Postoperative Complications

POSTPNEUMONECTOMY
-PULMONARY EDEMA OCCURS IN 1 TO 5% OF PATIENTS UNDERGOING PNEUMONECTOMY, WITH A HIGHER INCIDENCE AFTER RIGHT PNEUMONECTOMY. -CLINICALLY, SYMPTOMS OF RESPIRATORY DISTRESS MANIFEST HOURS TO DAYS AFTER SURGERY. -RADIOGRAPHICALLY, DIFFUSE INTERSTITIAL INFILTRATION OR FRANK ALVEOLAR EDEMA IS SEEN. -THE PATHOPHYSIOLOGIC CAUSES REMAIN POORLY UNDERSTOOD BUT ARE RELATED TO FACTORS THAT INCREASE PERMEABILITY AND FILTRATION PRESSURE AND DECREASE LYMPHATIC DRAINAGE FROM THE AFFECTED LUNG. THE SYNDROME REPORTEDLY IS ASSOCIATED WITH A NEARLY 100% MORTALITY RATE EVEN WITH AGGRESSIVE THERAPY. -TREATMENT CONSISTS OF 1.VENTILATORY SUPPORT 2.FLUID RESTRICTION 3.DIURETICS.

Other postoperative complications

1.AIR LEAK 2.BRONCHOPLEURAL FISTULA

1.-POSTOPERATIVE AIR LEAKS ARE COMMON AFTER PULMONARY RESECTION, PARTICULARLY IN PATIENTS WITH EMPHYSEMATOUS CHANGES, BECAUSE THE FIBROTIC CHANGES AND DESTROYED BLOOD SUPPLY IMPAIR HEALING OF SURFACE INJURIES. -PROLONGED AIR LEAKSTHAT IS, THOSE LASTING OVER 5 DAYSMAY BE TREATED BY DIMINISHING OR DISCONTINUING SUCTION (IF USED), BY CONTINUING CHEST DRAINAGE, OR BY INSTILLING A PLEURODESIC AGENT, USUALLY TALCUM POWDER. -IF THE LEAK IS MODERATE TO LARGE, A HIGH INDEX OF SUSPICION SHOULD BE MAINTAINED FOR BRONCHOPLEURAL FISTULA FROM THE RESECTED BRONCHIAL STUMP, PARTICULARLY IF THE PATIENT IS IMMUNOCOMPROMISED OR RECEIVED INDUCTION CHEMOTHERAPY AND/OR RADIATION THERAPY.

Other postoperative complications

2.-IF A BRONCHOPLEURAL FISTULA IS SUSPECTED, FLEXIBLE BRONCHOSCOPY IS PERFORMED.

MANAGEMENT OPTIONS INCLUDE

*CONTINUED PROLONGED CHEST TUBE DRAINAGE, *REOPERATION AND RECLOSURE (WITH STUMP REINFORCEMENT WITH INTERCOSTALS OR A SERRATUS MUSCLE PEDICLE FLAP), OR, FOR FISTULAS <4 MM *BRONCHOSCOPIC FIBRIN GLUE APPLICATION. *PATIENTS OFTEN HAVE CONCOMITANT EMPYEMAS, AND OPEN DRAINAGE MAY BE NECESSARY.

Solitary Pulmonary Nodule

-SOLITARY PULMONARY NODULE IS TYPICALLY DESCRIBED AS A SINGLE, WELL-CIRCUMSCRIBED, SPHERICAL LESION. -IT IS 3 CM IN DIAMETER AND IS COMPLETELY SURROUNDED BY NORMAL AERATED LUNG PARENCHYMA. -THE AMERICAN COLLEGE OF CHEST PHYSICIANS DISCOURAGES USE OF THE TERM COIN LESION BECAUSE THESE LESIONS ARE SPHERICAL.

-THE MAJORITY ARE DETECTED INCIDENTALLY ON CHEST RADIOGRAPHS OR CT SCANS OBTAINED FOR SOME OTHER PURPOSE.
-ORIGINALLY DEFINED BY FINDINGS ON CHEST RADIOGRAPHS, SOLITARY PULMONARY NODULES WERE IDENTIFIED ON 0.09 TO 0.2% OF ALL CHEST RADIOGRAPHS IN LARGE SCREENING STUDIES AS EARLY AS 1950. -APPROXIMATELY 150,000 SOLITARY NODULES ARE FOUND INCIDENTALLY EACH YEAR. THE CLINICAL SIGNIFICANCE OF SUCH A LESION DEPENDS ON WHETHER OR NOT IT REPRESENTS A MALIGNANCY

Differential Diagnosis
-THE DIFFERENTIAL DIAGNOSIS OF A SOLITARY PULMONARY NODULE CAN BE DISTILLED DOWN TO A DIFFERENTIATION BETWEEN MALIGNANCY AND OTHER NUMEROUS BENIGN CONDITIONS. -IDEALLY, DIAGNOSTIC APPROACHES WOULD PROVIDE A CLEAR DISTINCTION BETWEEN THE TWO, SO THAT DEFINITIVE SURGICAL RESECTION COULD BE RESERVED FOR THE MALIGNANT NODULE AND RESECTION AVOIDED WHEN THE NODULE IS BENIGN.

-IN UNSELECTED PATIENT POPULATIONS, A NEW SOLITARY PULMONARY NODULE OBSERVED ON A CHEST RADIOGRAPH HAS A 20 TO 40% LIKELIHOOD OF BEING MALIGNANT, WITH THE RISK APPROXIMATELY 50% OR HIGHER IN SMOKERS.

Differential Diagnosis
-FACTORS INFLUENCING THE PROBABILITY OF CANCER IN A SOLITARY PULMONARY NODULE INCLUDE *EVIDENCE FOR GROWTH OVER TIME *DENSITY OF THE LESION ON CT SCAN - 40 TO 50% OF PARTIAL SOLID NODULES CANCEROUS COMPARED WITH ONLY 15% OF SOLID NODULES <1 CM AND NONSOLID NODULES *PATIENT AGE, SEX, CIGARETTE SMOKING HISTORY, OCCUPATIONAL HISTORY, AND THE PREVALENCE OF ENDEMIC GRANULOMATOUS DISEASE.

Differential Diagnosis
-INFECTIOUS GRANULOMAS ARISING IN RESPONSE TO A VARIETY OF ORGANISMS COMPRISE 70 TO 80% OF THIS TYPE OF BENIGN SOLITARY NODULE -HAMARTOMAS ARE THE NEXT MOST COMMON SINGLE CAUSE, ACCOUNTING FOR APPROXIMATELY 10%. THE DIFFERENTIAL DIAGNOSIS OF A SOLITARY PULMONARY NODULE SHOULD INCLUDE A BROAD VARIETY OF CONGENITAL, NEOPLASTIC, INFLAMMATORY, VASCULAR, AND TRAUMATIC DISORDERS.

IMAGING -CHEST THIN SECTION CT SCANNING IS CRITICAL IN

CHARACTERIZING NODULE LOCATION, SIZE, MARGIN MORPHOLOGY, CALCIFICATION PATTERN, AND GROWTH RATE. -CT OFTEN REVEALS MORE THAN A SINGLE PULMONARY NODULE; UP TO 50% OF PATIENTS THOUGHT TO HAVE A SINGLE LESION BASED ON CHEST RADIOGRAPH ARE PROVEN TO HARBOR MULTIPLE NODULES WHEN EXAMINED BY CT. -LESIONS >3 CM ARE REGARDED AS MASSES AND ARE MORE LIKELY MALIGNANT. -IRREGULAR, LOBULATED, OR SPICULATED EDGES STRONGLY SUGGEST MALIGNANCY.

-CALCIFICATION WITHIN A NODULE SUGGESTS A BENIGN LESION. FOUR PATTERNS OF BENIGN CALCIFICATION ARE COMMON: DIFFUSE, SOLID, CENTRAL, AND LAMINATED OR "POPCORN." GRANULOMATOUS INFECTIONS SUCH AS TUBERCULOSIS CAN DEMONSTRATE THE FIRST THREE PATTERNS, WHEREAS THE POPCORN PATTERN IS MOST COMMON IN HAMARTOMAS. -PET SCANNING TAKES ADVANTAGE OF ANOTHER BIOLOGIC PROPERTY OF NEOPLASMS: INCREASED GLUCOSE UPTAKE COMMENSURATE WITH INCREASED METABOLIC ACTIVITY.

-F-FLUORODEOXYGLUCOSE (FDG) - IS USED TO MEASURE GLUCOSE METABOLISM IN CELLS IMAGED BY PET. MOST LUNG TUMORS HAVE INCREASED SIGNATURES OF GLUCOSE UPTAKE, COMPARED WITH HEALTHY TISSUES. PET IS BECOMING WIDELY USED TO HELP DIFFERENTIATE BENIGN FROM MALIGNANT NODULES.

BIOPSY VS. RESECTION

-ONLY THROUGH BIOPSY CAN A PULMONARY NODULE BE
DEFINITIVELY DIAGNOSED.

-BRONCHOSCOPY HAS A 20 TO 80% SENSITIVITY FOR DETECTING A NEOPLASTIC PROCESS WITHIN A SOLITARY PULMONARY NODULE, DEPENDING ON THE NODULE SIZE, ITS PROXIMITY TO THE BRONCHIAL TREE, AND THE PREVALENCE OF CANCER IN THE POPULATION BEING SAMPLED.
TRANSTHORACIC FINE-NEEDLE ASPIRATION (FNA) BIOPSY CAN ACCURATELY IDENTIFY THE STATUS OF PERIPHERAL PULMONARY LESIONS IN UP TO 95% OF PATIENTS; THE FALSE-NEGATIVE RATE RANGES FROM 3 TO 29%.

BIOPSY VS. RESECTION

VATS OFTEN IS USED FOR EXCISING AND DIAGNOSING INDETERMINATE PULMONARY NODULES.

-LESIONS MOST SUITABLE FOR VATS ARE THOSE THAT ARE LOCATED IN THE OUTER ONE THIRD OF THE LUNG AND THOSE THAT ARE <3 CM IN DIAMETER.
-THE NODULE MUST NOT BE DIRECTLY MANIPULATED WITH INSTRUMENTS, THE VISCERAL PLEURA OVERLYING THE NODULE MUST NOT BE VIOLATED, AND THE EXCISED NODULE MUST BE EXTRACTED FROM THE CHEST WITHIN A BAG TO PREVENT SEEDING OF THE CHEST WALL.

BIOPSY VS. RESECTION

-SOME GROUPS ADVOCATE PROCEEDING DIRECTLY TO VATS IN THE WORK-UP OF A SOLITARY PULMONARY NODULE IN APPROPRIATE CLINICAL CIRCUMSTANCES, CITING SUPERIOR DIAGNOSTIC ACCURACY AND LOW SURGICAL RISKS.