The postoperative care of any patient who undergoes pulmonary resection starts long before the incision is made and comprises three main areas. The first is patient selection, the second is the actual operation itself, and the third is postoperative care. This chapter briefly reviews some of the specifics that go into these three areas. In addition, it discusses the incidence, prevention, and treatment of some of the most common postoperative problems that continue to vex thoracic surgeons around the world.
Perhaps the best way to minimize postoperative complications is to operate only on young healthy patients. Unfortunately, thoracic surgeons, like most other surgeons, are now presented with older and sicker patients with increasing comorbidities. The median age of our society has increased and so has obesity and patients with chronic pain syndromes. We are increasingly challenged with larger tumors in older patients with smaller pulmonary reserve. As the bar for the upper age limit has been raised, the threshold for the acceptable FEV1% and DlCO % has fallen. Currently there are few, if any, absolute contraindications to pulmonary resection based on chronological age or pulmonary function.
During the perioperative period, many factors contribute to pulmonary compromise. Estimates of the overall surgical mortality for pulmonary resection range in large series from 2% to 4%. The estimated mortality increases with the size of the resection—from less than 1% for a wedge resection of the lung, to 2% to 3% for a lobectomy, and 6% to 8% for a pneumonectomy.
The morbidity associated with elective pulmonary resection is also high. Complications have been reported to occur in 36% to 75% of patients undergoing pneumonectomy and 41% to 50% of patients after lobectomy. Most complications are minor and include air leak, atrial fibrillation, and atelectasis. However, a significant number are major; these most commonly include pneumonia, aspiration, respiratory failure, myocardial infarction, bronchopleural fistula (BPF), and pulmonary embolus.
Preoperative Assessment and Optimization
Preoperative evaluation focuses on assessment of pulmonary function and its optimization, evaluation of cardiac status, and careful consideration of issues related to quality of life.
Assessment of the patient's risk for pulmonary resection starts preoperatively in the clinic. One important but difficult factor to quantify is the patient's desire to undergo the work required to recuperate from a thoracic surgical procedure. The importance of walking and deep breathing after lung resection cannot be overstated. A study performed by the Lung Cancer Study Group suggested that the patient's attitude toward his or her malignancy was the best indicator of long-term survival.1 A patient who appears to be unwilling to participate in his recovery should be allowed ample opportunity to explore reasonable alternative therapies, such as radiation. Moreover, if ...