Postthoracotomy Complications

Thomas Hachenberg, Torsten Loop

Abstract

Thoracotomy is required to get surgical access to the thoracic cavity through the chest wall to the pleural space and the thoracic organs such as heart, lung, thymus, and esophagus. The principles and techniques of thoracotomy are differentiated in an anterolateral (= muscle sparing) and posterolateral (= nonmuscle sparing) approach, which requires a lateral position of the patient. In addition, sternotomy, anterior or axillary thoracotomy, clamshell, or hybrid techniques are further techniques in supine positioning. Despite extensive and aggressive perioperative management, postoperative respiratory failure or cardiac complications may still occur. Postoperative complications resulting from thoracotomy encompasses serious risks in general, such as bleeding or hemorrhage or mainly because of the procedure per se, such as bronchopleural fistula, atelectasis, infection, or organ damage.

Keywords

thoracotomy; postthoracotomy complications; thoracic anesthesia; risk factors; respiratory insufficiency

Introduction

Thoracotomy is required to get surgical access to the thoracic cavity through the chest wall to the pleural space and the thoracic organs, such as heart, lung, thymus, and esophagus. The principles and techniques of thoracotomy are differentiated in the anterolateral (= muscle sparing) and posterolateral (= nonmuscle sparing) approach, which requires a lateral position of the patient. In addition, sternotomy, anterior or axillary thoracotomy, clamshell, or hybrid techniques are further techniques that are performed in supine positioning.

Despite extensive and aggressive perioperative management, postoperative respiratory failure or cardiac complications may still occur. Postoperative complications because of thoracotomy encompasses serious risks in general, such as bleeding or hemorrhage or mainly because of the procedure per se, such as bronchopleural fistula, atelectasis, infection, or persistent organ damage.

Postoperative cardiopulmonary complications occur in 10% to 40% of patients undergoing lung resection surgery, resulting in prolonged hospital stay and increased healthcare costs.^1–4 The most common factors contributing to this high rate are postoperative respiratory complications with respiratory insufficiency. The various causes are shown in Table 27.1.

Table 27.1

Causes and Frequencies of Respiratory Insufficiency
Atelectasis/secret retention	Nearly all patients
With the need for bronchoscopy	3.6%
Pneumonia	Up to 25%
Therapeutic atrial arrhythmia	10.7%
Bronchopleural fistula >5 d	8%
Reintubation	3.4%
ARDS	1.1%
Phrenic/recurrent nerve paresis	0.5%
Pulmonary embolism	0.4%
Empyema	0.3%

ARDS, Acute respiratory distress syndrome.

Modified from Cao C, Louie BE, Melfi F, et al. Outcomes of major complications after robotic anatomic pulmonary resection. J Thorac Cardiovasc Surg. 2019;159(2):681–686.

Cao et al. evaluated 1264 patients who underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%) (Fig. 27.1).⁵ Male sex, decreased forced expiratory volume in 1 second (FEV₁), reduced diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection are associated with increased likelihood of a major postoperative complication.

• Fig. 27.1 Outcomes of major complications after robotic anatomic pulmonary resection. *DLCO,* Diffusing capacity for the lung for carbon monoxide; *FEV1,* forced expiratory volume in 1 second; *ICU,* intensive care unit; *LOS,* length of stay; Tx, Treatment. (From Meert AP, Grigoriu B, Licker M, Van Schil PE, Berghmans T. Intensive care in thoracic oncology. *Eur Respir J*. 2017;49(5):1602189.)

Morbidity and mortality further depend on the type, invasiveness, and extent of the thoracic surgical procedure. The planned admission to the intensive care unit (ICU), high dependency unit (HDU), or postanesthetic care unit depends on the clinician’s pre- and intraoperative prediction of potentially preventable major complications. In addition, adverse events may demand unplanned admission to the HDU or ICU for further diagnosis and treatment of complications. The overall risk profile for thoracic surgical patients is shown in Fig. 27.2.

• Fig. 27.2 Overall risk profile for thoracic surgical patients. *HDU,* High dependency unit; *ICU,* intensive care unit; *PACU*, postanesthesia care unit. (Modified from Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. *Eur J Anaesthesiol*. 2015;32(2):88–105.)

The definition of postoperative pulmonary complications (PPCs) is heterogeneous. Typically, PPCs are categorized as a composite outcome measure.⁶ The PPCs after thoracotomy are defined as need for noninvasive ventilation because of hypercapnia or hypoxia, need for tracheal intubation because of hypercapnia or hypoxia, prolonged air leak for 5 or more days after surgery, new thoracic drainage from an increased pleural effusion with respiratory compromise, and the presence of pleural empyema. Pneumonia was diagnosed according to the European Perioperative Clinical Outcome definition. This included new pulmonary infiltrate with associated leukocytosis, fever, new purulent sputum, need for antibiotic therapy, and increased oxygen demand via face mask. PPCs are ranked as the leading causes of early mortality after lung surgery, whereas sepsis and cardiac events are ranked second and third, respectively.⁷ Thoracotomy by itself was defined as a risk factor for PPCs.⁸ There is more compelling evidence that the thoracoscopic approach reduces the incidence of PPCs. Chen et al. performed a metaanalysis of 20 studies with 3457 patients comparing video-assisted thoracoscopic surgery (VATS) lobectomy with open lobectomy.⁹ There was no difference in operation time between the two groups (P = .14), but distinct advantages in terms of intraoperative blood loss, chest drainage time, hospital stay, and complication incidence were found in the VATS group (P < .01). Moreover, the 5-year survival rate of VATS group was significantly higher than the thoracotomy group.

Prediction of Postoperative Pulmonary Complications

The preoperative identification of risk factors and the prediction of PPCs has the potential to optimize the perioperative care of patients and could help to reduce PPC. Canet et al. assessed the incidence and characteristics of PPCs in a large sample of 2464 patients and built a scoring system with a reduced number of significant variables that would identify PPC risk in most clinical settings (Assess Respiratory Risk in Surgical Patients in Catalonia [ARISCAT]) (Tables 27.2 and 27.3).¹⁰^,¹¹

Table 27.2

ARISCAT Score for Postoperative Pulmonary Complications¹⁰
Age, years	≤50 (0)	51 – 80 (+3)	>80 (+16)
Preoperative SpO₂	≥96% (0)	91 – 95% (+8)	≤90% (+24)
Respiratory infection in the last month	No (0)		Yes (+17)
Preoperative anemia (Hb <10 gdL⁻¹) (6.2 mmolL⁻¹)	No (0)		Yes (+11)
Surgical incision	Peripheral (0)	Upper abdominal (+15)	Intrathoracic (+24)
Duration of surgery	<2 hours (0)	2 – 3 hours (+16)	> 3 hours (+23)
Emergency procedure	No (0)		Yes (+8)

Table 27.3

Postoperative Pulmonary Complications Risk Score
	Risk Score Intervals
	Low Risk <26 Points	Intermediate Risk 26–44 Points	High Risk >45 Points
Postoperative pulmonary complication rate in %	1.6	13.3	42.1

From Chen FF, Zhang D, Wang YL, Xiong B. Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage non-small cell lung cancer: a meta-analysis. Eur J Surg Oncol. 2013;39(9):957–963.

Postthoracotomy Complications in General and/or Specific to the Thoracic Procedure

Postthoracotomy complications may be categorized in general and/or specific to the thoracic procedure and may be related to patient- and procedure-specific risk factors.

Risk Factors

Patient-specific risk factors for the occurrence of PPCs include continued nicotine abuse, the male sex, the presence of chronic obstructive pulmonary disease (COPD), increased comorbidity (American Society of Anesthesiologists [ASA] ≥3), cachexia, increased age, obesity, preoperative impaired lung function, and preexisting hypoxia.¹^,²^,⁴^,⁸

With regard to surgical risk factors, the extent of parenchymal resection, thoracotomy compared with thoracoscopy, as well as an extended duration of surgery, contribute to an increase in risk factors for the occurrence of PPCs.⁸^,¹²^,¹³ As previously mentioned, thoracoscopy as an alternative procedure to thoracotomy is the most important surgical factor in reducing PPCs.^13–15 During the intraoperative management, a liberal intraoperative volume therapy, a high tidal volumes >8 mL/kg body weight) to the dependent lung were identified as the main risk factors for the occurrence of PPCs.⁴^,¹³^,¹⁶ Serpa Neto et al. evaluated 15 randomized controlled trials (2127 patients).¹⁷ There were 97 cases of PPC in 1118 patients (8.7%) assigned to protective ventilation and 148 cases in 1009 patients (14.7%) assigned to conventional ventilation. Patients who developed postthoracotomy complications were older, presented higher ASA scores, had a higher prevalence of sepsis or pneumonia, received more frequent blood transfusions, and were ventilated with higher tidal volumes, lower positive end-expiratory pressure (PEEP) levels, or both.¹⁸^,¹⁹ These factors increase postoperative respiratory failure after thoracic procedures. Additional patient-specific risk factors are expiratory peak flow limitations during COPD, which result in increased work of breathing and muscle fatigue and ultimately respiratory failure. The frequent presence of postoperative atelectasis formed intraoperatively often persists postoperatively and may increase intrapulmonary shunt and predisposes acute lung injury. The incidence of postoperative lung injury after thoracotomy and thoracic surgery may be as high as 4.3%.¹⁸

Postthoracotomy Complications

Despite the developments and improvements in surgical technique, examples of general complications after thoracic surgical procedures are extra- or intrathoracic bleeding after hemorrhage, hemothorax, pleural effusion, nerve injuries, chylothorax, acute, and postthoracotomy pain, pneumonia without/with septic condition. More specific complications particularly during thoracic procedures are: air leakage and/or bronchopleural fistula, pneumothorax, subcutaneous emphysema, lung torsion, lung infarction after pulmonary resection, anastomotic insufficiency after esophagectomy, and airway complications: aspiration of gastric contents and retained secretions.

Postoperative Thoracic Complications

Bleeding

Postoperative bleeding after thoracic surgery is a rare but life-threatening complication. A national database with over 33,000 patients found an incidence of intraoperative bleeding of 1.9% for open, 1.3% for VATS, and 1.7% for robotic-assisted lobectomy resections.¹⁹ Not all postoperative bleedings are subject to immediate exploration in the operating room (OR). A chest tube drainage of 1000 mL of bloody secretion within the first hour after lung resection must be considered for immediate exploration in the OR. Furthermore, a serial drainage rate of more than 200 mL/h over 2 to 4 hours postoperatively indicates an intrathoracic hemorrhage and requires surgical revision as well.

Lobe Torsion

The torsion of a pulmonary lobe after previous lung resection leads to a circulatory disorder and bronchial stenosis because of rotation around the supplying vessels and bronchial structures. The incidence is stated to be about 0.1% to 0.3%.²⁰ Lobar torsion was frequently reported after upper lobectomy (74.4%) and the middle lobe was the most vulnerable to torsion (29.4%). The main clinical presentations were dyspnea (38.4%), fever (23.3%), and chest pain (17.4%). Radiologic findings (computed tomography [CT] scan) included worsening consolidation and abrupt truncation/tapering of the pulmonary artery. The overall mortality was 8.3%.²¹ Lobe torsion is a life-threatening situation; if a pulmonary lobe torsion was detected after clinical and CT diagnostics, an immediate surgical revision must be performed (Figs. 27.3 and 27.4).

• Fig. 27.3 (A) Mass (*arrow*) measuring around 3.5 cm in greatest diameter in right upper lung field.(B) Follow-up chest radiograph showed a wedge-shaped opacity of large area in the middle lung field.

• Fig. 27.4 Computed tomography scan show collapsed (see Fig. 27.3) and hemorrhagic consolidation of the right middle lobe. (From Froehlich JB, Fleisher LA. Noncardiac surgery in the patient with heart disease. *Med Clin North Am*. 2009;93(5):995–1016.)

A chest x-ray and a CT scan were taken of a 50-year-old woman who presented with a 2-month cough and mild symptoms of hemoptysis. On routine examination, the patient was found to have a mass measuring around 3.5 cm in right upper lung field. The patient underwent right upper lobectomy through a standard right posterolateral thoracotomy. The chest radiographs on postoperative day 1 and 2 showed adequate lung expansion with no obvious abnormality. Five days postoperatively, the patient presented fever and mild dyspnea. Follow-up chest radiograph showed a wedge-shaped opacity of large area in the middle lung field. Bedside bronchoscopy showed tight orifice of right middle lobe. CT scan showed collapse and hemorrhagic consolidation from right middle lobe torsion (see Fig. 27.4).

Postthoracotomy Cardiac Complications

Major adverse cardiac events (MACE) and myocardial infarction (MI) significantly contribute to postoperative morbidity and mortality. The vast majority of the patients admitted for lung resection are current smokers or ex-smokers at the time of surgery and have at least one risk factor for coronary artery disease (CAD). The identification of patients at risk may help to guide the utilization of clinical resources and preventive interventions.

Myocardial Ischemia

Perioperative myocardial ischemia is a strong predictor of adverse cardiac events in different surgical specialties, including thoracic surgery.²² The diagnosis of perioperative MI is associated with a 30% to 50% risk of death after vascular surgery.²³^,²⁴ Age over 70 years and FEV₁ of 70% or less combined with coronary heart disease are independent prognostic factors for postoperative major complications.²⁵ Myocardial ischemia results from an imbalance between oxygen supply and demand, which may result from multiple factors before, during, and after thoracic surgery. Major determinants include intravascular fluid shifts, blood loss, alterations of coagulation, increased production and release of inflammatory substances, and pain, which increases production of catecholamines. A combination of tachycardia, decreased mean diastolic aortic pressure, and hypoxemia, which may occur during one-lung ventilation (OLV), are particularly detrimental for the development of perioperative myocardial ischemia. Thus the intra-operative prevention and/or control of these determinants is crucial in thoracic surgical patients.

The incidence of a MACE, death, or MI perioperatively is mainly related to the baseline risk. The revised cardiac risk index was developed for prediction of major cardiac complications after elective noncardiac surgery (Table 27.4).

Table 27.4

Summary of Risk Scores
ASA		Revised Cardiac Risk Index		Thoracic Revised Cardiac Risk Index
Risk Factors	Points	Risk Factors	Points	Risk Factors	Points
ASA I	0	History of coronary artery disease	1	History of coronary artery disease	1.5
ASA II	2
ASA III	4	History of heart failure	1	History of cerebrovascular disease	1.5
ASA IV	5	History of cerebrovascular disease	1
ASA V	6			Pneumonectomy	1.5
Surgical risk: low/ intermediate/ high/emergency intervention	0/1/2/1	High-risk surgery (vascular, intraperitoneal, or intrathoracic)	1	Serum creatinine >2 mg/dL >177 µmol/L	1
		Preoperative insulin therapy	1
		Serum creatinine >2 mg/dL >177 µmol/L	1

ASA, American Society of Anesthesiologists.

(From Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015;32(2):88–105.)

Prolonged anticoagulation has to be considered before, during, and after thoracic surgery in patients with cardiac stents. The duration of anticoagulation depends on the type of the stent. Bare-metal stents are subjected to dual antiplatelet therapy for 4 to 6 weeks, whereas drug eluting stents are treated with acetylsalicylate and clopidogrel for 6 to 12 months.²³ Low-molecular-weight heparin is initiated preoperatively once antiplatelet therapy is temporarily paused. Patients who have not had previous coronary stenting, but are daily taking acetylsalicylate, should continue acetylsalicylate therapy throughout the perioperative period (class IIb recommendation). Continuation of acetylsalicylate perioperatively is certainly reasonable in patients with high-risk CAD or cerebrovascular disease, unless there is concern for an increased bleeding risk in certain thoracic procedures. However, some practitioners have concerns regarding giving a full dose acetylsalicylate (325 mg) when thoracic epidural is planned. Current guidelines provide a class III recommendation against initiating acetylsalicylate therapy preoperatively because of a higher risk of bleeding.²⁶

Prophylactic coronary artery revascularization before thoracic surgery offers no further benefits over optimal medical treatment.²⁷^,²⁸ Van Diepen et al. evaluated the postoperative risks for patients with CAD undergoing noncardiac surgery, patients with heart failure (HF), and atrial fibrillation (AF). They created four cohorts of consecutive patients with either nonischemic HF (NIHF; n = 7700), ischemic HF (IHF; n = 12,249), CAD (n = 13,786), or AF (n = 4312) who underwent noncardiac surgery (Fig. 27.5). The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (Fig. 27.6). They concluded that although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD.²⁷

• Fig. 27.5 Overlap between nonischemic heart failure (*NIHF*), ischemic heart failure (*IHF*), coronary artery disease (*CAD*), and atrial fibrillation/flutter (AF) cohorts. (From van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. *Circulation*. 2011;124(3):289–296.)

• Fig. 27.6 Unadjusted 30-day perioperative mortality (*blue*), rehospitalization (*red*), and cardiac rehospitalization (*green*); HF, Heart failure. (From van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. *Circulation*. 2011;124(3):289–296.)

When percutaneous coronary intervention is performed before noncardiac surgery, elective noncardiac surgery should be delayed 14 days after balloon angioplasty, 30 days after bare-metal stent implantation, and 365 days after drug-eluting stent (DES) implantation. The recent European Society of Cardiology (ESC) guidelines suggest that with newer-generation DES implantation, a 6-month duration of dual-antiplatelet therapy may be considered if there is increased need for noncardiac surgery. The American College of Cardiology (ACC)/American Heart Association (AHA) 2014 Guideline for the Management of Patients with Non–ST-Elevation Acute Coronary Syndromes recommends that if the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of antiplatelet drug—P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable.²⁹

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