Other Complications

Dorn Spinal Therapy

Spine Healing Therapy

Get Instant Access

It seems surprising that wound infection does not occur more often. Cultures from patients with an open tracheostoma or granulation tissue at a stenosis produce Staphylococcus aureus, often resistant, and/or Pseudomonas aeruginosa, as well as a variety of other pathogens, including Streptococcus and Escherichia coli. A moderate incidence of wound infection might be expected because of the open nature of the surgery with the passage of tubes and instruments through the larynx and pharynx, concurrent exposure of the mediastinum, and, frequently, of the partially or completely divided sternum. This is not the case. Techniques of surgery and perioperative management may well play important roles. Since I have no intention of performing randomized series to explore this surprisingly benign situation, clarification may not be possible.

Laryngeal edema is rare, but is somewhat more common when surgery involves the larynx directly, in resection of laryngotracheal stenosis and in laryngoplasty for tumors of the upper airway. Edema is manifested by wheezing or stridor upon extubation at the conclusion of the operation or during the next 24 hours. Direct examination of the vocal cords in the patient who is still lightly anesthetized or awakening usually allows differentiation of edema from vocal cord paralysis.

Major pulmonary complications are very rare after cervical or cervicomediastinal tracheal resection, despite the fact that many patients have limited pulmonary reserve due to chronic obstructive pulmonary disease or emphysema. Postoperative pneumonia is more common after carinal resection and reconstruction. This can be minimized by careful postoperative care. However, postoperative ARDS may occur without warning, despite attempted prophylaxis, particularly after a right carinal pneumonectomy. The operation may have been uneventful. The immediate postoperative course appears to be similarly uneventful. Most frequently, patients have been extubated promptly and do not then require respiratory assistance.

In approximately 36 hours, however, a light infiltrate appears, often in midfield of the remaining lung. This worsens steadily over the next few days (Figure 21-1). The patient does not produce significant sputum, and bronchoscopy reveals only scant secretions which culture normal flora. As the radiologic picture worsens, the patient goes into florid ARDS with widespread pulmonary infiltrate, and finally whiteout of the remaining lung. Intubation, maximum conventional respiratory support, aspiration bronchoscopy, adjuvants including wide-spectrum antibiotics, diuretics, and corticosteroids all usually fail to salvage the patient. At autopsy, the lungs are found to be very heavy with interstitial fluid. Cultures do not reveal significant pathogens, although a few colonies may appear, consistent with intubation and ventilation. These patients were diagnosed as having died from "bronchopneumonia." This was more a diagnosis of convention. The clinical picture is that of noncardiogenic "postpneumonectomy pulmonary edema," which was described by Zeldin and Peters and colleagues after routine pneumonectomy.7 Peters' thesis was that this represents pulmonary edema due to the inability of the lung to rid itself of interstitial water from perioperative fluid overload, perhaps compounded by a decrease in lymphatic capability. This was not confirmed in other studies and ARDS was also seen to follow a lobectomy occasionally.8,9 Although we had scrupulously managed such patients, ever since our initial encounters, by rigorous fluid restriction perioperatively and with the other measures noted, the syndrome nonetheless occurred unpredictably. A subsequent reduction in the incidence of this dire complication may be attributed to the adjustment of the intraoperative airway ventilatory pressure and tidal volumes to reduce and avoid barotrauma to the lungs. Additional complications that are common to any kind of surgery, and some more common after intrathoracic procedures, have been few in number. These include pneumothorax, line infection, atrial fibrillation, myocardial infarction, and deep venous thrombosis. Special postresectional problems, such as those inherent in airway surgery after irradiation, and those following unusual procedures for cervicomediastinal exenteration, posterior wall splinting, correction of postpneumonectomy syndrome, tracheoplasty for congenital stenosis, and resections of rare inflammatory lesions, are discussed in the chapters devoted to these diseases and techniques.

figure 21-1 Development and progression of "postpneumonectomy pulmonary edema" to fatal acute respiratory distress syndrome. Uneventful right carinal pneumonectomy was performed for a squamous cell bronchogenic carcinoma invading the carina. A, The patient was extubated and clinically doing very well. At 24 hours, dyspnea appeared with diffuse left lung infiltrate. B, At 48 hours, the infiltrate had worsened. The patient was reintubated and ventilated. C, Progression at 72 hours. D, Chest roentgenogram at 120 hours, with marked worsening of the parenchymal infiltration. The patient continued to deteriorate and died 12 days after operation. This predated our use of nitric oxide treatment.

figure 21-1 Development and progression of "postpneumonectomy pulmonary edema" to fatal acute respiratory distress syndrome. Uneventful right carinal pneumonectomy was performed for a squamous cell bronchogenic carcinoma invading the carina. A, The patient was extubated and clinically doing very well. At 24 hours, dyspnea appeared with diffuse left lung infiltrate. B, At 48 hours, the infiltrate had worsened. The patient was reintubated and ventilated. C, Progression at 72 hours. D, Chest roentgenogram at 120 hours, with marked worsening of the parenchymal infiltration. The patient continued to deteriorate and died 12 days after operation. This predated our use of nitric oxide treatment.

Quadriplegia can occur infrequently as a devastating and irreversible consequence after tracheal resection. I have personally never encountered it, although one such event occurred in our thoracic surgical unit. It has happened in young, otherwise healthy patients who had no hypotension or untoward events during anesthesia and operation. Suspicion has focused on cervical hyperextension during surgery, and perhaps extreme flexion postoperatively, in an effort to lessen anastomotic tension. Extremes of extension and flexion were not used in our one patient.

Midcervical quadriplegia has followed neurosurgical procedures with patients operated upon in a sitting position with accompanying cervical flexion. Spinal cord ischemia is therefore suspect. Anesthesiologists caution that the chin and the chest should not be closer than one inch in this position.10 Dominguez and colleagues reported this complication immediately after tracheal resection, upon assumption of a sitting position plus "extreme" cervical flexion.11 Magnetic resonance imaging 19 days later revealed findings consistent with cervical spinal cord ischemia. Two other instances of quadriplegia after tracheal resection were cited. I have also been told of a fifth patient elsewhere.

It must be emphasized that the "guardian suture" is placed to prevent postoperative hyperextension, not to gain extreme cervical flexion. Given the uncertainties noted, it is also best to avoid extreme cervical hyperextension in positioning the patient for anterior tracheal resection.

Late coronary artery disease has been noted in some patients who received mediastinal irradiation following tracheal resection for a malignant tumor (in doses often exceeding 5,000 cGy), most likely as a result of irradiation.

Was this article helpful?

0 0
Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Post a comment