Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring

Our plain-English summary of Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring, by A.S. Wolf, F.L. Jacobson, T.R. Tilleman, et al (European Journal of Cardio-thoracic Surgery, 2010).

The study

• Authors: A.S. Wolf, F.L. Jacobson, T.R. Tilleman, Y. Colson, W.G. Richards, D.J. Sugarbaker
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2010;37(4):770-5
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: Rapid fluid evacuation of the pneumonectomy space can cause ipsilateral mediastinal shift, contralateral lung hyperexpansion, compromised caval blood return and a precipitous drop in cardiac output. Conversely, rapid fluid accumulation can cause contralateral mediastinal shift with compression of the remaining lung and respiratory insufficiency. In this retrospective analysis, we evaluate the efficacy of intrathoracic pressure monitoring and intermittent fluid aspiration to manage the pneumonectomy space in the early postoperative period following extrapleural pneumonectomy.

Methods: Prior to chest closure, a 14 F Rob-Nel catheter was placed in the pneumonectomy space and connected to pressure tubing to monitor ipsilateral intrathoracic pressure continuously. Central venous pressure monitoring and serial chest X-rays were performed according to usual intensive care routine. Pneumonectomy space fluid was aspirated intermittently when there was increase in intrathoracic pressure, refractory hypotension, mediastinal shift on chest X-ray, or clinical decline. Postoperative imaging was re-evaluated retrospectively for confirmation of mediastinal shift by a senior radiologist.

Results: From January to December 2008, 47 patients underwent extrapleural pneumonectomy for pleural mesothelioma (median age 65 years with range 34-79 years, 77% male). Twenty (43%) patients had left-sided disease and 32 (68%) received local heated intra-operative cisplatin-based chemotherapy. The median baseline pneumonectomy space pressure was 3 cm H(2)O (range: -6 to +12). The median amount of fluid withdrawn over the first 2 days postoperatively was 300 cc (range: 0-1980 cc). Thirty-one (69%) patients had minimal, if any, change in mediastinal position during the first 2 postoperative days with intermittent drainage performed when the pneumonectomy space pressure rose. Eleven (25%) patients had increasing contralateral shift, four of whom had return of the mediastinum to baseline during this time period. The median fluid drained from the four patients whose contralateral shift resolved was 290 cc (range: 220-800 cc) compared to 200 cc (range: 150-480 cc) from the seven patients whose contralateral shift remained, but this difference did not reach significance (p=0.365).

Conclusions: Intrathoracic pressure monitoring may be used as a guide for intermittent fluid evacuation of the pneumonectomy space prior to onset of clinical signs or symptoms, to avoid the cardiopulmonary risks of rapid fluid removal. Contralateral mediastinal shift should be treated with incremental drainage when there is a rise in intrathoracic pressure to prevent cardiovascular complications.

Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

In plain English

This study looked back at 47 consecutive patients who had extrapleural pneumonectomy (removal of a lung together with the pleura, diaphragm and pericardium) for malignant pleural mesothelioma at Brigham and Women's Hospital in Boston during 2008. It did not examine asbestos exposure. Before the chest was closed, a thin catheter was left in the empty chest space to measure pressure continuously. Fluid was drawn off through it, generally 150 cc at a time, only for persistently high pressure, refractory (treatment-resistant) low blood pressure, an X-ray shift, or clinical decline. Two patients were excluded, leaving 45. Over the first 2 days the median fluid removed was 300 cc (range 0 to 1980 cc). Thirty-one patients (69%) had little or no shift of the mediastinum, the central chest structures. Four patients (9%) had a shift toward the other side that resolved, with a median of 290 cc removed. Seven (16%) had such a shift that did not resolve, with a median of 200 cc removed. This difference was not statistically significant (p = 0.365). The authors called the study a hypothesis-generating retrospective analysis. They concluded that pressure monitoring may guide drainage before symptoms appear.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a single-centre cohort (described by the authors as hypothesis-generating) evaluating a postoperative technique
• Who was studied: 47 consecutive patients who had extrapleural pneumonectomy for malignant pleural mesothelioma at Brigham and Women's Hospital, Boston, January to December 2008. Median age was 65 (range 34 to 79) and 77% were male. 20 (43%) had left-sided disease and 32 (68%) received intra-operative heated cisplatin-based chemotherapy. Two were excluded from analysis, leaving 45.
• Exposure: No asbestos exposure was studied. The intervention was a 14F Rob-Nel catheter placed in the pneumonectomy space to monitor intrathoracic pressure continuously and to withdraw fluid intermittently, generally in 150 cc increments. Fluid was withdrawn only for persistently elevated intrathoracic pressure, refractory hypotension, mediastinal shift on chest X-ray, or clinical decline.
• Main results:
  • Median baseline pneumonectomy space pressure for all patients was 3 cm H2O, with a range of -6 to +12. Some patients had negative pressure because air was removed at the end of surgery.
  • Median fluid withdrawn over the first 2 postoperative days was 300 cc (range 0 to 1980 cc). The catheter stayed in place a median of 3 days (range 2 to 5 days).
  • There was no significant association between the amount of fluid aspirated and gender, side, or use of intra-operative heated chemotherapy
  • 31 of 45 patients (69%) had minimal or no mediastinal shift over the first 2 days: 14 with mild shift and 17 with a midline mediastinum on all X-rays. Their median fluid aspirated was 300 cc (range 0 to 790 cc).
  • 2 patients (4%) had large ipsilateral (same-side) shifts that resolved without intervention. 1 patient (2%) had a large ipsilateral shift with 1980 cc aspirated, in the context of postoperative bleeding.
  • 4 patients (9%) had contralateral shifts that resolved with serial aspiration (median 290 cc, range 220 to 800 cc). 7 patients (16%) had contralateral shifts that did not resolve (median 200 cc, range 150 to 480 cc). The difference was not statistically significant (p = 0.365).
• The authors' conclusion: The authors concluded that intrathoracic pressure monitoring may be used to guide intermittent fluid evacuation of the pneumonectomy space before clinical signs or symptoms appear. They recommended that contralateral mediastinal shift be treated with incremental drainage when intrathoracic pressure rises. They described their data as preliminary.
• Limitations the authors state:
  • The study was a retrospective analysis of an empiric technique
  • The patient cohort was heterogeneous: some patients had induction chemotherapy, protocol enrolment or intracavitary chemotherapy and others did not
  • Sample sizes were too small for statistically significant results once patients were divided into shift groups
  • The small number of extrapleural pneumonectomies each year limits the ability to run a large randomised trial

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pneumonectomy, Extrapleural Pneumonectomy (EPP), Intrathoracic, Chest X-Ray, Pleural Mesothelioma, Cisplatin, Chemotherapy, Mediastinum.

Related studies

• Intrathoracic chemo-thermotherapy with radiofrequency waves after extrapleural pneumonectomy for malignant pleural mesothelioma — T. Tokunaga, M. Higashiyama, et al. (2011)
• Trimodality strategy for treating malignant pleural mesothelioma: results of a feasibility study of induction pemetrexed plus cisplatin followed by extrapleural pneumonectomy and postoperative hemithoracic radiation (Japan Mesothelioma Interest Group 0601 Trial) — S. Hasegawa, M. Okada, et al. (2016)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)
• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Epithelial malignant pleural mesothelioma after extrapleural pneumonectomy: stratification of survival with CT-derived tumor volume — R.R. Gill, W.G. Richards, et al. (2012)

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