with lung manipulation during surgery can place the lung at risk for injury and edema. Additionally, pulmonary resection is associated with transient right heart dysfunction, further complicating post-operative fluid management [19].
As with other post-operative complications, prevention is the best strategy. Minimizing IV fluids, especially in patients with epidurals who are prone to hypotension, and instead supplementing care with alpha-agonists to maintain adequate perfusion pressures is our preferred strategy.
When pulmonary edema is detected – either with increasing oxygen requirements or evidence of such on chest x-ray, prompt therapy with diuretics is indicated. A special note should be made of post-pneumonectomy patients: these patients are more sensitive to pulmonary edema than lobectomy patients. Edema can result in hypoxemia with subsequent pulmonary vasoconstriction.
As the right heart is already strained by the post-pneumonectomy state, this can rapidly result in a deterioration spiral that can be difficult to salvage. Transfer to the ICU for invasive monitoring, echocardiography, and potential early intubation are warranted in these patients.
A final, devastating complication to be aware of is bronchial torsion. Typically occurring in the middle lobe after an upper lobectomy, this rare complication requires rapid diagnosis and return to the operating room for management. Most frequently, this will involve resection of the torsed lobe or segment.
Cases at highest risk are those with a complete fissure, extensive skeletonization of the hilar structures and failure of the lung to fill the post-operative space. Attention to appropriate orientation on re-inflation of the lung is critical, and adjunctive measures such as suture plication of the lobe, or the use of adhesives has been reported [20].

Late complications

Late complications usually occur following discharge from the index operation, and many can occur at any time in the post-operative period. Fortunately, these are uncommon.
The most common late complication is chronic pain. Originally attributed to thoracotomy incisions, this can occur after video-assisted or robotic approaches, last for years, and be debilitating for the patient. Chronic pain is reported in between 30-80% of patients and is defined as pain along the incision’s dermatome that persists for more than two months [21].
Trauma to the intercostal nerve is the putative cause. Techniques that minimize crush injury, such as mobilizing the intercostal muscle without division from the cephalad rib prior to retractor placement, and placement of paracostal sutures through the rib rather than around the rib, are shown to decrease pain [22].
Patients with pre-existing pain are also at risk for developing post thoracic surgery pain. Multimodality pain management is essential, and includes the use of acetaminophen, non-steroidal anti-inflammatory drugs, alpha-2 receptor agonists, gabapentin, and nerve blocks [23].
Cryoanalgesia has re-emerged as a technique that may be used to aid general post-operative pain, and potentially in the treatment of chronic post-thoracotomy pain. However, most trial data are now two decades old, and there are no newer data available to support its routine use [24].
A less common complication is herniation, typically of the lung, but also abdominal contents in the setting of a sternotomy. Lung herniation has been reported after any case that involves the chest wall – chest wall resections, thoracotomy, VATS/Robotic access sites, and even in some cases, tube thoracostomy sites [25].
The incidence is unknown but can result in significant discomfort and anxiety in the patient. Repair involves reduction of the hernia and typically patch reconstruction using a mesh prosthesis. The outcomes with this are excellent, and repair can be performed with low morbidity [26].
Sub-xiphoid hernias occur in around 1% of post sternotomy patients and can be attributed to the failure of fascial closure in the inferior aspect of the incision. These are functionally an iatrogenic Morgagni hernia and can be repaired with a direct open incision, or via laparoscopy. Mesh repair is commonly required in these cases [27].
Pleural effusions can occur both early and late following thoracic surgery. In the late setting, intervention is directed at the cause. Most often effusions are diagnosed on imaging obtained during either post-operative follow up or surveillance imaging. Symptomatic patients – typically those with dyspnea on exertion, evidence of hypoxemia or other signs of failure to thrive require more urgent intervention.
Initial treatment is drainage via thoracentesis. The fluid can then be grossly assessed, as well as sent for cytology, culture, and chemical studies to help guide a differential diagnosis. Recurrent effusions benefit from more durable management than repeat drainage, though concerns regarding protein-loss malnutrition, electrolyte disturbances, or renal failure from repeat drainage appear unwarranted [28].
A more durable solution to recurrent pleural effusion is the placement of a tunneled indwelling pleural catheter (TPC), or by performing chemical (using doxycycline, sterile talc slurry, or talc powder) or mechanical pleurodesis. When deciding to perform chemical pleurodesis, care must be taken to ensure adequate visceral-parietal apposition.
In cases where this does not occur, the lung becomes trapped and the effusion returns. When this happens, TPC, pleuro-peritoneal shunt, or surgical decortication become the only options for managing the effusion [29].
Perhaps the most devastating late complication is that of bronchopleural fistula. More prevalent following a pneumonectomy, where rates from 4.5% to 20% are reported, this complication can occur following any anatomic lung resection [30].
Clinical symptoms manifest within the first two weeks of resection, and typically consist of productive cough – usually of thin, watery secretions, fever, fatigue, dyspnea, and failure to thrive. A chest x-ray will show a drop in the air-fluid level or a new pneumothorax. Control of the resection space by tube thoracostomy is paramount and the diagnosis is confirmed with bronchoscopy.
If the fistula is found in the first few days following resection, one can attempt closure of the stump, though this is prone to failure. More commonly, efforts to appropriately nourish the patient, and clean the space by decortication or open thoracostomy window are required. When the patient has suitable nutrition, and no further signs of infection, closure can be attempted with vascularized tissue transfer – e.g. latissimus dorsi [31], or omentum [32].
Endoscopic interventions have been described, with some enthusiasm over septal occlusion devices [33]. Prevention of this dreaded complication centers on appropriate patient selection and division of the stump – either by stapler or hand sewing – as close to the origin as possible.
A final note on a complication all thoracic surgeons should be aware of is post-pneumonectomy syndrome. Thought to be more prevalent in pediatric patients secondary to the increased compliance of the mediastinum [34], this is a constellation of symptoms secondary to extensive mediastinal shift into the post-pneumonectomy space. The rotation of the mediastinum causes compression of the tracheobronchial tree and/or the pulmonary veins. Patients experience shortness of breath, recurrent pneumonia, and occasional laryngeal palsy, heartburn, and dysphagia.
Treatment is aimed at re-medialization of the mediastinum, usually with saline filled prosthesis [35]. Often this procedure will need extracorporeal membrane oxygenation to perform, and the surgeon must take care to liberate all adhesions that may tether the airway, or the medialization procedure may fail.

Summary

Complications are unfortunately common following thoracic surgical procedures. Appropriate patient selection, attention to a meticulous operation, prevention and early recognition of complications will minimize morbidity and lead to the best outcomes.

References

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