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Eur J Cardiothorac Surg 2004;26:189-196
© 2004 Elsevier Science NL

Indications and results of completion pneumonectomy

^a Department of Thoracic Surgery, University Hospital of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
^b Department of Medical Biometry and Statistics, University Hospital of Freiburg, Freiburg, Germany

Received 11 December 2003; received in revised form 1 March 2004; accepted 19 March 2004.

^* Corresponding author. Tel.: +49-761-270-2457; fax: +49-761-270-2499
e-mail: jungrait{at}chir.ukl.uni-freiburg.de

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
Objectives: Completion pneumonectomy (CP) is widely known to be associated with a high morbidity and mortality. However, in certain instances, CP offers the only chance for a cure. The results of the following three groups were investigated: progressive or recurrent benign disease, recurrence of a malignant tumour and complication after lung resection. Methods: Between January 1986 and April 2003, 525 patients underwent pneumonectomy, 86 of these being completion pneumonectomies (16.4%). Six patients suffered from a progression or recurrence of a benign disease, 41 patients had a recurrence of a malignant tumour (local recurrence, secondary carcinoma and recurrent metastases) and 39 patients had a complication after lung resection. Among patients with a complication, the indication for CP was either an emergency or urgent condition. Right CP was carried out in 48 cases and left CP in 38. Results: The overall 30-day mortality was 20.2, 0% in the group with benign disease, 10% in the group with a recurrent malignant tumour and 33.3% in the group with a complication after lung resection. The 30-day mortality of CP was significantly higher (P=0.014) on the right side (29.8%) than on the left side (7.7%). Differentiation between emergency and urgent indications resulted in 30-day mortalities as follows: 54 and 23%, respectively. This difference is significant (P=0.002). The 30-day mortality for patients with anastomotic or stump insufficiency was 41% (P=0.002). Five-year survival of all patients was 28% and in the group of patients with a complication after lung resection 32%. Conclusions: Lethality of CP remains high, especially after CP for a complication performed in an emergency condition. Possible risk factors are right side of operation, CP performed in an emergency condition and CP for anastomotic or stump insufficiency, either or not involving sepsis. However, considering the long-term survival, CP is certainly justified.

Key Words: Completion pneumonectomy • Lung carcinoma • Complication • Risk factors

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
Completion pneumonectomy (CP) is the removal of the lung or what is left of it from a previous ipsilateral lung resection. It is widely known that this procedure is associated with a considerably greater mortality (12%) [2,4,8,11] compared to standard pneumonectomy, where mortality rates are 6.2% [15]. On the other hand, for a majority of patients suffering a recurrent or complicated disease of the rest of the lung, CP offers the only chance for a cure. Accordingly, the indication for CP is rare, only 10% of all pneumonectomies are CPs.

The following groups are indications for CP: patients with a benign disease with progression, although Gregoire [8] pointed out a higher rate of morbidity (41%) after CP in this group. A second group of patients are those with a carcinoma, including a secondary carcinoma and recurrent metastases. In this group, Al-Kattan describes survival rates similar to survival rates following standard pneumonectomy [7]; however, follow-up was performed only for malignancies and benign diseases but not for complications.

The third major group comprises patients with a complication after previous lung resection, the indication being either emergency or urgent therapy. CPs that have to be performed due to a complication are broncho-pleural fistulas (BPFs) [3], bronchial stenoses or anastomotic insufficiency after sleeve resection [5]. Especially the latter group bears a higher risk of morbidity and mortality. To our knowledge, there are still no publications on this indication.

In this single-centre study, the intention was to analyse our patients regarding indications, risks and short- and long-term follow-up of CP.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
Between January 1986 and April 2003, 86 patients underwent CP in the Department of Thoracic Surgery, University of Freiburg. This represented 16.4% of the 525 pneumonectomies performed during the same period. There were 19 female and 67 male patients with an average age of 58 years (range 26–79 years). Right CP was carried out in 48 cases and left CP in 38.

The indications for CP were divided into three groups (Table 1) .

2.1. Benign diseases
Surgery was performed on 1 male and 5 female patients with an average age of 44.3 years (26–68). The time between the first operation and CP was 2887 days (131–100,80), or 8 years.

There were 3 lobectomies, 1 upper bilobectomy and 2 segmental resections. The first operation and indications are shown in Table 2 .

CP was performed in 26 cases for recurrent malignant disease, in 9 cases for metastases and in 6 cases for a secondary tumour of the lung (Table 3) .

Twelve of the CPs were performed on the right side, 14 of the CPs were performed on the left side.

The status according to UICC at the time of the first operation was I in 10 cases, II in 4 cases, III in 6 cases and was missing in 6 cases.

CP was carried out after an average of 1275 days (28–6940), or 3.5 years. Fifteen of the recurrent carcinomas were classified 5 of the patients were stage I, 10 of the patients were stage III, according to UICC. Two patients had postoperative chemotherapy, 1 patient had combined radio-chemotherapy preoperatively.

2.2.2. Secondary carcinomas
A secondary carcinoma was defined as a malignant tumour occurring 2 years after the first operation at a different site without having another carcinoma at the time of the first operation. This group consisted of 6 CPs, 5 on the right side after 2 lower lobectomies, 1 upper bilobectomy, 1 resection of the lower lobe and 1 resection of the upper lobe and 1 CP on the left side after an unclassified lung resection. The average time between the first operation and CP was 2151 days (510–4680), or 5.9 years. In 2 cases, the histology changed from a squamous cell carcinoma to a large-cell carcinoma, in 1 case from an adenocarcinoma to a large-cell carcinoma, in another case from a broncho-alveolar carcinoma to an adenocarcinoma, in 1 case from a malignant histiocytoma to a malignant schwannoma and in 1 case a squamous cell carcinoma reoccurred.

2.2.3. Metastases
Nine patients underwent CP for recurrent metastases. Five of them were female, 4 were male with an average age of 63 years (55–74). CP was performed on the left side in 5 patients after 1 resection of the upper lobe, 1 resection of the lingula, 1 segmental resection and 1 wedge resection and on the right side in 4 patients after 1 resection of the upper lobe, 1 resection of the lower lobe, 1 segmental resection and 1 wedge resection. The time between the first operation and CP was 724 days on an average (145–1800), or 2 years. The type of primary malignancy was adenocarcinoma of the colon in 4 cases, malignant histiocytoma in 1 case, leiomyosarcoma of the uterus in 1 case, squamous cell carcinoma of the cervix, malignant melanoma in 1 case and broncho-alveolar carcinoma of the lung in 1 case.

2.3. CP for complications
CP was performed on 39 patients because of complications, 36 of them were male and 3 of them were female. The average age was 60.2 years (44–80). The indication for CP was either an emergency (13) or urgent (26) condition (Table 4) . The emergency operation refers to the prompt reoperation in patients who had an unstable respiratory or circulatory status, sometimes even in a patient who had to be reanimated. In contrast, the indication of urgency allows careful preparation and amelioration of the general condition prior to SP, thereby keeping perioperative morbidity and mortality as low as possible. The indication for an emergency operation was bronchus stump insufficiency in 8 cases, for infarction of the lung in 3 cases, empyema in 1 case and haematothorax in another case. The median time between the first operation and CP was 17 days (1–5040). Patients in an emergency condition were operated on after a median of 14 days (1–2160) and patients in an urgent condition were operated on after a median of 21 days (7–5040).

Twenty-five CPs were carried out on the right side after 7 resections of the lower lobe, 6 resections of the upper lobe, 4 sleeve resections of an upper lobe, 1 resection of the middle lobe, 3 lower bilobectomies, 3 upper bilobectomies and 1 decortication.

Fourteen CPs were performed on the left side after 2 resections of the lower lobe, 7 resections of the upper lobe, 2 sleeve resections of the upper lobe, 2 decortications and 1 unclassified resection.

The aetiology of the original disease in patients with 30-day mortality was malignant. These patients mainly underwent CP for BPF (Table 7) .

Muscle-sparing posterolateral thoracotomy, using the previous incision, was carried out. The length of the bronchial stump was less than 0.5 cm. The bronchial stump was closed with two suture lines, coverage of the stump was carried out with a pericardial, azygous, thymus, or pleural flap. A 24-Silicon drain was inserted into the thoracic cavity before closure of the thorax.

2.5. Statistical methods
Baseline patient data are presented as a means with standard deviations (SD) for quantitative variables and as absolute and relative frequencies for qualitative variables. Prognostic relevance of different patient characteristics on 30-day mortality was assessed by Fisher's exact test. Survival probabilities were estimated by the Kaplan–Meier method. All significance tests were two-sided and P<0.05 was considered statistically significant. Data processing and analysis were performed using SPSS (version 11.0 for Windows).

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
3.1. Morbidity
The overall morbidity after CP was 37.2%. Intra-operative morbidity was 3.5%, postoperative 30-day morbidity was 34.9%, and late morbidity (>30 days) was 2.3%.

Nine patients had a BPF, 11 patients had pneumonia or empyema (n=6 ipsilaterally), 2 patients had an ARDS, 3 patients had multi-organ failure, 2 patients had a haematothorax, 4 patients had a circulatory failure and 1 patient had a paresis of the recurrent laryngeal nerve.

The morbidity in the group with a benign disease had an overall morbidity of 33.3%, in the group with recurrent malignant tumours overall morbidity was 29.3%, and in the group with complications after first operation, overall morbidity was 49%. Fifty-one percent (20/39) of the complications were in a septic condition. A septic condition was defined as the presence of fever in combination with inflammation of the lung parenchyma or thorax. 16.3% of all patients had a septic disease (14/86). Sixty percent (12/20) continued in a septic state after CP.

3.2. Mortality
Follow-up was conducted until patients died or until the day of evaluation (April 15th, 2003).

Overall, intra-operative mortality was 0% and the 30-day mortality was 20.2% (17/84). The 30-day mortality of CP was 29.8% on the right side and 7.7% on the left side.

The 30-day mortality was 0% (0/6) in the group with a benign disease, 10% (4/41) in the group with a recurrent tumour and 33.3% (13/39) in the group with complications after the first operation. In the latter group, CP was performed on the right side in 25 cases and on the left side in 14 cases. The 30-day mortality was 43.5% on the right side and 30% on the left side. Differentiation between emergency and urgent indications resulted in 30-day mortality as follows: 54 and 23%, respectively. This difference is significant (P=0.002, Fisher's exact test). The 30-day mortality for patients with anastomosis or stump insufficiency was 41%. For septic complications, the 30-day mortality was 36% for all patients, 31% on the right side, 14% on the left side.

3.3. Long-term survival
Sixty-two patients were followed up for a mean period of 34 months (2–129). The overall actuarial 3- and 5-year survival (Kaplan–Meier) after CP were 31 and 28%, respectively (see Fig. 1) .

View larger version (11K): [in this window] [in a new window]   Fig. 1. Actuarial 5-year survival curve after SP for all patients and for complication after lung resection (dotted line).

3.4. Prevalence of risk factors
Possible risk factors influencing 30-day mortality were site of surgery, indication for emergency, urgent or elective CP, presence of anastomosis or stump insufficiency and a septic condition of the patient (Table 5) .

CP was performed after radio- and chemotherapy in 13 patients (15.1%), 30-day mortality being 23% and 30-day morbidity 46.2%. 33.3% of the patients with a recurrent carcinoma were classified according to UICC as stage I, 66.6% as stage III.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
CP or residual pneumonectomy becomes necessary in order to provide the chance of healing otherwise life-threatened patients. The indications are the benign underlying disease, recurrent carcinoma as well as complications arising after primary surgery.

Whereas the number of patients subjected to CP due to a benign disease are usually rather low, patients with a recurrent carcinoma generally represent the major proportion of patients indicated for CP. The group requiring CP following a complication at our department was almost as large as the group following a recurrent carcinoma. As far as we are aware, up until now this subgroup of 39 patients has only been described to a limited extent. These patients are thus given especial consideration in our study.

4.1. Morbidity
In our patient groups, early and late morbidity was 37.2%. In the literature, this varies between 18 [7] and 55% [11].

Many authors very much lament the morbidity, especially in benign disease, as inflammatory adhesions and the progressively destructive disease can lead to technical difficulties and hence an increasing number of complications. In this group, our 30-day morbidity was 33.3%, in McGovern's case it was as much as 55.2% [11]. In part, this could be related to our small number of patients operated on for benign disease, but overall CP for this indication seems justified.

The BPF, empyema and haematothorax can be named as being the common complications of CP in benign diseases [6]. These complications occurred in the group of our patients who had been subjected to CP due to a complication following lung resection; namely, in 49% (19/39). Especially in those cases where the reason for CP was empyema or a BPF (51%), i.e. the presence of a preoperative infection, a renewed infection situation occurred as a complication following CP (60%). Of these patients, a majority had an existing concomitant disease or a risk factor such as pAVK, C2 abuse, COPD, diabetes mellitus or a fundamental underlying disease such as a secondary carcinoma (79%). It is possible that these conditions have an important influence on the occurrence of postoperative complications.

In the group of patients subjected to CP because of a recurring carcinoma, complications occurred in less than half of the cases (29.3%). This number is comparable to those reported by other authors, even though our absolute numbers are higher [3,11].

4.2. Mortality
Within the benign group (n=6), the hospital mortality was 0%. The complete absence of postoperative complications in this group could—although admittedly in a small number of patients—explain the lack of mortality; Terzi et al. describe a significantly higher operative mortality rate of 35% [9].

The largest group in our patients leading to CP was the recurring carcinoma following surgery for a malignant lung tumour (n=41). With an incidence of recurrent carcinomas remaining almost stable, this condition represents the main domain of indication for CP following prior lung surgery. We treated 26 patients with recurrence of a primary bronchial carcinoma, 6 patients for a secondary carcinoma and 9 patients for metastases.

Al-Kattan reported a 30-day mortality of 0% [7], Massard 10.8% [12], Verhagen 15.3% [16] and Miller as high as 21% [1]. Our 30-day mortality as a result of a recurrent malignancy was 10%. Considering the operative mortality of standard pneumonectomy, which is about 6.2% [15], CP appears justified in this group.

One group representing an exception, as is reported by other authors, is the group of patients with metastases. The average age here was 60 years (55–67) and thus even lay above the average age of all the patients. The operative mortality as well as morbidity was 0%. Reasons for this good result could be that the general condition of the patients at the time of surgery was good, the primary tumour condition was generally well under control and the resection volume small. CP for metastases is, as it always has been, debatable; the available data tend to speak in favour of exercising reserve and careful patient selection [10]. A promising alternative therapeutic measure avoiding CP is metastasectomy with the Nd:YAG laser, which is able to reduce tissue loss, postoperative air leakage and duration of hospital stay. However, influence of long-term survival is not proven [17,18].

The second largest group comprised the patients with a complication following primary surgery (n=39); a large number, that is not to be found in the literature to date. Terzi et al. [9] report on a 30-day mortality of 57% in the group of patients with early complications, Al Kattan [7] states a 30-day mortality rate of only 2.6%. The lethality in our study was 33.3%, thus being considerably higher than in the group with a benign and malignant disease. In the majority of the cases, this involved anastomotic and stump insufficiency (BPF) with a septic condition, as well as empyemas and gangrene of the lung. An absolute indication for surgery existed in these cases. Accordingly, a much higher mortality is to be expected.

4.3. Long-term survival
The value of CP must also be considered with respect to the long-term survival, which, being 28% in our patients, lies only moderately below that for standard pneumonectomy. Exceptions, as already mentioned above, are the CPs carried out as an emergency measure within the group with complications in which there remained no scope for an either/or decision. Considering the complication rate and the long-term survival of patients who required secondary surgery because of urgent or elective indications, CP appears to be justified. Of all the patients who were still living at the time of evaluation (n=15) only 3 patients were from the group who had undergone complication surgery, yet 12 patients from the group with a carcinoma, so that the diagnosis in cases of a recurrent carcinoma also appears to be correct.

In our opinion, with a 5-year survival rate of 50% in patients with benign disease, the absence of postoperative mortality and a low hospital morbidity rate—insofar as it is possible to conclude from this small number of patients—CP also appears to be justified.

The 5-year survival rate for patients with a recurrent carcinoma was 23%, although 66.6% had a tumour stage III. At the time of evaluation 33.3% were still alive with a mean survival time of 30.5 months, so that these patients in the advanced tumour stage III also profited from CP [3]. Based on our data, CP for metastases must undisputedly be advocated for. The numbers are small, however.

Moreover, we saw a difference between the survival time of the patients with a secondary carcinoma compared to the patients with a recurrent carcinoma. On average, 60% of the patients with a secondary carcinoma survived for 29 months and only 10% of the patients with a recurrent carcinoma lived for an average of 21 months. This advantage regarding survival could also be confirmed by Gregoire [8].

4.4. Risk factors for mortality following CP
The careful preparation and selection of the patients indubitably plays an important role with respect to diagnosis. In a uni- and multivariate analysis, Miller et al. pointed out factors that influence the morbidity and mortality of CP [1], it being possible to apply selection criteria. However, the following patient groups do not permit this approach: 39 patients (45.3%) in our collective were subjected to CP due to a complication, so that prognostic factors, which contribute to the decision of whether CP is indicated, could not given any consideration. On the other hand, the potentially life-saving CP stands as an alternative to the quite definitely lethal, acute disease. This applies especially in the patients who, within this group, had to undergo emergency CP. Whereas the mortality here was 54%, in the recurrent carcinoma group it was merely 10%. The patient in this situation was wheeled into the operating theatre under reanimation conditions or at least having an unstable respiratory or circulatory status. It seems notable that all these patients had a malignant underlying disease. The question arises as to whether or not to operate on these patients since they carry an even higher risk of not surviving. Nevertheless, in view of the 100% lethal outcome of the further progression of the disease without surgical intervention, CP would seem justified.

It is well known that right CPs have an increased morbidity and mortality rate [1,13,14]. With a 30-day mortality of 29.8% compared to the left side of 7.7%, mortality of right CP in our patients was also significantly greater. Although Miller did not report an increased mortality following right side CP, all seven BPFs occurred on the right side [1].

In 31% of the cases, the reason for the 30-day mortality on the right side was a septic course of the disease, starting out from pneumonia, empyema or a broncho-pulmonary fistula. In these cases, the septic course of the disease occurred twice as often, anastomotic and stump insufficiency even more than twice as often on the right than on the left side, although, as a standard procedure, we covered each bronchial stump on both sides with one of the above-mentioned flaps.

The reason for the lower rate of BPFs on the left side is possibly due to the superior mediastinal protection as a result of the physiological withdrawal of the left primary bronchus after its amputation.

In more than half of the septic courses of the disease (60%), there was a septic clinical picture after CP, i.e. a previously existing infection status predisposed to a form of postoperative infection. There are two possibilities to solve this problem: either resection of the focus of infection as a radical measure or antiseptic treatment first, followed by definitive surgical treatment, but no uniform guidelines or trials for comparison exist.

	5. Summary

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 
CP remains a surgical technique bearing high risks. Considering the morbidity and mortality we have shown, above all in the two large CP groups, due to the recurrent carcinomas and as a result of complications, this operation can nevertheless be considered justified.

Decisive for the outcome is the careful diagnosis, including the preparation and selection of the patients in order to reduce postoperative complications and, hence also, postoperative mortality. This also includes the consideration of the increased risk involved in right CP, in anastomotic or stump insufficiency as well as pre-existing septic conditions. In the group of patients who, as the result of a complication, had to be subjected to emergency CP, this is not possible. Because of the otherwise lethal course of the disease, however, CP must be recommended for these patients as well.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Summary References

 

1. Miller D.L., Deschamps C., Jenkins G.D., Bernard A., Allen M.S., Pairolero P.C. Completion pneumonectomy: factors affecting operative mortality and cardiopulmonary morbidity. Ann Thorac Surg 2002;74:876-884.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joachim Hasse Erich Stoelben Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jungraithmayr, W. Articles by Stoelben, E. Search for Related Content PubMed PubMed Citation Articles by Jungraithmayr, W. Articles by Stoelben, E. Related Collections Lung - cancer Lung - other