Lung Surgery
Misc
- Postop air leak
Pathophysiology of air leak - Air leak >5 days: Lobectomy 8,6%, segmentectomy 6,7%, wedge 3,5%
- Air leak after segmentectomy - Propensity score matched historical cohort (N=42)
Patients with persistent air leakage after segmentectomy treated with chemical pleurodesis have worse post operative pulmonary function than those treated conservatively
FVC at 12 months -20,8% vs 6,8%, FEV1 at 12 months 19,6% vs 9,7%
Cancer surgery
- Patient Selection
- Prognosis
Thor årsrapport 2018 - Lung cancer surgery
Mortality: Total 30D: 0,9%, Pulmectomy:2,3%, Bilobectomy: 1,1%, Lobectomy: 0,5%, Segment: 0,4%, Wedge: 0%
Complications: Reop: 4,4%, Air leak: 9,1%
5-Year survival: 65%, IA: 79%, IB: 70%, IIA: 55%, IIB: 50%, IIIA: 40%,
Metastatectomy: 5 year survival 52%
Metastatectomy:
PulmICC - (RCT 93 pat, 1-6 metastases) - Op/NoOp - median survival 3,5-3,8 yr, HR 0,93 (NS)
Dutch Lung Cancer Registry 2020 - (Historic cohort 2012-2017, 2090 pat) Primary, Colorectal 52%, Urogen 14,2%. 80% Single metastasis. 30d mortality 0,7%
Pneumothorax
- Patient Selection
Trauma PTX - Conservative meðferð gengur vel með <35 mm spalt, mælt á CT (96% sjúklinga klára conservative treatment)
Spontaneous PTX - RCT á unilateral miðlung til stórum PTX (>32% samfall) sýndi non-inferiority með conservative treatment við 8 vikur
(Conservative: Ekkert dren, 4 klst obs og ný rtg eftir það ekki aukinn PTX né mikil einkenni, 15% treatment failure)
- Prognosis
Pleurodesis with Talc powder vs slurry - Enginn munur, 22-24% failure rate at 90 days
Empyema
20-40% of hospitalized pneumonias develop parapneumonic effusion, 5-10% of those develop empyema 1 2
ABX therapy is recommended for at least 2 weeks from time of drainage
Stages:
Stage I: Exudative (Parapneumonic effusion)
Stage II: Fibrinopurulent (Pus, positive bacterial cultures, fibrous pockets)
Stage III: Organizing (Pleural peel forms, hemithoracal contraction and rib space narrowing)
Thoracocentesis for drainage is not recommended, pleural drain placement is
Image guided small bore catheters are recommended for loculated effusions in patients who are not surgical candidates
Chest tube placement should be followed by a CT to confirm adequacy of drainage, undrained fluid should prompt more aggressive management
Drain flushing is considered routine, due to high likelihood of drain obstruction
Fibrinolytic therapy with Alteplase and a DNase can decrease the need for surgical intervention
Surgery
2 goals: Evacuation and Expansion
VATS should be the first-line approach in patients with acute empyema without an organized pleural peel (stage II) who can tolerate single lung ventilation
Extensive resection is to be avoided, because bronchial stumps in infected fields are prone to fistulization
Tissue flaps (muscle or omentum) can be used to fill space when total expansion is not achieved
Thoracoplasty with rib resection may be conisidered for difficult cases, open thoracic window +- VAC treatment is another option
Post pulmectomy empyema
Prompt intervention is recommended to rule in or out the diagnosis
An aggressive surgical approach is recommended