Medical management of the thoracic surgery patient

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Diagnosis, Treatment and technologies

Lobar torsion represents a rotation of the bronchovascular pedicle with resultant airway obstruction and vascular compromise. This disorder has been described in 3 different circumstances: as a complication of thoracic surgery, after blunt trauma, and spontaneously [ ]. The overall incidence of lung torsion has been reported as 0.

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The pathophysiological mechanisms of torsion development were previously postulated as an airless lobe, incision of the inferior pulmonary ligament, pleural effusion, a long slim lobar pedicle, and lack of pleural adhesions. Only meticulous observations of both clinical and radiological manifestations, although uncharacteristic, can provide an indication of torsion development.

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Thereafter, bronchoscopy, contrast chest computed tomography, or angiography can be diagnostic in finding the distorted or occluded bronchi or tapered pulmonary artery. Subsequent manoeuvres, such as contrast computed tomography, would have been diagnostic and prompted reoperation. Intrathoracic bleeding was suspected considering the history of extensive mediastinal adhesions, voluminous drainage, and blood loss.

The distinguishing features were: the chest opacity appeared hypertensive, and the resultant huge tension markedly shifted the mediastinum; the serous fluid drainage, albeit a large amount, was inconsistent with the severity of the anaemia; and radiographically, there was a convex pulmonary margin around the chest tube.

Torsion could happen in any lobe [ ]. Options for surgical intervention include simple detorsion or resection of the involved pulmonary segments. Detorsion alone is advocated only in patients who undergo re-intervention within a few hours of the primary procedure; while in the majority of patients, pulmonary resection is mandatory due to pulmonary gangrene. Embolisms to other vital organs are the main complications after surgery, which should therefore be carefully monitored.

It seems reasonable to staple or suture the middle lobe to the lower lobe after a right upper lobectomy if the oblique fissure is complete to prevent middle lobe torsion. Postoperatively, the possibility of a lobar torsion after lobectomy should be considered when an infiltrate or complete atelectasis persists or worsens; bronchoscopic intervention should be performed promptly. Pericardial tamponade, though rare after open lobectomy, should be considered along with other complications when a patient repeatedly develops hypotension with therapies that causes venodilation.

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A rising CVP and its equalization with pulmonary artery diastolic pressure indicate cardiac tamponade. Symptoms include those related to cardiac tamponade: low cardiac output and Beck's triad hypotension, muffled heart sounds, and increased central venous pressure. Diagnosis of this complication again requires a high index of suspicion.

Echocardiography is the diagnostic study of choice to visualize impaired filling of the right ventricle because of increased pericardial pressure from the pericardial effusion. Treatment include an urgent pericardiocentesis as a temporizing measure followed by reopening of the thoracotomy or a formal median sternotomy, which allows full inspection of the interior of the pericardium and provides adequate access for definite management of the cause. Minor injuries during retraction and dissection can produce life-threatening conditions like pericardial tamponade.

Episodes of unexplained hypotension suggest a cardiac aetiology; a high index of suspicion and urgent surgical intervention can prevent adverse outcome. The thoracic duct can be injured during any thoracic procedure. Pleuro-pulmonary procedures, esophageal resection, intrapericardial and mediastinal procedures, and even less invasive procedures like subclavian puncture may lead to thoracic duct injury and subsequent chylothorax [ ]- [ ].

The incidence of chylothorax after pulmonary resection is between 0. Aetiologies in thoracic surgery include aggressive mediastinal lymph node dissection with incomplete ligation of lymphatic channels or direct injury to the thoracic duct either during extra pleural pneumonectomy or division of the pulmonary ligament. There will be loss of calories, fluids, and proteins cause nutritional deficiency, dehydration, and immunologic dysfunction and if not drained can cause respiratory compromise. Chylothorax can compress the lung resulting in shortness of breath and respiratory distress.

Empyema is a rare complication due to the bacteriostatic nature of lecithin and fatty acids. Sterile chyle does not cause pleuritic pain or a fibrotic inflammatory reaction. Loss of proteins and vitamins, more than fat, leads to metabolic and nutritional defects, immunodeficiency, coagulopathy, malnutrition and death. A prompt diagnosis and an accurate early treatment are therefore essential. The total protein concentration in the effusion is near or equal to the plasma protein concentration. Mostly, it occurs from 2 days to 4 weeks postoperatively and varies from slight to severe forms determined by the volume and rate of chyle loss.

Conservative treatment initially involves replacing the nutrients lost in the chyle and draining large chylothoraces using chest drain insertion if necessary, to ensure complete lung expansion, nil by mouth or the administration of low fat medium chain triglycerides by mouth. Medium chain triglycerides are directly absorbed in to the portal system, bypassing the intestinal lymph system. This reduces the flow of chyle in the thoracic duct allowing it the opportunity to heal. These agents reduce intestinal chyle production, thereby reducing the volume flowing through the injured thoracic duct.

Chemical pleurodesis with TALC is an alternative option in the majority of patients that are too unwell for surgical closure of the chyle leak.

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Surgical therapy [ ] is recommended in cases where despite conservative management the patient drains more than 1. Surgery is also recommended if there has been a rapid decline in nutritional status despite conservative management. Thoracic duct ligation can be performed during thoracotomy or by thoracoscopic intervention. Collateral circulation redirects the chyle around the ligation point ensuring that the chyle still completes its journey to the circulation. In cases of loculated or complicated chylothorax pleural decortication with pleurodesis may be performed.

One of the common problems after thoracic surgery is prolonged postoperative air leak. Not all patients have an air leak after pulmonary resection. However, many patients having a lobectomy, segmentectomy, or a complicated wedge resection will leave the operating room with a leak.

Post Operative Complications and Management in Thoracic Surgery

The vast majority of postoperative air leaks, however, are alveolar air leaks, and therefore initial management should be aimed at treating this entity. The management of bronchopleural fistulas is substantially different than that of alveolar air leaks, often requiring early surgical intervention.

Air leaks that persist beyond a certain point may prolong the hospital length of stay. The Society of Thoracic Surgeons database mentions air leaks are those which are typically present when the patient could otherwise be discharged were it not for a continued air leak. Prolonged air leak may be associated with an increased complication rate and certainly may increase length of stay.

Okereke et al. Varela and colleagues [ ] found that air leak lasting at least 5 days was associated with greater pulmonary morbidity, such as atelectasis, pneumonia, and empyema. They also found that the length of stay was extended by 6 days. Most leaks will stop within 2 to 3 weeks. By far the most common treatment of airleaks is watchful waiting with continuous drainage through a tube thoracostomy. Blood patch or chemical pleurodesis may be considered as the next step. Experience with these techniques is variable. The instillation of sclerosing materials into the pleural space through the thoracostomy tube promotes symphysis of visceral and parietal pleura and may produce leak closure.

Given the low rate of infection reported in published series, it remains unclear whether antibiotics should routinely be used. Autologous blood patch is another nonsurgical option to treat PAL after the operation or spontaneous pneumothorax [ ]- [ ]. To summarize, blood-patch pleurodesis involves the instillation of autologous blood into the pleural space through a chest catheter. It is simple, relatively painless, and often effective, but some information suggests that blood-patch pleurodesis may also carry an increased risk of intrathoracic infection.

Although there are six articles on this subject, it is difficult to draw definitive conclusions due to the variable study sizes from 2 patients to 32 patients , quantity of blood injected 50 to mL , and endpoint definitions. Pneumoperitoneum instilled through a transabdominal catheter has been reported to be effective in some cases [ ], [ ]. Surgical options to accomplish pleural symphysis or control the source of an alveolar air leak, or both, include video-assisted thoracic surgery VATS with parenchymal stapling, VATS with chemical pleurodesis, VATS with pleural abrasion [ ], [ ], VATS with application of topical sealants [ ], [ ], and the less well-supported use of VATS with laser sealing of the site of leak [ ].

Omental or muscle flaps placed at re-thoracotomy can also be used successfully to obliterate the pleural space in patients with incomplete lung expansion and residual air leaks [ ]. Injuries can happen to the oesophagus, phrenic nerve, recurrent laryngeal nerve, dural lacerations and spinal cord injury and peripheral embolisation of tumour. Thoracic surgical procedures can produce phrenic nerve injury. It happens when there are adhesions or in redo surgeries. Surgeries like anterior mediastinal tumor excision, resection of superior sulcus tumours, repair of thoracic outlet syndrome, or right-sided mediastinal lymph node dissection could all cause phrenic nerve injury.

Such injuries may be temporary or permanent. Presenting features are shortness of breath on exertion and impaired exercise tolerance [ ]. If patients are on a ventilator then there may be difficulty in weaning of ventilator.

X-ray shows elevation of the affected hemi diaphragm. This is confirmed by ultrasound or fluoroscopy, which is the diagnostic study of choice in evaluation of these injuries. The best method of management of unilateral palsy is diaphragmatic plication [ ]. Injury to the recurrent laryngeal nerve generally present in the postoperative phase with a weak hoarse and whispery voice. They nay describe a voice, which gets weaker as the day progresses, which may cause aspiration or impaired physiotherapy due to inability to cough effectively.

A laryngoscopy is done to confirm the diagnosis and adduction of the affected vocal cord or sluggish motion will be absent. Treatment depends on whether the injury is temporary or permanent.

Cardiothoracic Surgery (Thoracic Surgery)

A fibre optic evaluation is necessary to test swallowing and sensation. To assist with pulmonary physiotherapy and decrease the risk of aspiration, medialization laryngoplasty may be suggested [ ]. This can be done as an office procedure with the aid of autologous fat, Gel foam, collagen, or polytetrafluoroethylene. Infectious complications after pulmonary surgery include operative wound infection, empyema, and nosocomial pneumonia.

Antibiotic prophylaxis should therefore be guided against these three entities. In one study These infections should be aggressively treated with appropriate antibiotics after culture. Chest physiotherapy, pain control, bronchodilators, and early ambulation should be done for all patients but regardless of these pneumonia develops.

Postoperative atelectasis after pulmonary surgery should be aggressively managed before it deteriorates into pneumonia. Our policy is to give Ticarcillin Sodium and Potassium Clavulanate 3. The incidence of empyema is dropping but could happen if there is prolonged air leak. Generally they are managed with antibiotics but may necessitate thoracotomy and wash out. Other complications include pulmonary embolism, deep venous thrombosis, renal failure, strokes, major gastrointestinal bleed and late empyema.

These complications should be recognised very early and aggressive management should be instituted if they are to be tackled successfully. Thus postoperative care and management of postoperative complications is a team approach and good preoperative and intraoperative measures minimize the incidence of postoperative complications and early recognition and treatment is essential for successful outcomes.

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Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient
Medical management of the thoracic surgery patient Medical management of the thoracic surgery patient

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