pneumonectomy

[Greek pneumōn, lung; see pneumonic + -ECTOMY.]

Definition

Pneumonectomy is the medical term for the surgical removal of a lung.

Purpose

A pneumonectomy is most often used to treat lung cancer when less radical surgery cannot achieve satisfactory results. It may also be the most appropriate treatment for a tumor located near the center of the lung that affects the pulmonary artery or veins, which transport blood between the heart and lungs. In addition, pneumonectomy may be the treatment of choice when the patient has a traumatic chest injury that has damaged the main air passage (bronchus) or the lung's major blood vessels so severely that they cannot be repaired.

Demographics

Pneumonectomies are usually performed on patients with lung cancer, as well as patients with such noncancerous diseases as chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. These diseases cause airway obstruction.

Approximately 361,000 Americans die of lung disease every year. Lung disease is responsible for one in seven deaths in the United States, according to the American Lung Association. More than 25 million Americans are now living with chronic lung disease.

Lung Cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. It is expected to claim nearly 157,200 lives in 2003. Lung cancer kills more people than cancers of the breast, prostate, colon, and pancreas combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States.

Lung cancer is the second most common cancer among both men and women and is the leading cause of death from cancer in both sexes. In addition to the use of tobacco as a major cause of lung cancer among smokers, second-hand smoke contributes to the development of lung cancer among nonsmokers. Exposure to asbestos and other hazardous substances is also known to cause lung cancer. Air pollution is also a probable cause, but makes a relatively small contribution to incidence and mortality rates. Indoor exposure to radon may also make a small contribution to the total incidence of lung cancer in certain geographic areas of the United States.

In each of the major racial/ethnic groups in the United States, the rates of lung cancer among men are about two to three times greater than the rates among women. Among men, age-adjusted lung cancer incidence rates (per 100,000) range from a low of about 14 among Native Americans to a high of 117 among African Americans, an eight-fold difference. For women, the rates range from approximately 15 per 100,000 among Japanese Americans to nearly 51 among Native Alaskans, only a three-fold difference.

Chronic Obstructive Pulmonary Disease

The following are risk factors for COPD:

• current smoking or a long-term history of heavy smoking
• employment that requires working around dust and irritating fumes
• long-term exposure to second-hand smoke at home or in the workplace
• a productive cough (with phlegm or sputum) most of the time
• shortness of breath during vigorous activity
• shortness of breath that grows worse even at lower levels of activity
• a family history of early COPD (before age 45)

Diagnosis/Preparation

Diagnosis

In some cases, the diagnosis of a lung disorder is made when the patient consults a physician about chest pains or other symptoms. The symptoms of lung cancer vary somewhat according to the location of the tumor; they may include persistent coughing, coughing up blood, wheezing, fever, and weight loss. In cases involving direct trauma to the lung, the decision to perform a pneumonectomy may be made in the emergency room. Before scheduling a pneumonectomy, however, the surgeon reviews the patient's medical and surgical history and orders a number of tests to determine how successful the surgery is likely to be.

In the case of lung cancer, blood tests, a bone scan, and computed tomography scans of the head and abdomen indicate whether the cancer has spread beyond the lungs. Positron emission tomography (PET) scanning is also used to help stage the disease. Cardiac screening indicates how well the patient's heart will tolerate the procedure, and extensive pulmonary testing (e.g., breathing tests and quantitative ventilation/perfusion scans) predicts whether the remaining lung will be able to make up for the patient's diminished ability to breathe.

Preparation

A patient who smokes must stop as soon as a lung disease is diagnosed. Patients should not take aspirin or ibuprofen for seven to 10 days before surgery. Patients should also consult their physician about discontinuing any blood-thinning medications such as coumadin or warfarin. The night before surgery, patients should not eat or drink anything after midnight.

Description

In a conventional pneumonectomy, the surgeon removes only the diseased lung itself. The patient is given general anesthesia. An intravenous line inserted into one arm supplies fluids and medication throughout the operation, which usually lasts one to three hours.

The surgeon begins the operation by cutting a large opening on the same side of the chest as the diseased lung. This posterolateral thoracotomy incision extends from a point below the shoulder blade around the side of the patient's body along the curvature of the ribs at the front of the chest. Sometimes the surgeon removes part of the fifth rib in order to have a clearer view of the lung and greater ease in removing the diseased organ.

A surgeon performing a traditional pneumonectomy then:

• deflates (collapses) the diseased lung
• ties off the lung's major blood vessels to prevent bleeding into the chest cavity
• clamps the main bronchus to prevent fluid from entering the air passage
• cuts through the bronchus
• removes the lung
• staples or sutures the end of the bronchus that has been cut
• makes sure that air is not escaping from the bronchus
• inserts a temporary drainage tube between the layers of the pleura (pleural space) to draw air, fluid, and blood out of the surgical cavity
• closes the chest incision

Aftercare

Chest tubes drain fluid from the incision and a respirator helps the patient breathe for at least 24 hours after the operation. The patient may be fed and medicated intravenously. If no complications arise, the patient is transferred from the surgical intensive care unit to a regular hospital room within one to two days.

A patient who has had a conventional pneumonectomy will usually leave the hospital within 10 days. Aftercare during hospitalization is focused on:

• relieving pain
• monitoring the patient's blood oxygen levels
• encouraging the patient to walk in order to prevent formation of blood clots
• encouraging the patient to cough productively in order to clear accumulated lung secretions

If the patient cannot cough productively, the doctor uses a flexible tube (bronchoscope) to remove the lung secretions and fluids.

Recovery is usually a slow process, with the remaining lung gradually taking on the work of the lung that has been removed. The patient may gradually resume normal non-strenuous activities. A pneumonectomy patient who does not experience postoperative problems may be well enough within eight weeks to return to a job that is not physically demanding; however, 60% of all pneumonectomy patients continue to struggle with shortness of breath six months after having surgery.

Risks

The risks for any surgical procedure requiring anesthesia include reactions to the medications and breathing problems. The risks for any surgical procedure include bleeding and infection.

Between 40% and 60% of pneumonectomy patients experience such short-term postoperative difficulties as:

• prolonged need for a mechanical respirator
• abnormal heart rhythm (cardiac arrhythmia); heart attack (myocardial infarction); or other heart problem
• pneumonia
• infection at the site of the incision
• a blood clot in the remaining lung (pulmonary embolism)
• an abnormal connection between the stump of the cut bronchus and the pleural space due to a leak in the stump (bronchopleural fistula)
• accumulation of pus in the pleural space (empyema)
• kidney or other organ failure

Over time, the remaining organs in the patient's chest may move into the space left by the surgery. This condition is called postpneumonectomy syndrome; the surgeon can correct it by inserting a fluid-filled prosthesis into the space formerly occupied by the diseased lung.

Normal Results

The doctor will probably advise the patient to refrain from strenuous activities for a few weeks after the operation. The patient's rib cage will remain sore for some time.

A patient whose lungs have been weakened by noncancerous diseases like emphysema or chronic bronchitis may experience long-term shortness of breath as a result of this surgery. On the other hand, a patient who develops a fever, chest pain, persistent cough, or shortness of breath, or whose incision bleeds or becomes inflamed, should notify his or her doctor immediately.

Morbidity and Mortality Rates

In the United States, the immediate survival rate from surgery for patients who have had the left lung removed is between 96% and 98%. Due to the greater risk of complications involving the stump of the cut bronchus in the right lung, between 88% and 90% of patients survive removal of this organ. Following lung volume reduction surgery, most investigators now report mortality rates of 5–9%.

Alternatives

Lung Cancer

The treatment options for lung cancer are surgery, radiation therapy, and chemotherapy, either alone or in combination, depending on the stage of the cancer.

After the cancer is found and staged, the cancer care team discusses the treatment options with the patient. In choosing a treatment plan, the most significant factors to consider are the type of lung cancer (small cell or non-small cell) and the stage of the cancer. It is very important that the doctor order all the tests needed to determine the stage of the cancer. Other factors to consider include the patient's overall physical health; the likely side effects of the treatment; and the probability of curing the disease, extending the patient's life, or relieving his or her symptoms.

Chronic Obstructive Pulmonary Disease

Although surgery is rarely used to treat COPD, it may be considered for people who have severe symptoms that have not improved with medication therapy. A significant number of patients with advanced COPD face a miserable existence and are at high risk of death, despite advances in medical technology. This group includes patients who remain symptomatic despite the following:

• smoking cessation
• use of inhaled bronchodilators
• treatment with antibiotics for acute bacterial infections, and inhaled or oral corticosteroids
• use of supplemental oxygen with rest or exertion
• pulmonary rehabilitation

After the severity of the patient's airflow obstruction has been evaluated, and the foregoing interventions implemented, a pulmonary disease specialist should examine him or her, with consideration given to surgical treatment.

Surgical options for treating COPD include laser therapy or the following procedures:

• Bullectomy. This procedure removes the part of the lung that has been damaged by the formation of large air-filled sacs called bullae.
• Lung volume reduction surgery. In this procedure, the surgeon removes a portion of one or both lungs, making room for the remaining lung tissue to work more efficiently. Its use is considered experimental, although it has been used in selected patients with severe emphysema.
• Lung transplant. In this procedure a healthy lung from a donor who has recently died is given to a person with COPD.

Resources

Books

Argenziano, Michael, M.D., and Mark E. Ginsburg, M.D., eds. Lung Volume Reduction Surgery, 1st ed. Totowa, NJ: Humana Press, 2002.

Devita, Vincent T., Samuel Hellman, and Steven A. Rosenberg, eds. Cancer: Principles and Practice of Oncology, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins Publishers, 2001.

Henschke, Claudia I., Peggy McCarthy, and Sarah Wernick. Lung Cancer: Myths, Facts, Choices—And Hope, 1st ed. New York, NY: W. W. Norton & Company, Inc., 2002.

Johnston, Lorraine. Lung Cancer: Making Sense of Diagnosis,Treatment, and Options. Sebastopol, CA: O'Reilly & Associates, 2001.

Pass, H., M. D., D. Johnson, M. D., James B. Mitchell, PhD., et al., eds. Lung Cancer: Principles and Practice, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2000.

Periodicals

Crystal, Ronald G. "Research Opportunities and Advances in Lung Disease." Journal of the American Medical Association 285 (2001): 612-618.

Grann, Victor R., and Alfred I. Neugut. "Lung Cancer Screening at Any Price?" Journal of the American Medical Association 289 (2003): 357-358.

Mahadevia, Parthiv J., Lee A. Fleisher, Kevin D. Frick, et al. "Lung Cancer Screening with Helical Computed Tomography in Older Adult Smokers: A Decision and Cost-Effectiveness Analysis." Journal of the American Medical Association 289 (2003): 313-322.

Pope, C. Arden, III, Richard T. Burnett, Michael J. Thun, et al. "Lung Cancer, Cardiopulmonary Mortality, and Long-Term Exposure to Fine Particulate Air pollution." Journal of the American Medical Association 287 (2002): 1132-1141.

Organizations

American Cancer Society. 1599 Clifton Road, N.E., Atlanta, GA 30329-4251. (800) 227-2345. www.cancer.org.

American Lung Association, National Office. 1740 Broadway, New York, NY 10019. (800) LUNG-USA. www.lungusa.org.

National Cancer Institute (NCI), Building 31, Room 10A03, 31 Center Drive, Bethesda, MD 20892-2580. Phone: (800) 4-CANCER. (301) 435-3848. www.nci.nih.gov.

National Comprehensive Cancer Network. 50 Huntingdon Pike, Suite 200, Rockledge, PA 19046. (215) 728-4788. Fax: (215) 728-3877. www.nccn.org/.

National Heart, Lung and Blood Institute (NHLBI). 6701 Rockledge Drive, P.O. Box 30105, Bethesda, MD 20824-0105. (301) 592-8573. www.nhlhi.nih.gov/.

Other

Aetna InteliHealth Inc. Lung Cancer. [cited May 17, 2003]. www.intelihealth.com..

American Cancer Society (ACS). Cancer Reference Information. [cited May 17, 2003].www3.cancer.org/cancerinfo.

— Maureen Haggerty Crystal H. Kaczkowski, M Sc

Key Terms: Bronchopleural fistula, Empyema, Pleural space.

Definition

Pneumonectomy is the surgical removal of a lung.

Purpose

Pneumonectomy is most often used to treat lung cancer when less radical surgery cannot achieve satisfactory results. It also may be the most appropriate treatment for a tumor that is located near the center of the lung and that affects the pulmonary artery or veins, which transport blood between the heart and lungs. For the treatment of cancer, pneumonectomy may be combined with chemotherapy or radiation therapy. Pneumonectomy may also be the treatment of choice when traumatic chest injury has damaged the main air passage (bronchus) or the lung's major blood vessels so severely that they cannot be repaired. A form of this procedure known as extra-pleural pneumonectomy is often used to treat malignant mesothelioma.

Precautions

Before scheduling a pneumonectomy, the surgeon reviews the patient's medical and surgical history and orders a number of tests to determine how successful the surgery is likely to be.

Blood tests, a bone scan, and computed tomography (CT) scans of the head and abdomen reveal whether the cancer has spread beyond the lungs. Positron emission tomography scanning (PET) is also used to help "stage" the disease. Cardiac screening indicates how well the patient's heart will tolerate the procedure, and extensive pulmonary testing (breathing tests and quantitative ventilation/perfusion scans) predicts whether the remaining lung will be able to compensate for the body's diminished breathing capacity.

Because extrapleural pneumonectomy is such an invasive operation, the patient must have no serious illness other than the cancer the surgery is designed to treat.

Description

Traditional pneumonectomy removes only the diseased lung. A more complex surgery generally performed in specialized medical centers, extrapleural pneumonectomy also removes:

• a section of the membrane (pericardium) covering the heart
• a portion of the muscular partition (diaphragm) that separates the chest and abdomen
• the membrane (parietal pleura) that lines the affected side of the chest cavity

General anesthesia is given to a patient undergoing either of these procedures. An intravenous (IV) line inserted into one arm supplies fluids and medication throughout the operation, which usually lasts between one and three hours; extrapleural pneumonectomies may last up to six hours.

The surgeon begins the operation by cutting a large opening on the side of the chest where the diseased lung is located. This posterolateral thoracotomy incision extends from below the shoulder blade, around the side of the patient's body, and along the curvature of the ribs at the front of the chest. Sometimes removing part of the fifth rib gives the surgeon a clearer view of the lung and makes it easier to remove the diseased organ.

A surgeon performing a traditional pneumonectomy then:

• deflates (collapses) the diseased lung
• ties off the lung's major blood vessels to prevent bleeding into the chest cavity
• clamps the main bronchus to prevent fluid from entering the air passage
• cuts through the bronchus
• removes the lung
• staples or sutures the end of the bronchus that has been cut
• makes sure that air is not escaping from the bronchus
• inserts a temporary drainage tube between the layers of the pleura (pleural space) to draw air, fluid, and blood from the surgical cavity
• closes the chest incision

Besides removing the diseased lung, a surgeon performing an extrapleural pneumonectomy:

• cuts the pleura away from the chest wall
• removes parts of the pericardium and diaphragm on the affected side of the chest
• substitutes sterile synthetic patches for the tissue that has been removed
• closes the incision

Preparation

A patient who smokes must stop as soon as the disease is diagnosed.

A patient who takes aspirin or any other other blood-thinning medication must stop taking the medication about a week before the scheduled surgery, and patients may not eat or drink anything after midnight on the day of the operation.

Aftercare

Chest tubes drain fluid from the incision and a respirator helps the patient breathe for at least 24 hours after the operation. The patient may be fed and medicated intravenously. If no complications arise, the patient is transferred from the surgical intensive care unit (ICU) to a regular hospital room within one to two days.

A traditional pneumonectomy patient will probably be discharged within 10 days. A patient who has had an extrapleural pneumonectomy is likely to remain in the hospital between 10 and 12 days after the operation. While the patient is hospitalized, care focuses on:

• relieving pain
• monitoring to ensure that concentrations of oxygen in the blood do not become dangerously low (hypoexemia)
• encouraging the patient to walk in order to prevent formation of blood clots
• encouraging the patient to cough productively in order to clear accumulated lung secretions. If the patient cannot cough productively, the doctor uses a flexible tube (bronchoscope) to remove lung secretions and fluids (bronchoscopy).

Recovery is usually a slow process, with the remaining lung gradually taking on the tasks of the lung that has been removed and the patient gradually resuming normal, non-strenuous activities. Within eight weeks, a pneumonectomy patient who does not experience postoperative problems may be well enough to return to a job that is not physically demanding, but 60% of all pneumonectomy patients continue to experience marked shortness of breath six months after having surgery.

Questions to Ask the Doctor

• Why is it necessary to remove the whole lung?
• Why might I also need chemotherapy or radiation therapy?
• What should I do to prepare for this operation?
• How long will I have to stay in the hospital?
• Why is recovery such a slow process?

Risks

In the United States, the immediate survival rate from the surgery for patients who have had the left lung removed is between 96% and 98%. Due to the greater risk of complications involving the stump of the cut bronchus in the right lung, between 88% and 90% of patients survive removal of this organ.

Between 40% and 60% of pneumonectomy patients experience such short-term postoperative difficulties as:

• prolonged need for a mechanical respirator
• abnormal heart rate (cardiac arrhythmia), heart attack (myocardial infarction), or other heart problems
• pneumonia
• infection at the site of the incision
• a blood clot in the remaining lung (pulmonary embolism)
• an abnormal connection between the stump of the cut bronchus and the pleural space due to a leak in the bronchus stump (bronchopleural fistula)
• accumulation of pus in the pleural space (empyema)
• kidney or other organ failure

Over time, the chest's remaining organs may move toward the space created by the surgery. This condition is called postpneumonectomy syndrome, and a surgeon can correct it by inserting a fluid-filled prosthesis into the space the diseased lung occupied.

Normal Results

The doctor will probably advise the patient to refrain from strenuous activities for a few weeks after the operation. Ribs that were cut during surgery will remain sore for some time.

A patient whose lungs have been weakened by non-cancerous diseases like emphysema or chronic bronchitis may experience long-term shortness of breath as a result of this surgery.

Abnormal Results

A patient who experiences a fever, chest pain, persistent cough, or shortness of breath, or whose incision bleeds or becomes inflamed, should notify his or her doctor immediately.

Resources

Books

Pass, H., D. Johnson, et al. Lung Cancer: Principles and Practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000.

Other

ACS Cancer Resource Center. [cited July 17, 2005]. .

Pneumonectomy. [cited July 17, 2005]. .

—Maureen Haggerty

Excision of lung tissue, of an entire lung (total pneumonectomy) or less (partial pneumonectomy), or of a single lobe (lobectomy).

Appearance of the cut surface of a pneumonectomy specimen containing a lung cancer, here a Squamous cell carcinoma (the whitish tumor near the bronchi).

A pneumonectomy (or pneumectomy) is a surgical procedure to remove a lung. Removal of just one lobe of the lung is specifically referred to as a lobectomy, and that of a segment of the lung as a wedge resection (or segmentectomy).

Contents 1 Indications 2 Types 3 History 3.1 Pioneering dates 4 References 5 External links

Indications

The most common reason for a pneumonectomy is to remove tumourous tissue arising from lung cancer. In the days prior to the use of antibiotics in tuberculosis treatment, tuberculosis was sometimes treated surgically by pneumonectomy.

The operation will reduce the respiratory capacity of the patient; before conducting a pneumonectomy, the surgeon will evaluate the ability of the patient to function after the lung tissue is removed. After the operation, patients are often given an incentive spirometer to help exercise their remaining lung and to improve breathing function.

A rib or two is sometimes removed to allow the surgeon better access to the lung.

Types

There are two types of pneumonectomy:

1. Simple pneumonectomy: removal of just the affected lung
2. Extrapleural pneumonectomy (EPP): removal of the affected lung, plus part of the diaphragm, the parietal pleura (lining of the chest) and the pericardium (lining of the heart) on that side.^[1] The linings are replaced by Gore-Tex in this radical and painful surgery that is used primarily for treatment of malignant mesothelioma. This technique produces the best long-term survival rates for this serious and fatal disease.^[2]

History

Pioneering dates

• 1895: first pneumonectomy in multiple stages by William Macewen on a patient with tuberculosis and emphysema
• 1931: first successful pneumonectomy in two stages by Rudolph Nissen on a patient with crush injury to the thorax
• 1932: first lobectomy, by Harold Brunn
• 1933: first successful single-stage total pneumonectomy by Graham and Singer^[3]
• 1939: first segmentectomy, by Churchill and Belsey

References

1. ^ http://www.cancer.gov/templates/db_alpha.aspx?CdrID=367446
2. ^ http://www.impmeso.org/extra_pleural_pheumonectomy/c30_p24/Mesothelioma_Treatments/Traditional_Treatments/Mesothelioma_Surgery/Pleural_Mesothelioma/Extrapleural_Pneumonectomy.html
3. ^ Horn, L; Johnson DH (July 2008). "Evarts A. Graham and the first pneumonectomy for lung cancer". Journal of Clinical Oncology 26 (19): 3268–3275. PMID 18591561. http://jco.ascopubs.org/cgi/pdf_extract/26/19/3268. 

External links

• Fuentes, P.Pneumonectomy: historical perspective and prospective insight European Journal of Cardio-thoracic Surgery 23 439–445

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