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Extrapleural Pneumonectomy

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Abstract

Extrapleural pneumonectomy (EPP) is a formidable surgical procedure performed on patients with limited life expectancy. Anesthetic management may contribute to containment of perioperative morbidity and mortality through the control of intraoperative physiologic disruptions and postoperative pain and an appreciation of the associated postoperative complications to affect early intervention. “EPP-specific” anesthetic concerns (above those for standard pneumonectomy) are discussed.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Ju-Mei Ng

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  1. Ju-Mei Ng
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Correspondence to Ju-Mei Ng .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case

A 50 year-old male is scheduled for right extrapleural pneumonectomy. The diagnosis of mesothelioma was made on pleural biopsy, and he has completed six cycles of chemotherapy. He is a nonsmoker, and apart from well-controlled hypertension, he has no other significant comorbidities.

Questions

  1. 1.

    Apart from routine preoperative assessment for pulmonary resection:

    1. (a)

      Are any specialized cardiac and pulmonary function tests indicated?

      • Echocardiography commonly used to assess cardiac function.

      • Stress test only when history, examination, and echocardiography suggest significant cardiac disease.

      • FEV1, DLCO, and exercise capacity routinely assessed.

      • Ventilation/perfusion scans recommended if FEV1 < 2 L.

      • Predicted postoperative FEV1 < 1 L may preclude EPP.

    2. (b)

      What is the importance of radiologic investigations?

      • Surgical staging and tumor resectability.

      • Anesthetic implications include safe placement of epidural catheters at the thoracic region, level of intravenous access, quantity of blood and blood products available, and the potential necessity for cardiopulmonary bypass during resection.

  2. 2.

    How is an extrapleural pneumonectomy different from pneumonectomy?

  3. 3.

    What are the common causes of hypotension and the management strategies? (Table 36.5)

  4. 4.

    How would the application of intraoperative intracavitary heated chemotherapy affect the anesthetic management?

    • Renal protective strategies should be employed (Table 36.1).

    • Restrictive physiology exhibited by EPP patients during one-lung ventilation is exacerbated by the weight of the perfusate, and positive end-expiratory pressure is especially important to prevent atelectasis.

    • Fluid management is delicate balance between renal protection and the potential for exacerbation of acute lung injury in fluid overload.

Table 36.5 Hypotension during critical phases of surgery
Full size table

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Ng, JM. (2019). Extrapleural Pneumonectomy. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_36

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_36

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

  • eBook Packages: MedicineMedicine (R0)

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