Pneumonectomy for Lung Cancer - An Overview

Types of Pneumonectomy and Reasons This Surgery May be Done

surgical incision on chest from a pneumonectomy
What is a pneumonectomy and what can you expect with this surgical procedure?. istockphoto.com

A pneumonectomy is a type of lung cancer surgery in which an entire lung is removed as a treatment for lung cancer. A pneumonectomy is also performed occasionally for other conditions, such as tuberculosis, severe COPD, or trauma that interrupts major blood vessels near the lungs.

(Other surgeries done for lung cancer include wedge resection and lobectomy.)

Types of Pneumonectomy

There are two primary surgical procedures under the heading of pneumonectomy:

  • Standard Pneumonectomy: With a standard pneumonectomy, either the right lung (which contains 3 lobes) or the left lung (containing 2 lobes) is removed.
  • Extrapleural pneumonectomy: In an extrapleural pneumonectomy, one of the lungs is removed along with part of the diaphragm, the membrane lining the chest cavity (pleura), and part of the membrane lining the heart (pericardium). This procedure is most often done for mesothelioma, a form of cancer that begins in the lining surrounding the lungs.

When is a Pneumonectomy Done?

The type of lung cancer surgery your doctor recommends will depend upon several factors, including:

  • The location of your tumor.
  • The size of your tumor.
  • Whether or not your tumor has spread to nearby tissues.
  • Your general state of health.
  • How well your lungs are functioning prior to surgery.

A pneumonectomy is most commonly done as a treatment for non-small cell lung cancer, when a less invasive procedure, such as a lobectomy, cannot remove the entire tumor.

This may occur if the tumor is large, if it has spread beyond a single lobe, or if it is located in the central area of the lungs.

Because a pneumonectomy involves the removal of an entire lung, the procedure is usually reserved for those people who have adequate lung function and will be able to tolerate living with only one lung.

That said, many people have gone on to live active lives following a pneumonectomy.

Preparing for Your Pneumonectomy

In preparing for your pneumonectomy for lung cancer, you will visit with your doctor and have several tests done to make sure the procedure is as successful as possible. Since surgery is not the usual treatment for lung cancer that has spread beyond the lungs, your doctor will recommend tests to rule out any spread (metastasis) of the cancer. These may include a bone scan to look for spread of the cancer to bone, a brain scan to rule out brain metastases, and an abdominal scan to rule out liver metastases and adrenal metastases.

Tests will then be done to make sure you will be able to tolerate living with only one lung. Pulmonary function tests will evaluate your healthy lung and determine its ability to deliver adequate oxygen to your body alone. Your doctor may also recommend tests to make sure your heart is functioning well since surgery can add stress to the heart. A careful history, physical exam and lab work will be done to make sure you are as healthy as possible.

After your doctor has studied the results of your tests, she will carefully discuss the benefits and risks of surgery. It is very helpful to bring a list of questions with you to make sure any concerns you have are not overlooked.

If you are on any medications that can increase bleeding, such as Coumadin (warfarin). aspirin, or anti-inflammatory medications such as Advil (ibuprofen), your doctor will recommend discontinuing these for a period of time before your surgery.

Make sure to let your doctor know if you are using any herbal remedies or nutritional supplements, since some of these can thin your blood as well. If you smoke, your physician will strongly recommend that you quit as soon as possible prior to your surgery. Studies have shown that lung cancer surgery is more successful and has fewer complications if people stop smoking beforehand.

The night before surgery, your doctor will recommend that you “fast” – that is, not eat or drink anything (even water) for at least 8 hours.

On the morning of your surgery, a nurse will ask you several questions and place an IV (intravenous line) in your arm. She will also fit you with monitors so that your blood pressure, heart rate, and oxygen levels can be monitored throughout surgery. Your surgeon will visit to again discuss the procedure and ask you to sign a consent form. The anesthesiologist will also visit to talk about the anesthesia you will be given, and ask about any problems you or your family members have experienced with anesthesia in the past. The operating room staff will guide your family to a waiting area, where the surgical staff can keep them updated on your progress and speak with them when your surgery is done.

During Your Pneumonectomy - The Procedure

In the operating room, you will be given a general anesthetic to put you to sleep, and an endotracheal tube will be placed through your mouth to allow a ventilator to breathe for you during surgery.

A long incision will be made along your side following the curve of your ribs. The surgeon will spread your ribs and may remove a portion of a rib to gain access to your lung.

When your lung is adequately exposed, the surgical team will collapse your lung that contains the cancer. The major blood vessels (arteries and veins) traveling to your lung will be tied off, and the bronchus leading to the lung will be tied off and sewn shut.

After your lung is removed, the surgeon will carefully check to make sure all bleeding is controlled, and will then close the incisions.

The space remaining where your lung had been will gradually fill in with fluid.

After Your Pneumonectomy - Recovery

When your surgery is complete, you will be taken to the recovery room where you will monitored closely for several hours. In some cases, you may be taken directly to the intensive care unit (ICU). Following recovery, most people spend the first several days in the ICU. For the first day, your breathing may be assisted with a ventilator. Since this can cause some anxiety, you will be given medications that keep you very drowsy until the tube is removed.

When the ventilator is removed and you become less sleepy, a respiratory therapist will ask you to cough, and will assist you in the use of an incentive spirometer. This is a device that you breathe into in order to exercise your lungs, and to help keep the small air sacs in your lungs open.

When you are able, the nursing staff will help you sit, and then encourage you to get up and walk with assistance. You may not feel like being active, but increasing your activity will help you regain your strength more quickly, and reduces the risk of developing blood clots. Most people spend at least 6 to 10 days in the hospital following surgery.

Some people return to work after 8 weeks, but your doctor will give you special restrictions, such as avoiding any heavy lifting. It will also take time for your remaining lung to take over, and shortness of breath may persist for several months following surgery.

When to Call Your Doctor

When you are released from the hospital, you will be given careful instructions on how to care for yourself at home and when to follow up with your doctor. Between appointments, you should call your doctor if you have any symptoms or questions that concern you. Call your doctor right away if you develop a fever, have chest pain that is different from what you have been experiencing, become more short of breath, have any bleeding or redness near your incision, or if you develop any pain in your calves (possible blood clots).

Pneumonectomy Complications and Prognosis

Because a pneumonectomy is a major medical procedure, pneumonectomy complications are not uncommon. Your doctor will discuss these with you before your surgery. Some potential complications may include:

  • The need for a respirator for a prolonged period after surgery
     
  • Infections, such as pneumonia
     
  • Bleeding
     
  • Bronchopleural fistula – a connection between the bronchus that was cut and the space between the pleura
     
  • Heart problems, such as a heart attack or abnormal heart rhythms
     
  • Stroke
     
  • Blood clots in the legs (deep vein thrombosis) or traveling to your lungs (pulmonary embolism)
     
  • Empyema – pus in the space between the membranes (pleura) lining the lungs
     
  • Problems related to anesthesia
     
  • Kidney problems or kidney failure
     
  • Postpneumonectomy syndrome – symptoms caused by organs in the chest filling the space that is left vacant from the removed lung
     
  • Persistent pain in your incision or where your ribs were cut

Pneumonectomy Prognosis

The prognosis following a pneumonectomy depends on many factors. Some of these include which lung is removed (the prognosis is better for left pneumonectomy than right pneumonectomy), the stage of the cancer, gender (women tend to do better than men), the type of lung cancer, and how healthy you are in general prior to surgery. Recurrence of cancer in the lung is not common after a pneumonectomy, but sometimes lung cancer may recur in distant regions of the body.

Sources:

American Cancer Society. Detailed Guide: Lung Cancer – Non-Small Cell. Surgery. Updated 05/16/16. http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-treating-surgery

Erhunmwunsee, L. and M. Onaitis. Smoking cessation and the success of lung cancer surgery. Current Oncology Reports. 2009. 11(4):269-74.

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