Pneumonectomy is a surgical procedure to remove a patient’s lung. Its primary purpose is to remove the lung to prevent cancer spread. It is a highly aggressive and invasive form of localized treatment for lung cancer. It is also sometimes indicated for the treatment of malignant pleural mesothelioma.
Who Qualifies for Pneumonectomy
Despite significant improvements in the surgical procedure and postoperative care, pneumonectomy has significantly higher morbidity and mortality risks than surgeries that only remove part of a lung. The operative risks and survival and quality of life benefits of the procedure must be considered by the patient and their oncology and surgery teams.
There are many circumstances in which a surgeon will advise against performing a pneumonectomy. For example, if a patient’s cancer has already spread beyond the lung to other parts of the body, or if the condition of the remaining lung is considered to be too poor to function after the diseased one has been removed. Candidates for this surgery also need to have a generally high standard of health, most notably strong heart function. These criteria are required due to the permanent reduction in pulmonary function and cardiac function associated with the procedure.1
A pneumonectomy is performed under general anesthesia. First, with the patient lying on their unaffected side, the surgeon makes an incision in the chest along the side and back where the affected lung is. This procedure is called a thoracotomy. In some cases, it may be necessary to remove some or all of a rib to allow for greater visibility and access during the surgery.
Once the affected lung is collapsed, the pulmonary vessels and the main stem bronchus of the affected lung are contained, usually using stapling, but sometimes clamping and oversewing. Next, these structures are thoroughly inspected to ensure no leakage of blood or air, respectively. Then, the diseased lung is extracted through the incision site. A temporary drainage tube will then be inserted into the chest cavity to remove excess blood, fluid, and air from the cavity before the chest is finally closed.
Recovery from Surgery
Once the operation has been completed, recovery begins in the surgical intensive care unit (ICU), with respiratory support provided for a day with the use of a respirator. The tube for chest drainage remains in place to prevent excessive fluid buildup. Medicine and food are provided intravenously.
Within a few days, the patient is usually able to leave the ICU and continue recovering in a regular hospital room. During this time, their care plan focuses on reducing and relieving pain, observing blood oxygen levels, expunging lung secretions with cough assist devices, and maintaining a high level of mobility to prevent blood clots from developing.
Patients are usually able to go home seven days after the surgery. A patient’s surgeon will advise them to abstain from heavy lifting and avoid strenuous activity until they are satisfied with the patient’s recuperation. While taking narcotic pain medication, the patient must also abstain from driving. A full recovery from surgery usually takes weeks to months, sometimes requiring up to six months or longer for the patient not to feel short of breath on exertion. Follow-up care with the surgeon who performed the procedure occurs during this time.
For the treatment of malignant pleural mesothelioma, the pneumonectomy functions as a procedure within another procedure known as extrapleural pneumonectomy (EPP). An EPP is designed to remove the cancerous lung and the affected half of the diaphragm, the parietal pleura (the lining of the chest), pericardium (the heart sac), and any lymph nodes that are affected in the localized area. By removing as much of the tissue affected by the cancer as possible, surgeons aim to improve a patient’s breathing and quality of life, and decrease cancer spread. Hospital recovery from EPP may last one or two days longer than recovery from pneumonectomy.
Despite the extreme nature of the surgery compared to other available treatments for mesothelioma, a successful operation can increase the chances of a patient’s survival by months or potentially years. Due to the high-risk nature of the procedure, EPP is only offered to patients deemed healthy enough to survive surgery and in circumstances where the cancer is located in only one area of the chest cavity.
Risks and Possible Complications of Pneumonectomy
The rate and quality of recovery a patient is likely to experience can vary greatly depending on individual circumstances, such as overall health, age, which lung was removed, and cancer stage and subtype. The majority of patients will experience noticeable shortness of breath following the surgery, as the remaining lung is still adapting to handling all respiratory functions. It can take up to six months or longer for the patient not to feel short of breath on exertion.
As with all surgical procedures, there is the possibility of complications developing from the surgery. In addition to the risks of pain, bleeding, and a possible adverse reaction to anesthesia, some of the complications that may affect patients who have had a pneumonectomy include
- Prolonged dependence on a respirator
- Atelectasis: lung collapse
- Pulmonary edema: accumulation of fluid in the remaining lung
- Wound infection
- Pneumonia: lung infection
- Empyema: accumulation of pus in the pleural space between the lung and the chest wall
- Pulmonary embolism: blood clot in the healthy lung
- Injury to the diaphragm, spleen, or a major blood vessel
- Lung injury or respiratory failure
- Kidney injury or kidney failure
- Cardiac problems including arrhythmia (irregular beating of the heart) or myocardial infarction (heart attack)
- Development of a bronchopleural fistula: the stump of the tapered bronchus fuses to the pleural space in the chest cavity
- Post-pneumonectomy syndrome: organs within the chest cavity shift or enter the space left from the removal of the cancerous lung, compressing the remaining lung structures and esophagus
- Post-pneumonectomy cardiac herniation: an abrupt and life-threatening drop in blood pressure
Benefits of Pneumonectomy and Extrapleural Pneumonectomy
While the risks of surgery can never be taken lightly, the potential improvements in survival and quality of life for a patient following pneumonectomy or extrapleural pneumonectomy are significant. Not only can a successful procedure add months or years, sometimes up to five years, to a patient’s life, but it can also have a profound effect on reducing the symptoms of lung cancer and mesothelioma.2