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Complications of thoracic operations

Thoracotomy

  • Thoracotomy allows access to the chest cavity
  • Position of incision depends on intended operation or procedure
  • Two different approaches exist
    • Lateral thoracotomy
    • Median sternotomy
  • Lateral thoracotomy can be carried out in three different positions
    • Posterolateral
    • Anterolateral
    • Lateral or axillary
  • Median sternotomy allows access to the anterior and superior mediastinum
  • Sternum is divided with oscillating or Gigli saw or Lebske knife
  • Ooze from the bone marrow may be stopped with bone wax
  • Sternum is usually closed with steel wire

Intrathoracic bleeding

  • Usually occurs from lung parenchyma or bronchial vessels
  • May present with clinical features of hypovolaemia
  • Usually detectable from mediastinal or pleural drains
  • Drains may however a block and haemothorax may be detected on chest x-ray
  • Can often be treated conservatively with transfusion
  • Re-operation required if:
    • Rapid blood loss via chest drain
    • Significant intrapleural collection on chest x-ray
    • Persistent hypovolaemia despite transfusion
    • Hypoxia due to compression of underlying lung

Sputum retention and atelectasis

  • Failure to clear bronchial secretions can result in:
    • Bronchial obstruction
    • Atelectasis
    • Lobar collapse
    • Secondary pulmonary infection
  • Presents as tachypnoea and hypoxia
  • Examination usually shows reduced bilateral basal air entry
  • Prevention is preferred to treatment
  • Risk of sputum retention can be reduced by:
    • Preoperative cessation of smoking
    • Adequate postoperative pain relief
    • Chest physiotherapy
    • Humidification of inspired oxygen
    • Bronchodilator therapy
    • Early mobilisation after surgery
  • Treatment required formal chest physiotherapy
  • Mini-tracheostomy and suction may be required
  • Antibiotics should be reserved for those with proven pneumonia

Air leak

  • Following lung resection residual lung tissue expands to fill pleural cavity
  • Raw area can result in an air leak into the pleural cavity
  • Presents as persist air leak or bubbling of chest drain
  • Usually settles spontaneously over 2-3 days
  • May require suction on pleural drains
  • Apposition of lung to parietal pleura encourages efficient healing

Bronchopleural fistula

  • Results from major air leak from pneumonectomy bronchial stump
  • Seen in 2% of patients undergoing pneumonectomy
  • Airway thus directly communicates with pleural space
  • Usually occurs as a result form a leak from a suture line
  • Occurs particularly in those with factors impairing wound healing
  • Most commonly occurs 7-10 days after surgery
  • Presents with sudden breathlessness and expectoration of bloodstained fluid
  • Fluid is that which normally fills the postpneumonectomy space
  • Emergency treatment consists of lying patient with operated side downwards
  • Providing oxygen and draining the pleural space
  • Thoracotomy and repair of fistula may be required
  • Repair may be reinforced with omental or intercostals muscle patch
  • Thoracoplasty may be required to obliterate the postpneumonectomy space

Bibliography

Deschamps C, Pairolero P C, Allen M S, Trasteck V F. Management of postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin N Am 1996; 6: 519-527.

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