Thoracic Surgery General Management III

Author: Ammar Asban, MD & Brian Mitzman, MD
Institution: University of Utah
Date Reviewed: March 2025
Original Case: Stephen Yang, MD
Learning Domain: General Thoracic
Learning Objective: Risk assessment and postoperative complications for pneumonectomy
PowerPoint File: File TS03 - Thoracic Surgery General Management III.pptx

 

Learning Goals

  • The basic level concepts focused on:
    • Risk Assessment:  Lung
  • The advanced level concepts focused on:
    • Postop Complications:  Lung

 

Case #1

60 yo M presents with SOB on exertion.  PFTs are performed.  What does this P/V flow loop show?

 

Discussion

 

Case #2 Part 1

  • 68 yo F presents for evaluation of a localized 2 cm NSCLC of the lingula.  
  • Work up included:
    • ppoFEV1 30%
    • DLCO 40%
    • ECHO LVEF 50%, RVSP 30
    • MVO2 max 8 ml/kg/min
  • What should we offer this patient surgically, if anything?

 

Case #2 Part 2

  • 68 yo F undergoes a RML/RLL bilobectomy.
  • You reinflate the remaining RUL, but worry there will be a significant pleural space left.
  • What are some maneuvers to minimize the pleural space?

 

Case #2 Part 3

1 after RLL lobectomy for NSCLC, you look at the patient and see this?  What is going on and what do you do?

 

Case #3

  • A 72 yo undergoes a VATS RUL lobectomy with lymph node dissection having a positive R10 LN
  • On POD3, she is eating and walking with one chest tube
  • The chest tube drainage begins to increase to between 1000-1500 cc of opalescent fluid in 24 hours.  
    • No organisms are identified in the fluid
  • Diagnosis?
  • Initial management should include?

 

Management of Chylothorax 

  • In postoperative setting 
    • Dietary control measures, fasting, low-fat diet and total parenteral nutrition 
    • What will you do if there is evidence of mediastinal shift?
  • Adjunct therapy 
    • Somatostatin, octreotide, and midodrine 
  • How long would you monitor this patient and what type of intervention would you consider?
    • Pleurodesis
    • Thoracic duct embolization 
    • Thoracic duct disruption 
    • Thoracic duct ligation
    • Combination therapy 

Therapeutic lymphangiography for traumatic chylothorax. Hara et al. Journal of Vascular Surgery: Venous and Lymphatic Disorders, Volume 6, Issue 2, March 2018, Pages 237-240

 

Case #4

  • 60 yo M construction worker with a 40-pack year smoking history was evaluated for resection of a carcinoma involving the bronchus intermedius
  • Preoperative pulmonary function tests showed FVC = 2.5L, FEV1 = 1.8 L, DLCO = 35% of predicted, room air Pa02 = 60 mmHg
  • What do his PFTs suggest and should he undergo resection?

 

Case #5 Part 1

  • A 55 yo underwent a difficult right pneumonectomy for advanced NSCLC requiring intrapericardial dissection vessel control.  
  • Preop PFTs were excellent and he is generally healthy
  • POD2 he develops sudden SVT, hypotension and desaturation.  
  • Initial management of his SVT is unsuccessful  
  • CXR is shown. What next?

 

Case #5 Part 2

  • 3 days after right pneumonectomy patient noted to have a new LLL infiltration, cough, frothy sputum, and respiratory failure 
    • What is your differential diagnosis?
    • How will you proceed to work this up?
    • What is the most common cause?
    • How would you manage this patient?
    • What operation would you offer this patient?

 

Case #5 Part 3

  • 6 weeks after right pneumonectomy patient comes to clinic with fever, new onset cough productive blood-tinged sputum. CXR shows air-fluid level in the right hemothorax
    • What is your work up?
    • What your differential diagnosis?
    • How would you manage this patient? 

 

Case #6

  • Your 71yo M patient is undergoing a routine RUL VATS lobectomy.  
  • Prior to induction of anesthesia, a right subclavian catheter is placed for IV access. 
  • During placement develops pulmonary wheezing, tachypnea, and tachycardia. Physical exam reveals a "mill wheel" churning murmur.  
  • What is done next?  

 

Case #7

  • A 72 yo M is 1 year out following R pneumonectomy for T2N0 NSCLC  Has been doing well except for progressive SOB since surgery Particularly worse since the last clinic visit 4 months ago 
  • CXR is shown 
  • What next?

 

Discussion: Post-pneumonectomy Syndrome

     

 

Case #8

  • 65-year-old man underwent uneventful right pneumonectomy for lung cancer.  
  • POD1, he experienced profound dyspnea when standing.  His BP was 120/80 with a HR of 88 both standing and supine.  His O2 sat was 92% on room air while in the supine position and was 80% in the standing position.  
  • The patient has no significant cardiopulmonary history and his preoperative pulmonary function tests were excellent. 
  • What is done next?  What is the diagnosis?  

 

Discussion: Platypnea-orthodeoxia