Post-thoracic surgery, common complications include atelectasis, hemorrhage, pulmonary edema, pneumonia and respiratory failure. Around 20% of patients experience complications, and pneumonia is a frequent cause. Pain management is important to prevent respiratory issues. Atelectasis can be treated with breathing exercises and chest physiotherapy. Respiratory failure requires oxygen supplementation and may necessitate mechanical ventilation. Other potential complications include arrhythmias, wound infections, air leaks and bronchopleural fistulas. Close monitoring and treatment of underlying issues are important to address post-operative complications.

1. Post Thoracic Surgery Complications
Firas Aljanadi
RVH
Wed 05-08-2020
F.Aljanadi

2. F.Aljanadi

3. Introduction
 Thoracic surgical patients :elderly, coexistent disease, current smoking, underlying
carcinoma, and chronic lung disease.
 prone to respiratory complications
 ~20% of patients undergoing lung resection suffer one or more complications
after surgery, and about 2% die.
 These risks are doubled following pneumonectomy, less common after limited
wedge resection.
 Important factors: Pulmonary hygiene and physiotherapy, fluid and pain
management and management of pleural spaces.
F.Aljanadi

4.  Common complications : Atelectasis, haemorrhage, pulmonary oedema, atrial
fibrillation, wound infection, pneumonia, persistent air leak, and respiratory failure.
 Less frequent complications : bronchopleural fistula, empyema, cardiac herniation,
pulmonary torsion, chylothorax, thromboembolism, right ventricular failure, and
neurological injury
F.Aljanadi

5. Post op pain
 A source of complications ,Controlled pain less respiratory complications
 Locoregional :epidural analgesia,extrapleural or paravertebral block
 Systemic analgesics, PCA ,and IV,IM , PO analgesics
 Multiple different agents ,reduce dose and adv effects.
 Oral : Shortec/Longtec(oxycodone), MST/ Sevredol (morphine) ,codeine, co-codamol,
paracetamol
F.Aljanadi

6. Atelectasis
 Collapse of segment/lobe or lung -V/Q mismatch-hypoxia
 Most common post-op complication
 Usually 1-2 days post lung resection in 40% of patients, 5-10%
significant
 RF : Inability to cough, sputum retention, hypovent due to pain ,
sedation, diapgragmatic splinting , pleural effusion,
 CXR:
 Mx : Prevention always better
 Non –invasive: regular physio, early mobilise,out of bed,Inc.
Spirometry, Breathing exercises,NEBs,Humodified O2
 Invasive: Naso-trach suction,CPAP,bronch,mini-trachy
F.Aljanadi

7. Respiratory Failure
 Causes : Narcotic overdose /inadequate reversal ,bronchospasm,atelectasis,
pneumonia,pulmonary oedema, minimal reserve preop , PE, ARDS
 Classification:Type I –Hypoxaemia ,Type II ventilatory or primary hypercapnia,
Mixed :hypoxaemia with hypercapnia
 Main cause of mortality , in2% , -50-100% mortality
 Mx : O2 (mask-CPAP) ,Naloxone,dieuretics,Abx, Anticoagulation, NEBs , Bronch, -
 TT and Mech ventilation
F.Aljanadi

8. ARDS
 Acute lung injury ,Bilateral pulm infiltrations,Severe
hypoxia,No cardiogenic pulmonary oedema
 Increased alv-cap permeability  excessive fluid in
alveolar space ,
 2-3 days post surgery, dyspnea,hypoxia
 Rapid deterioration ,
 5% post pneumonectomy , 2% post lobectomy,
 CXR : widespread bilat infiltrations,
 Mechan vent
 Mortality > 75%
F.Aljanadi

9. Pulmonary Oedema
 Accumulation of fluid in the alveoli and lung paranchyma
impaired gas exchange
 Causes to avoid : excessive fluid administration, LVF, RVF
(following pneumon),rapid expansion of collapsed lung
Post op pneumonia
 Nosocomial infection ,  sputum retention,atelectasis
 Staph,strep pneum ,HI,Pseud,Kleb,E-coli
 CXR ; Patchy consolidation
 Mx :Abx, O2,Chest physio
F.Aljanadi

10. Air leak
 Persistent or prolonged > or = 7days(STS >5 days) , 10-
15% following lobectomy ,
 RF: age>70,COPD,Steroids,poor nutrition,redo,incomplete
fissure, LVRS ,decortication, lobectomy,incomplete lung
expansion,
 Mx: if lung is fully inflated , most AL will heal in time:
watchful waiting
 Talc pleurodesis
 Blood patch 60-150 mls of patient's blood into pleural cav.
 Reduce suction, connect to portex bag or flutter bag ,
mobilise
 Bronch (stump dihescence ?)—if all fail  surgery
 Surgical emphysema:
 ICD drainage is inadequate ,check drain , increase
suction, CXR is ICD satisfactory –CT scan, 2nd ICD ,
 Worsening think of BPF , bronchoscopy .
F.Aljanadi

11. BPF
 Communication bet Tracheo Bronch tree and pleural cavity
 May happen after surgery , 1-2% post lob, 6-10% post
pneumo
 Early Within 2 wks , late >2 months , R>L, elderly more
 RF age >70, pre op chemo, radio, low FEV1 , post op
ventilation, incomplete resection, TB, extended LND,long
stump,
 Productive cough(seraang fluid) ,fever, subcut emphysema,
air leak,empyema (late)
 CXR : falling air-fluid level , increasing surg emphysema,
increased air space ,
 Mx : protect other lung , ICD , Bronch, Abx , reoperation
F.Aljanadi

12. Post pneumonectomy syndrome
 Mediastinal shift towards resected lung compression and stretching of T.B tree
and oesophagus
 Rare
 Months-years after pneumonectomy
 More common in younger patients, F>M
 Presents with : SOB ,some presents dysphagia , heartburn
 In severe cases: reexploration to repostion mediastinum
F.Aljanadi

13. Bleeding
 <5% of all lung resections
 Sources :bronchial art., adhesions, intercostal art.segmental veins
 RF: Pre op :redo,bronchiectasis ,coagulopathy,cyanosis. Intra-op
:adhesions,pleurectomy ,extrapleural resection, incomplete
fissures, inadequate haemostasis
 Mx :
 VS, examine, Drain output ,Hb, CXR ,
 Monitor HD,Drain output progress overtime
 ABC,IV F (colloid, blood)G&S , NBM, Coag(correct if need
FFP,PLT,Cryo) , Hb (keep >8g/l), CXR, Inform ,escalate
 Re-exploration: (to control and evacuate)
 HD Unstable despite IV Fluid
 >200-300ml/hr for3-4 hrs
 Significant haemothorax on CXR
F.Aljanadi

14. Arrythmias
 Atrial fibrillation/flutter most common ,
 10-15% following lobectomy, 40% post pneumonectomy
 1st -3rd day post op, no difference bet. Vats vs open
 Increased mortality , LOS
 RISK FACTORS :
 Pre-op >70,HTN,PMH of AF, CAD-Intra-op : Pneumonectomy,radical LN dissection,
Intrapericardial resection
 Mx : talk to pt, to seniors , involve team, assess,
 HD? Stability – Rate control, rhythm control,Electrolytes,Acidbase , Hypoxia,
 Medications , metoprolol, bisoprolol, digoxin , Amiodaron
 DC, acutely compromised
 Anticoagulation if SR not restored
F.Aljanadi

15. Wound complications
 Wound Haematoma: Inadequate haemostasis, anticoagulation , resolve spontan.If
large may require drainage .
 Wound Seroma: plasma leak, muscle sparing thoracotomy or flaps,if large may need
drainage
 Wound infection : rare for thoracotomy, superficial: Abx – may need debridment ,
deep infection underlying empyema ..empyema necessitans?
 Dehiscence: reopening and debridement, pleural drainage,closure
 Lung herniation :
 protrusion of lung through wound dehiscence,utility port or ICD site
 pain, swelling , cough impulse,localised inflammation
 Surgical repair
F.Aljanadi

16. Other complications
 Cardiac Herniation: rare, life threatening, moderate size defect in pericardium,(
intrapericardial pneumonectomy )
 Rapid deterioration 24-48 hrs, hypotension, chest pain, tachycardia- emergency
surgery
 Lobar Torsion :rare,post lobectomy,mainly involving RML ,
 Haemoptysis,CXR : density,rapid deterioration, sepsis
 Bronch, CXR , CT - Sx : lobar resection
 Prevension: predict (RUL with complete fissure)
F.Aljanadi

17. Other complications
 DVT :Pain in calf, swelling , more pain with ankle dorsal flexion , suspect DVT -
duplex scan - anticoagulation according to level
 PE :Increasing O2 requirement with decreasing Po2 , +/- chest pain, +/-
tachycardia , tachypnoea  think about PE  CTPA – Anticoagulation , HDU/ICU
 GI : constipation , ileus are common make sure laxatives are prescribed
 Diarrhoea : stop laxatives ,hydration, check CDf, Covid19 if suspected
 Confusion ,delirium: look for causes , talk & reassure patient , if neurological signs
- further investigations
 Urinary :urinary retention , UTI ,
 AKI: causes, fluid balance, U&Es,
F.Aljanadi

18. Thank you
F.Aljanadi