Overview of Pneumonectomy
Lung cancer is the third most common type of cancer in both the United States and the United Kingdom, with over 200,000 and 47,000 people diagnosed each year respectively. While the majority of lung cancer patients are treated with a surgery known as lobectomy (removal of a portion of the lung), recent findings suggest that smaller, localized surgeries could also be effective in certain cases.
On the other hand, for more severe cases, such as when the tumor is centrally located or has locally advanced, more complex surgeries like sleeve lobectomy (removal of a lobe of the lung) or pneumonectomy (removal of an entire lung) would be necessary to completely remove the tumor.
Over recent years, there has been a decrease in the number of pneumonectomies being performed. This procedure remains critical for specific patients even though it carries a higher risk of complications during and after the surgery compared to lobectomy or bilobectomy (removal of two lobes of the lung).
However, sometimes, pneumonectomy is the only surgical option that can completely remove the tumor for individuals with central or locally advanced tumors.
Pneumonectomy, first performed in 1933 by Evarts A Graham for lung cancer, involves the removal of an entire lung and is a crucial option for managing advanced and complicated lung diseases. A type of pneumonectomy, called Extrapleural pneumonectomy, involves the removal of additional parts like the lining of the lungs, part of the diaphragm, the lining of the heart, and certain lymph nodes.
Since the lungs are responsible for crucial functions like exchanging gases, producing enzymes, and providing immune defense, their removal poses a significant challenge to our body’s physiological balance. Despite the difficulties, pneumonectomy has evolved over the decades and is now essential in treating severe lung diseases when other lung-saving alternatives are not sufficient.
Anatomy and Physiology of Pneumonectomy
The lungs are vital organs that are shaped like pyramids and are nestled within your chest, connecting to your windpipe (trachea) via two main tubes called the right and left bronchi. They’re securely enveloped by the rib cage and are seated above your diaphragm (a large, dome-shaped muscle that helps with breathing). An important feature of the lungs is that each one is clothed with two layers of a protective film called pleura: one layer that sticks to the lung surface (visceral pleura) and one that clings to the chest wall and diaphragm (parietal pleura).
Interestingly, your right lung is split into 3 sections or lobes (upper, middle, and lower), while your left lung, which is slightly smaller to make room for your heart, only has 2 lobes (upper and lower). Each lobe is further segmented into bronchopulmonary segments, each having its own dedicated airway (tertiary bronchus) and blood supply, which enables different parts of your lungs to work independently and also facilitates targeted surgical procedures when needed.
A surgery called pneumonectomy, which involves removing an entire lung, drastically changes the structure and functioning of your chest. This operation is unique because it usually doesn’t require a tube to be inserted into your chest after the surgery, as it may cause the heart or the mediastinum (central part of your chest) to shift into the room left by the missing lung. Post-surgery, the space that was previously occupied by the lung is initially filled with air, which gradually gets absorbed and is replaced by fluid. The remaining lung often expands more than usual to fill up the space (hyperinflation), the mediastinum moves towards where the lung was removed (mediastinal shift), and the diaphragm lifts up. These adjustments are important to maintain good breathing function and chest stability, shedding light on the intricate complexity and challenges of a pneumonectomy.
Why do People Need Pneumonectomy
The surgical removal of an entire lung, known as a pneumonectomy, is primarily performed to tackle severe cancerous and complex noncancerous lung conditions. The majority of times, this kind of surgery is performed on patients who have widespread lung cancer, particularly if the cancer is located centrally or is too large to be adequately removed through less invasive surgical methods. This is often necessary in serious cases of non-small-cell lung cancer when the tumor is affecting the main airways of the lungs, or when the cancer spread across crucial parts of the lung. In even more severe cases, when the tumor reaches the part of the lungs known as the carina, a special type of surgery known as a sleeve pneumonectomy might be needed.
While less frequent, this surgery may also be considered for aggressive types of cancers such as mesothelioma or extensive thymoma, or certain complex cancers where the removal of lung tissues are not enough. However, lung cancer that has spread from other parts of the body rarely calls for a pneumonectomy.
On the other hand, for noncancerous conditions, pneumonectomy is considered in severe lung diseases caused by inflammation and in injuries to the lung caused by trauma. Diseases of the lung that cause inflammation often include those marked by chronic infections or destruction, and there may be a need for pneumonectomy when these conditions compromise lung function or lead to complications like abnormal connections between the lung and chest wall. It is really important for these patients to receive comprehensive care before surgery, including controlling infection, improving lung function, and nutritional support. This is crucial in minimizing complications such as abscesses in the lung and abnormal connections forming in the lung.
Severe lung injuries caused by accidents, including intense blunt force or wounds, represent another urgent reason for pneumonectomy, especially in patients with unstable health conditions. However, these cases come with a high risk of death, mainly due to fluid accumulation in the lungs and heart failure, with worse outcomes associated with blunt trauma compared to penetrating injuries.
When a Person Should Avoid Pneumonectomy
There are certain conditions that could increase the risks associated with a pneumonectomy, which is a surgical procedure to remove one of your lungs. It’s important for doctors to be aware of these conditions so they can ensure patients are safe and have the best outcomes possible from the procedure. For instance, factors such as being older in age, having reduced lung function, or needing a right-sided lung removal, can all add to the risks linked with this surgery.
When not urgently required, doctors typically complete lung function tests before a pneumonectomy to determine if the patient is well enough for the surgery. Two key measures they look at are the Forced Expiratory Volume in 1 second (FEV1) and the Diffusion Capacity of the Lung for Carbon Monoxide (DLCO). These provide doctors with an idea of post-surgery risks. If these levels are less than 40% of what’s expected, the patient could face a higher chance of complications and further assessments should be carried out.
Cardiopulmonary exercise testing, a group of tests that determine how well your heart and lungs work during physical activity, is usually done. A key measure here is maximal oxygen consumption (VO2 max). If the patient’s VO2 max is between 10 and 15 mL/kg/min or less, this suggests there could be an elevated risk of post-surgery complications. Doctors may also consider tests such as stair climbing, shuttle walk test, and the 6-minute walk test, but these have limited evidence supporting their use.
In addition to assessing lung function, it’s vital to evaluate the patient’s heart health. Conditions like severe heart valve disease, substantial pulmonary hypertension (high blood pressure affecting the arteries in the lungs and the right side of the heart), or poor heart pumping function can make a pneumonectomy risky.
The surgery might also be avoided if scans show the tumor has spread beyond the diaphragm to involve parts of the stomach area, the other side of the chest or ribs. Having an understanding of these ‘no-go’ conditions helps doctors choose patients who would most benefit from this procedure and plan the safest and most effective treatments. This might include considering other, less invasive options.
Equipment used for Pneumonectomy
A pneumonectomy, or the surgical removal of a lung, needs precise surgical tools and careful management to make sure the procedure is safe and gives the best results possible to the patient. This operation needs special tools designed for surgeries on the chest, or thoracotomy instruments. For example, we use tools like rib spreaders to make sure doctors can properly see and access the inside of the chest, as well as tools uniquely designed for working with lung tissue, such as tissue forceps and scissors. These help to gently and carefully cut and manipulate the tissue to prevent harming the surrounding areas.
On the other hand, the process of giving anesthesia or making the patient sleep also needs careful consideration in this kind of procedure. This is because it’s important to make sure that the lung that’s not getting removed continues to work and exchange gases properly while also staying stable for the operation. This is done through something called lung isolation techniques. Depending on the situation, doctors may use a left or right double-lumen endobronchial tube, a bronchial blocker, or even place a usual endotracheal tube in an alternative way to achieve this. Finally, an instrument called a flexible bronchoscope may be kept nearby to check that the tubes are placed correctly and that the remaining lung is successfully working on its own.
Who is needed to perform Pneumonectomy?
A pneumonectomy, or removal of a lung, is a complex and risky procedure. Specialized medical professionals are needed to make sure everything goes smoothly and to help the patient recover. The main person who does the operation is a heart and lung surgeon that has experience with this type of surgery. Also helping is an anesthesiologist, who is good at managing one-lung breathing and closely tracking important body functions. This is crucial because it allows the lung to be taken out while preserving vital body functions.
There are also surgical technologists who help during the operation. Their job is to handle specific tools used during chest surgery and ensure everything runs smoothly.
After the surgery, it is very important to monitor the patient because there can be dangerous complications like trouble breathing, bleeding, or excess fluid in the lungs. A specialized team is needed for this step, including nurses from the Intensive Care Unit (ICU) who know how to care for patients after chest surgery. There are also respiratory therapists who are skilled in managing breathing machines and keeping the lungs clean, along with critical care doctors who specialize in severe and life-threatening conditions.
Places that often perform this surgery and have specialized teams ready can typically provide superior care, leading to better patient recovery. This is because these teams are more adept in handling complex cases than those at lower-volume centers, or places that do not perform this kind of surgery as regularly.
Preparing for Pneumonectomy
Before going into surgery to remove a lung, which is known as a pneumonectomy, the patient undergoes comprehensive health checks so as to ensure their body can handle the major operation. An important part of this assessment includes breathing tests like spirometry and lung volume measurements. These tests help in predicting how well the patient will recover after the surgery by gauging their lung function and reserve, essentially measuring how well their remaining lung will be able to handle the work of breathing.
These tests, which include measuring FEV1 (the maximum amount of air a person can forcefully blow out in one second) and DLCO (the amount of oxygen transferring from your lungs to your bloodstream), can help predict post-surgery health risks. Generally, patients with an FEV1 and DLCO of more than 60% after surgery are considered low risk, while those below 30% may require additional testing and potentially other treatment options to reduce risks.
It is also essential to manage chronic health conditions like COPD (a type of obstructive lung disease), hypertension (high blood pressure), and diabetes before surgery. Smokers are also encouraged to quit weeks before surgery to improve lung function and wound healing. Moreover, doctors will also perform blood tests and other evaluations to assess the patient’s overall health condition.
It’s also important to conduct up-to-date lung imaging tests to prepare for the surgery. Sometimes, doctors might prescribe certain medications before surgery, like antibiotics or medicine to open up the airways.
In preparation for managing any potential pain the patient might experience after surgery, a special catheter may be inserted into the space surrounding the spine. This catheter can provide pain relief. During the surgery, the patient will be under general anesthesia, and their breathing will be managed by a special tube inserted into the lungs that can isolate one lung from the other, ensuring only the lung that is not operated on continues to work. The position and function of the tubes are continually checked to ensure proper functioning.
The surgery also involves monitoring the patient’s blood pressure. In certain cases, a central venous line may be put in place, and heart function is continuously evaluated, especially in patients with heart diseases. Everything is done with a sole aim – to maximize the positive outcome of surgery and minimize any potential risks.
How is Pneumonectomy performed
A pneumonectomy is a surgery that involves the removal of a lung. It is usually done through a specific type of incision called a posterolateral thoracotomy, which is usually made at the fourth or fifth level between the ribs (intercostal space). The reason this method is chosen is because it gives the best view of the area. There are other types of incisions that can be used, but these are generally less ideal as they provide limited access to the back of the chest. Some specific approaches are used when dealing with large tumors at the top of the upper lung lobe or near the middle of the chest.
The surgery itself involves several steps that require careful handling. These steps include:
- The doctor makes an incision – in this case, along the fourth or fifth space between the ribs. A rib spreader is used to make sure the surgeon can clearly see the lung and surrounding areas
- Next, the lung is moved around to release any attachments between the lung and the pleura (the membrane that lines the lung). This is done to ensure the lung can be fully moved without harming any adjacent areas.
- The vessels that transport blood to and from the lung (pulmonary vessels) are isolated and divided. Each vessel is split using a specific device while making sure that there is no bleeding. Extra caution is exercised especially if the blood vessels are fragile due to previous treatments.
- Once the vessels are secured, the bronchus (the major air passages of the lungs) is divided and stapled. Tests can be performed to confirm that the stapled area is sealed, so there are no air leaks.
- Following this, the lung that has been detached is removed. For larger specimens, the incision may need to be made bigger or sometimes the specimen is put in a protective bag to prevent contamination.
- Finally, any remaining blood is cleaned up within the chest cavity. A chest drain may be placed to remove any remaining air or fluid. The incision is then closed.
Minimally invasive lung surgeries have been gaining interest in the recent years. These involve techniques like video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). In these surgeries, one or more small incisions are made in the chest wall. One major advantage of these surgeries is that they usually result in less pain and complications when compared to traditional approaches. Another significant advantage is that with newer technologies, the surgeon can control movements of the instruments from a console, which allows for more precision. In comparison to RATS, VATS surgeries tend to be less costly, cause less blood loss and also take less time.
The fluid levels in the body are strategically managed during the surgery, and the breathing function is closely monitored to ensure there is minimal risk of injury to the lungs. After the surgery, there are numerous precautions and care taken to make sure the patient recovers well. This includes carefully managing the patient’s pain, ensuring adequate oxygen levels, and gradually reintroducing diet to avoid complications. Through careful surgical techniques and post-operative care, a pneumonectomy can be performed safely, with the main focus being to improve patient’s health and minimize any potential risks.
Possible Complications of Pneumonectomy
After a pneumonectomy, which is where a lung is removed, you might experience a decrease in how well your remaining lung functions. However, this decrease is often less pronounced than expected, despite the fact that half of your lung capacity has been taken out. Specifically, overexpansion of the remaining lung tissue could potentially explain why areas of the lung that regulate airflow experience less impact than anticipated.
Following the surgery, an X-ray of your chest would typically show the air-filled space where the lung was removed. As time progresses, this especially shows fluid filling the removed area, with the midline of your chest seeming to shift towards the side of the operation. Heart rate generally increases while the volume of blood your heart pumps with each beat decreases, resulting in compromised heart functionality over time.
Complications after pneumonectomy could arise, such as irregular heartbeats, a condition where the heart misplaces itself within the chest cavity (typically within 24 hours post surgery), or the formation of a bronchopleural fistula. A bronchopleural fistula is an abnormal connection between the bronchial tubes in your lung and the space around your lungs. This condition is rather serious and can lead to symptoms of fever, cough, coughing up blood, and a build-up of air underneath the skin.
If you stay on a ventilator after surgery, measures will be taken to reduce the air pressure to limit any leaks from your lung. Severe cases may require a new operation. Typically, post-surgery, your lung might also become swollen and filled with fluid, usually on the second or third day post-operation. This condition can also lead to an increase in the risk of death by up to fifty percent.
Pneumonia, a collapsed lung, or respiratory failure are also potential complications. Complications are often more common and serious in older patients, and might require that a patient is intubated and ventilated post-surgery.
Additionally, injuries to the surrounding organs, such as the diaphragm, liver, spleen, or major blood vessels, can also occur following pneumonectomy. Other potential complications include malfunctioning of multiple organs, acute lung injury, ARDS, and damage to the kidneys following surgery.
Studies often focus on the rates of survival at 90-days, 1-year, and overall survival following surgery. However, recent work shows that the 90-day survival rate is generally a more accurate indicator of survival post-operation, as this rate is around twice that of the 30-day survival rate.
What Else Should I Know About Pneumonectomy?
A pneumonectomy is a serious surgical procedure that’s often used to treat lung tumors that have grown too large or are in tricky locations where smaller operations wouldn’t work. This surgery can also offer a life-saving option for people with severe lung conditions, dangerous infections, and certain diseases, although it’s not used as often in these cases.
Even though this operation can save lives, it’s very risky and can lead to more complications than smaller lung procedures. This is because having a pneumonectomy means losing a large amount of lung capacity, which can in turn affect how your heart works. After the surgery, some patients might experience complications like lung swelling (pulmonary edema), infections, an abnormal connection between the air tubes in your lungs and the space that surrounds your lungs (bronchopleural fistula), and heart problems, including right heart failure.
To reduce the risk of these issues, doctors have to plan carefully before the surgery, continue to monitor closely after the surgery, and choose the right patients who can cope with this intense procedure. Even though it’s a challenging operation, a pneumonectomy can significantly increase survival rates and enhance quality of life for certain patients by removing the diseased parts of their lungs and offering them a chance for longer survival, especially in cases where cancer is involved.
