Perioperative management - Uniportal VATS pneumonectomy right

In general, the indications for a pneumonectomy have become significantly rarer with the improvement of surgical techniques and good results of bronchial anastomosis in sleeve resection.

Oncological

• For centrally located bronchial carcinomas in an operable stage
• In very rare exceptional cases for pleural mesothelioma or bronchial carcinoma with unilateral lung metastasis
• Palliative resection, for example, in obstruction of the main bronchus with recurrent pneumonias and lung abscesses or recurrent bleeding.

Non-Oncological

• Destroyed lung lobe after infectious disease (e.g., tuberculosis)
• Severe bronchiectasis
• Stenosis of the main bronchus
• Iatrogenic injury to the pulmonary artery, for example, during a lobectomy

Pneumonectomy carries a variety of postoperative consequences with particularly significant cardiopulmonary risks and usually a lifelong reduction in quality of life. The 30-day mortality rate remains high at 5% to 12%, making thorough patient selection and strict indication setting important.

• Lack of cardiopulmonary reserve for a lung resection procedure
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapy concept regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

• Oncological Diagnostics

In case of suspected bronchial carcinoma, the staging examinations outlined in the guidelines should be conducted before any surgery.

• Computed tomography of the thorax with upper abdomen, contrast-enhanced
• PET-CT
• MR of the skull
• Bronchoscopy
  • Note: Preoperative bronchoscopy by the surgeon is recommended, especially to recognize anatomical norm variants of the bronchial system.
• Cardiopulmonary endurance

The assessment of cardiopulmonary endurance and estimation of postoperative outcomes is a very important and sometimes challenging aspect of thoracic surgery. Based on the algorithms of the ERS (= European Respiratory Society) and ESTS (= European Society of Thoracic Surgeons), the following procedure has proven effective:

• Basic diagnostics: Medical history, ECG
  • If there is an indication of increased perioperative cardiac risk ('Revised-Cardiac-Risk-Index"), further cardiological evaluation is necessary.
  • If there is a discrepancy between the anamnesis-based resilience (climbing stairs, gardening, walking) and the parameters of lung function tests, the results should be critically questioned and the examinations repeated if necessary.
• Lung function: Diffusion capacity (DLCO), Body plethysmography (FEV1)
  • FEV1 and DLCO >80% of the predicted value allow for surgery up to pneumonectomy from a lung function perspective.
  • FEV1 and DLCO <80% require further diagnostics using spiroergometry and determination of maximum oxygen uptake (VO2max)
    • With VO2max > 20ml/kg/BW (>75%), surgery up to pneumonectomy is possible from a lung function perspective.
    • With VO2max < 10ml/kg/BW (< 35%), surgery is contraindicated.

Especially in cases of VO2max 10-20ml/kg/BW or restrictive cardiac preconditions, in addition to further diagnostics (e.g., perfusion scintigraphy, "lung segment counting"), an interdisciplinary individual case decision with experienced colleagues is essential.

• Shaving of the right thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Bronchial stump insufficiency, bronchial fistula requiring intervention, possibly also re-operation
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with possibly necessary re-operation
• Conversion to thoracotomy and possibly extension of the resection, approach depending on intraoperative findings
• Injury to adjacent structures, especially the trachea and main bronchi, large vessels, and the esophagus, requiring corresponding extension of the procedure
• Damage to the phrenic nerve with elevation of the diaphragm on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paresis on the affected side
• Positioning injuries
• Cardiac arrhythmias

Alternative treatment: Depending on the disease, in the case of an oncological diagnosis, definitive radiochemotherapy.