*Contributed equally
Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.
The removal of one entire lung-pneumonectomy-is not a surgical decision to be taken lightly. Although technically considered the simplest anatomical resection, its high mortality [10-60% (
As it is the only type of pulmonary resection that leaves the entire pleural cavity empty, specific changes are expected after pneumonectomy. Typically, after surgery, the empty space is filled with air, which is then gradually replaced by fluid. Then, in a course of 1-7 months (
Although patients eligible for pneumonectomy undergo a rigorous workup prior to surgery, certain post-operative complications still do occur. Complications may occur more frequently when oncological elective surgeries are delayed or even cancelled, e.g., due to associated comorbidities or due to the COVID-19 pandemic (
As for the post-operative management of any other type of pulmonary anatomical resection, the standard cautions and care apply when it comes to pneumonectomies, but there are specific post-operative complications that the patient must be monitored for: post-pneumonectomy empyema, post-pneumonectomy pulmonary oedema and post-pneumonectomy syndrome (
Search strategy and selection criteria: All of the available studies were searched on PubMed (
After a rigorous search, a total of 19 case reports that matched the selection criteria were identified (
These complications after pneumonectomy are not frequent in daily practice but they present usually as emergencies and their impact may be fatal.
The reviewed pneumonectomies were performed for spindle lung sarcoma (1 case), mesothelioma (3 cases), and primary lung carcinoma (15 cases).
All 19 patients underwent pneumonectomy for malignancy. There were 16 intrapleural pneumonectomies (of which 3 were with intrapericardial approach) and 3 extrapleural pneumonectomies (
Tension chylothorax after pneumonectomy for malignancy was the most frequent complication described, accounting for 14 patients out of 19 (73.68%); however, chylothorax is a rare complication with an incidence of <0.7% (
The development of tension chylothorax after pneumonectomy for malignancy may be explained by the injury during subcarinal or subaortic dissection of small lymphatics that drain the lung or the mediastinal lymph nodes directly into the thoracic duct (
Tension chylothorax occurred only after classic pneumonectomies (intrapleural extrapericardial), 7 right and 7 left (
After pneumonectomy, given an uneventful post-operative course, effusion in the post-pneumonectomy space usually accumulates
Tension hydrothorax after pneumonectomy is more frequent in patients who undergo peritoneal dialysis (
One case of tension pneumothorax after pneumonectomy for malignancy was reported, which was attributed by the authors to the chest wall damage after extrapleural pneumonectomy and a lower suction pressure of the chest drain was selected in order to avoid cardiac herniation (
One case of tension haemothorax was reported and the complication appeared almost 1 year after pneumonectomy, causing fatigue, dyspnoea, and oedema of the left arm; internal jugular, subclavian and axillary left veins presented thrombosis; the case was presented by our group in 2014(
Once the diagnosis is established, the treatment for the tensioned space is imperative, as this complication frequently poses a fatal risk. Normally, without a strong reason, thoracentesis and pleural puncturing are not the best solutions after pneumonectomy, since seeding the pleural cavity may lead to empyema. However, thoracentesis may be a lifesaving intervention in tension fluid-thorax; which was the most common initial approach in the literature: 9 thoracenteses, 2 for diagnostic and 7 for therapeutic purposes (
The final treatment was surgical in 12 cases, either by video-assisted thoracic surgery or open surgery: 10 thoracic duct ligations, 1 thoracoscopic exclusion of malignancy, and 1 evacuation of clots (
For tensioned chylothorax (14 cases), initial management was decompression in 10 cases, followed by either conservative or surgical management. In 4 cases of tensioned chylothorax, the initial management was surgical duct ligation. The general management of chylothorax is not the subject of this paper and will therefore not be further discussed, but the cause is the same: lymphatics interrupted during the mediastinal lymph node dissection.
For tension hydrothorax (3 cases), the initial management was evacuation thoracentesis, followed by exclusion of malignancy through cytology in one case, thoracoscopy and laparoscopy with pigtail catheter in another case and indwelling pleural catheter in the third case. No specific causes were observed.
In the case of tensioned pneumothorax, the adopted solution was the simplest and solved the problem: Increasing suction pressure and maintaining the drainage until the air leak disappeared.
In the case of tensioned haemothorax with recurrence, the evacuation of haemorrhagic fluid was performed thoracoscopically the first time and through thoracotomy the second time (fluid + clots). The cause was determined to be the anticoagulant therapy administered for venous thrombosis of the left internal jugular, subclavian and axillary veins.
Tensioned post-pneumonectomy space is a rare but potentially fatal complication. To date, a total of 19 cases of tensioned post-pneumonectomy space after pneumonectomy for cancer were published in the literature.
Tension chylothorax is the most frequent type (14 cases) and is most probably caused by mediastinal lymph node dissection (MLND); it is an assumed complication because MLND is mandatory for radical resection of lung cancer. It appeared after a maximum of 15 days post-pneumonectomy and it was solved similarly to any post-operative chylothorax.
Tension hydrothorax is the second-most frequent type (3 cases) and it appeared after complex pneumonectomies for mesothelioma and sarcoma.
Tension haemothorax and tension pneumothorax have one published case each, and each was caused by a particular condition of the case.
Shifted mediastinum with cardiac compression (leading to cardiac tamponade) causes haemodynamic instability and dyspnoea; in such cases, emergency thoracentesis may be required. After stabilization, a major surgical procedure may be necessary to definitively treat the cause of the tensioned post-pneumonectomy space.
The authors thank Professor Teodor Horvat (Clinic of Thoracic Surgery, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’ Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest) for mentorship.
Not applicable.
NM and VM contributed to the conception and design of the study, performed the literature review and wrote the manuscript. OR, MD, MCCI and OGT analyzed the data, integrated the medical information and prepared the figures. NM, VM, BS and MCC contributed to manuscript revision. All authors have read and approved the final manuscript. Data authentication is not applicable.
Not applicable.
Not applicable.
The authors declare that they have no competing interests.
Normal post-pneumonectomy aspect-CT scan at 2 months after left pneumonectomy for cancer using video-assisted thoracic surgery, for a central typical carcinoid with lung destruction after one year of evolution, in a 23-year-old female patient-section at the level of the great vessels (left) and at the level of the heart ventricles (right).
Incidence of complications reported for the 19 cases that matched the review criteria, stratified by time or occurrence after surgery.
CT scan presenting the tension haemothorax case (
Most common complications after pneumonectomy (
Type | Items |
---|---|
Acute complications | Early bronchopleural fistula |
Cardiac herniation | |
Haemorrhage | |
Early empyema | |
Chylothorax | |
Pulmonary edema | |
Pneumonia | |
Acute lung injury | |
Chronic complications | Tumor recurrence |
Late on-set empyema | |
Postpneumonectomy syndrome | |
Late bronchopleural fistula | |
Other common complications | Intrathoracic transdiaphragmatic |
herniation after extrapleural | |
pneumonectomy | |
Cardiovascular complications: | |
Arrythmias, myocardial infarction, acute heart failure | |
Pulmonary embolism | |
Vocal cord paralysis (permanent or transitory) | |
Cases screened in literature matching the review criteria, presented according to the type of tensioned fluid from the post-pneumonectomy space.
Nr. crt | Author (year) | Initial diagnosis | Right/ left lung | Type of surgery | Time between surgery and complication (number of post-operative time units) | Time of complication | Sex | Pleural fluid | First management | Analysis of pleural liquid | Definitive management | Known follow-up | (Refs.) |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Ammori (2006) | Lung squamous cell carcinoma T2N1M0) | Right | Intrapleural extrapericardial pneumonectomy | 14 days | Tension chylothorax | M | Chyle | Diagnosys thoracentesis | N/A | Surgery-mass ligation of the thoracic duct at the level of the diaphragm | No recurrence | ( |
2 | Coco (2020) | Adenocarcinoma | Left | Intrapleural extrapericardial pneumonectomy | 48 h | Tension chylothorax Tension | F | Chyle | Evacuatory thoracentesis | 1,922 leu/µl, trgly 825 mg/dl, chol 83 mg/dl | Chest drain | No recurrence | ( |
3 | Hemang (2014) | Lung squamous cell carcinoma (st.IIB T2N1M0) | Right | Intrapleural extrapericardial pneumonectomy | 9 days | chylothorax | F | Chyle | Chest drain | Milky white, trgly 1,729 mg/dl | First case without duct ligation: Pigtail catheter, daily instillation of antibiotic solution (gentamicin/ polymixin B) | Day 13 pigtail catheter removed | ( |
4 | Huwer (1991) | N/A | Left | Intrapleural extrapericardial pneumonectomy | Between the 5th and the 8th day | Tension chylothorax | N/A | Chyle | Chest drain | N/a | Surgery-ductal ligature | N/A | ( |
5 | Huwer (1991) | N/A | Left | Intrapleural extrapericardial pneumonectomy | Between the 5th and the 8th day | Tension chylothorax | N/A | Chyle | Surgery | N/a | Surgery-ductal ligature | N/A | ( |
6 | Van Mulders (1984) | Lung squamous cell carcinoma | Left | Intrapleural extrapericardial pneumonectomy | 4 days | Tension chylothorax | M | Chyle | Evacuatory thoracentesis | Trgly 387 mg/dl, LDH 176, chol 46 mg/100 ml | Surgery-ductal ligature | 3 days post- discharge from ICU | ( |
7 | Sarsam (1994) | Primary lung cancer | Left | Intrapleural extrapericardial pneumonectomy | Between the 5th and the 6th day | Tension chylothorax | N/A | Chyle | Chest drain | Chyle | Reinsertion of the chest drain. Surgery-direct suturing of the leak site | No recurrence | ( |
8 | Sarsam (1994) | Primary lung cancer | Left | Intrapleural intrapericardial pneumonectomy | Between the 5th and the 6th day | Tension chylothorax | N/A | Chyle | Surgery-ductal ligature-below the aortic arch, posterior to the bronchial suture line | Chyle | Surgery-ductal ligature-below the aortic arch, posterior to the bronchial suture line | No recurrence | ( |
9 | Sarsam (1994) | Primary lung cancer | Right | Intrapleural Extrapericardial pneumonectomy | Between the 5th and the 6th day | Tension chylothorax | N/A | Chyle | Surgery-ductal ligature-in the vicinity of the inferior pulmonary vein stump, medial to the esophagus | Chyle | Surgery-ductal ligature-in the vicinity of the inferior pulmonary vein stump, medial to the esophagus | No recurrence | ( |
10 | Sarsam (1994) | Primary lung cancer | Right | Intrapleural intrapericardial pneumonectomy | Between the 5th and the 6th day | Tension chylothorax | N/A | Chyle | Surgery-ductal ligature-in the vicinity of the Inferior pulmonary vein stump, medial to the esophagus | Chyle | Surgery-ductal ligature-in the vicinity of the inferior pulmonary vein stump, medial to the esophagus | No recurrence | ( |
11 | Karwande (1986) | Lung squamous cell carcinoma | Right | Intrapleural intrapericardial pneumonectomy | 5th day | Tension chylothorax | M | Chyle | Evacuatory thoracentesis | High trgly, low chol | Surgery-supra diaphragmatic ligation of the thoracic duct and mattressed suture of the leak at the hilum area | No recurrence | ( |
12 | Karwande (1986) | Hilar adenocarcinoma | Right | Intrapleural extrapericardial pneumonectomy | 15th day | Tension chylothorax | F | Chyle | Evacuatory thoracentesis | High trgly, low chol | Repeated evacuatory thoracentesis followed by 18 gauge chest drain | Patient deceased due to comorbidities (hemoragic duodenal ulcer). The high-output chylothorax persisted until her death | ( |
13 | Kanjanauthai (2009) | Primary lung cancer | Left | Intrapleural extrapericardial pneumonectomy | 14 days | Tension chylothorax | N/A | Chyle | Evacuatory thoracentesis | Chylothorax | Surgery-thoracic duct ligation | no recurrence | ( |
14 | Valliers (1993) | NSCLC adenocarcinoma | Right | Intrapleural extrapericardial pneumonectomy | 11 days | Tension chylothorax | F | Chyle | Diagnosis thoracentesis | High trgly, low chol | Chest drain with instillation of antibiotic solution | No recurrence. 96 h after the pleurostomy, the chest drain was removed | ( |
15 | Maguire (2013) | Mesothelioma | Left | Extrapleural pneumonectoy | 6 months | Tension hydrothorax | M | Exudative pleural effusion | Evacuatory thoracentesis | No malignant cells | (Cefazolin+ gentamicin) | N/A | ( |
16 | Sawar (2006) | Mesothelioma | Left | Extrapleural pneumonectoy | 9 months | Tension hydrothorax | M | Exudative pleural effusion | Evacuatory thoracentesis | No malignant cells | Thoracoscopy, laparoscopy- | N/A | ( |
17 | Vakil (2017) | Lung high grade spindle cell sarcoma | Left | Intapleural pneumonectomy with partial pericardiectomy | 17 months | Tension hydrothorax | F | Exudative pleural effusion | Evacuatory thoracentesis | Cytology negative for malignancy. Cultures negative for microorganisms | Malignancy excluded; pigtail | No recurrence | ( |
18 | Sakuraba (2018) | Thymoma st. IVb | Invasion of right lung hilum | Extrapleural pneumonectoy | 0 (zero) days | Tension pneumothorax | M | Air | Suction pressure increased from -5 to -15 cm H2O | N/A | Catheter | No recurrence | ( |
19 | Rus (2014) | Adenocarcinoma (T3N0M0) | Left | Intrapleural extrapericardial pneumonectomy | 15 months | Tension hemothorax | F | Hematic pleural liquid | Thoracoscopy | N/A | Evacuatory thoracentesis | No recurrence; alive and well in March 2022 | ( |
NSCLC, non-small cell lung cancer; M, male; F, female; N/A, not available; trgly, triglycerides; chol, cholesterol; LDH, lactate dehydrogenase; ICU, intensive care unit.