Pneumonectomy in children for destroyed lung and thelong-term consequencesSevval Eren, MDMehmet Nesimi Eren, MDAkin Eraslan Balcı, MD
Objectives: Destroyed lung introduces irreversible changes in lung parenchyma.This condition is uncommon in children. Operative intervention is essential forchildren in this state. We demonstrate our experience with this condition and reporton the respective long-term results.
Method: Seventeen children who underwent pneumonectomy for destroyed lungduring a 15-year period were retrospectively analyzed. Long-term results weredetected in 13 patients.
Results: Seventeen children underwent pneumonectomy. Five children were female(29.4%), and 12 children were male (70.5%). The median age of the study groupchildren was 9.1 years (3-16 years). Sputum was the most common presentingsymptom (n � 13, 76.4%). Bronchiectasis (n � 11), tuberculosis (n � 4), andnecrotizing lung disease (n � 2) were the main underlying conditions. Destroyedlung was detected on the left side in 14 children (82.4%) and on the right side in 3children (17.6%). Main bronchial stenosis was found in 4 children and mucosalthickening or congestion in 5 children. The median length of hospital stay was 15.5days. The mortality rate was 11.7% (n � 2), and the morbidity rate was 23.5%(n � 4). Follow-up information was available for 13 patients, and this ranged from1 year to 12 years (median 5.2 years). The respiratory capacity and scoliosis levelof the patients were examined.
Conclusions: Although pneumonectomy is considered a difficult procedure in chil-dren, its use for destroyed lung resolves complications and improves a patient’squality of life. In time, the remaining lung expands to compensate for the loss of theremoved lung. Children grew and developed normally after pneumonectomy. Pa-tients tend not to have major skeletal deformation as the result of pneumonectomyin the short term.
Destroyed lung is an uncommon condition in children causingirreversible changes in lung parenchyma, and surgical interven-tion becomes essential. Destroyed lung is most often caused byinflammatory lung diseases such as tuberculosis, whole lungbronchiectasis, necrotizing pneumonia, multiple or extensive lungabscesses, fungal infections, lung gangrene, and mycobacteria
other than tuberculosis.1-7 Other important causes include bronchial stricture andcongenital malformations.1,2
Destroyed lung gives rise to chronically morbid and sometimes acute life-threatening complications such as massive hemoptysis, empyema, secondary fungalinfections, secondary amyloidosis, septicemia, and pulmonary-systemic shunt-ing.2,5,8,9 Surgical resection in destroyed lung is used to resolve complications andimprove a patient’s quality of life.5 Almost all of our patients who underwentpneumonectomy had undergone numerous treatments. However, irregular and in-adequate treatment, the cessation of medication shortly after symptom improve-
From the Department of Thoracic and Car-diovascular Surgery, Dicle UniversitySchool of Medicine, Diyarbakir, Turkey.
Read at the annual meeting of the EuropeanSociety of Thoracic Surgeons, Istanbul,Turkey, Oct 26-28, 2002.
Received for publication Dec 10, 2002; re-vision requested Feb 7, 2003; revision re-ceived Feb 24, 2003; accepted for publica-tion March 18, 2003.
ment, and a lack of check-ups after treatment are among thefactors that accelerate the need to perform pneumonectomyin children.
The long-term outlook for the respiratory function ofchildren after pneumonectomy is good. Children are able toperform daily activities and exercises without difficultiesdespite reduced pulmonary reserves.10
This retrospective study was undertaken to review ourclinical experience and long-term results for pneumonec-tomy in children with destroyed lung.
Materials and MethodsThe files of all patients who underwent pneumonectomy at DicleUniversity School of Medicine, Department of Thoracic and Car-diovascular Surgery, between 1987 and 2002 were reviewed. Pa-tient demographics, medical history, presenting symptoms, caus-ative factors, preoperative evaluations, treatment, operativeprocedures, postoperative course, and pathologic findings werereviewed, and the follow-up results were evaluated.
ResultsHistory and SymptomsSeventeen patients, 12 boys and 5 girls, with an average ageof 9.1 years (range 3-16 years), underwent pneumonectomy.The most common underlying disease was bronchiectasis (n� 11); other underlying diseases included tuberculosis (n �4) and necrotizing pneumonia (n � 2). In 2 patients withbronchiectasis, the diagnosis was congenital cystic bronchi-ectasis. All patients except 2 were hospitalized for treatment(Table 1). Two patients who had received treatment for 1year or less demonstrated necrotizing pneumonia. One pa-tient with tuberculosis did not receive any antituberculosistreatment during the preoperative period, whereas 2 patientsreceived irregular or inadequate treatment. The diagnosis ofthe patient with tuberculosis who did not receive priortreatment was made by postoperative histopathologic exam-ination. We did not use routine perioperative antitubercu-lous chemotherapy unless there was evidence of activedisease.
Sputum was the most common symptom (n � 13,76.4%). Other symptoms included coughing (n � 12,70.5%), growth retardation (n � 10, 58.8%), clubbing (n �9, 52.9%), fever (n � 4, 23.5%), and hemoptysis (n � 3,17.6%).
Radiologic and Diagnostic ExaminationsDestroyed lungs were present on the left side in 14 patients(82.3%) and on the right side in 3 patients (17.6%). Radio-
logic diagnostic methods included chest radiography in allpatients, chest computed tomography (CT) in 14 patients(Figure 1), bronchography in 8 patients (Figure 2), andpulmonary ventilation-perfusion scan in 4 patients. Mainbronchial stenosis was found in 4 patients and mucosalthickening and congestion in 5 patients by means of bron-choscopy or bronchography (Figure 2).
Preoperative Evaluation and PreparationSputum samples were obtained from all patients. Growthsin culture were detected in only 5 patients. The pathogenscultured were Staphylococcus aureus in 2 patients, Kleb-siella pneumoniae in 1, and Pseudomonas aeruginosa in 1;1 patient had a mixed bacterial structure. There were noacid-resistant bacteria in the sputum and gastric fluids ofpatients who had tuberculosis or in whom tuberculosis wassuspected. The tuberculin skin test was positive in 1 patientwith tuberculosis; however, none of the patients had activetuberculosis. All patients underwent careful preoperativeassessment and preparations for pneumonectomy. Patientsreceived antibiotics (according to the antibiogram in pa-tients with a positive culture antibiogram) and expectorantfor 2 weeks before surgery. The volume of purulent sputumwas reduced by programmed postural drainage and activephysiotherapy. The patients received a high-energy, high-protein, and vitamin-supplemented diet. All patients under-went bronchoscopy 1 or more times before surgery fordiagnosis and treatment. A foreign body (plastic material)was detected in 1 patient. Bronchoscopic findings werecritical for surgery assessment and preparation. The patientswere considered ready for surgery when sputum productionwas minimal or absent, bronchial mucosa was no longer
TABLE 1. Treatment period of 17 patients by yearsPeriod (y) <1 1–3 3–5 5–8 8>
inflamed after a bronchoscopic check-up, and contralateralpneumonic changes were absent.
It was possible to perform pulmonary function tests in 8of the older children and in those able to cooperate. Theother 9 younger patients were evaluated by an exercise-tolerance test. The 6-minute walk test was performed alonga level hospital corridor. Oxygen saturation (SaO2) wasmeasured by finger pulse oximetry before and during thetest and monitored continuously. Measurements were re-corded at 30-second intervals. All patients were able to walkcontinuously for the 6-minute period. The lowest SaO2 wasused to calculate minimum SaO2. Mean minimum SaO2 was95.3. Care was taken to ensure that SaO2 did not decreaseless than 90%. Along with exercise, a 2% or more desatu-ration was considered to represent a risk. One patient seento be at risk received 3 weeks of additional chest physio-therapy, incentive spirometry, nutritional support, and am-bulation with physical therapy. The patient underwent op-eration after this course of treatment. No patient wasobserved to have effort dyspnea after the test. In addition,blood samples were taken from all patients for blood gasanalysis from the femoral artery.
According to the nutritional status (size and weight) ofthe children preoperatively, 3 children were in the 3rd to10th percentile, 9 children were in the 10th to 25th percen-tile, and 2 children were in the 25th to 50th percentile.
Operative CourseAll of the operations were elective. Fourteen patients(82.3%) underwent left pneumonectomy, and 3 patients(17.6%) underwent right pneumonectomy. A double-lumenendotracheal tube was used in older children (n � 7) toavoid the spillage of infected material into the contralateralbronchus. In most of the patients in which the double-lumenendotracheal tube was not used, bronchoscopy was per-formed, and the bronchus of the side ready for resection was
cleaned by aspiration before the introduction of an endotra-cheal tube. Frequent intraoperative aspiration was requiredfor these patients. A Fogarty embolectomy catheter wasused as a bronchus blocker in 2 patients, with unsatisfactoryresults. In these 2 patients, respiratory distress occurredbecause the Fogarty catheter was either not properly placedor the patient was moved and the catheter was disturbed. Asa result of this, the Fogarty catheter was withdrawn, and thesurgery was continued. The standard posterolateral thora-cotomy approach was used in all patients. Thoracotomy wasperformed in a way to conserve as much muscle as possible.All of the pneumonectomies were performed in the in-trapleural plane.
Intrapericardial pneumonectomy was performed in 2 pa-tients. The main bronchus was closed by stapler in 2 patientsand by hand suturing with nonabsorbable suture material(polypropylene) or absorbable Vicryl polyglactin 910 (Ethi-con, Inc, Somerville, NJ) in the other patients. The bron-chial stump was routinely covered by adjacent tissue, me-diastinal pleura, pericardium, intercostal muscle, or acombination of these. Ten patients underwent invasiveblood pressure monitoring, which also allowed regularblood gas analysis during the intraoperative and postopera-tive period. One intraoperative death occurred as the resultof respiratory failure and cardiac arrest. All patients exceptone were extubated in the operating theater. One patientremained in the recovery room awaiting extubation for 6hours because of low oxygen saturation levels. A chest tubewas routinely placed into the pleural cavity and removed onthe first or second postoperative day in most patients.
Postoperative Course and ComplicationsPostoperative complications were followed for 30 days. Thepostoperative morbidity rate was 23.5% (n � 4). One pa-tient developed empyema (left) without bronchopleural fis-tula (BPF) on postoperative day 7. This patient was treatedby closed tube thoracostomy, antibiotics according to aculture antibiogram, and postpneumonectomy space irriga-tion with a 5% dextrose solution containing 2 g of cepha-losporin through a catheter introduced from the midclavicu-lar line at the second intercostal space. A continuous inflow-outflow irrigation system was established through thepleural cavity at an infusion rate of 50 mL per hour. After2 weeks, the pleural fluid color had cleared. After culturesproved negative for 3 days, tube drainage was discontinuedand pleural fluid was allowed to reaccumulate to fill theremaining space. Postoperative hemorrhage occurred fromthe intercostal muscle in 1 patient, and this required retho-racotomy. Respiratory inadequacy occurred in 1 patient as aresult of atelectasis, which was treated by bronchoscopicaspiration and respiration exercise. Empyema and BPF de-veloped on postoperative day 25 in 1 patient; open-windowdressing was performed in this patient after closed thorax
Figure 2. Bronchogram of a destroyed left lung shows stenosis ofthe left main bronchus.
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drainage. Later, BPF closure and myoplasty procedureswere performed to obliterate the postpneumonectomyspace. This patient underwent a right pneumonectomy andhad a history of tuberculosis. There was 1 postoperativedeath after a left pneumonectomy as the result of postpneu-monectomy edema on postoperative day 3. The medianlength of inpatient hospital stay was 15.5 days. Diagnosiswas made by histopathologic examination of the resectedlung tissue in all patients. The pathologic findings in theresected pneumonectomy specimens were end-stage de-stroyed lung.
Follow-upFollow-up information was available for 13 patients, whichranged from 1 to 12 years (median 5.2 years). One patientdied 2 years after surgery because of infections in theremaining lung. This patient underwent myoplasty as theresult of BPF and empyema. Two children had respiratoryinfections that were managed by outpatient therapy. Theother patients had no associated problems. There wasmarked herniation of the remaining lung with a mediastinalshift to the opposite side on follow-up chest radiography orCT of all the patients (Figure 3).
A group of 13 patients were tested for respiratory func-tion. Chest x-ray films were taken, and CT was performed insome patients. All patients appeared to be well clinicallyand were performing their normal daily activities. The re-spiratory capacity and scoliosis level of the patients wereexamined (Table 2), and the degree of scoliosis was gradedby the Cobb method.11 In 6 of the patients, light (�10°)scoliosis was detected (Figure 4). Of these 6 patients, 5underwent pneumonectomy before the age of 7 years. Thedegree of scoliosis was less than 10° in these 5 patients, andthey had received no prior treatment for scoliosis. Onepatient was 14 years old at the time of surgery and alsounderwent myoplasty. In this patient, the degree of scoliosiswas 13°; the patient died 3 years after surgery. Scoliosis didnot progress in any of the other patients. Patients havingscoliosis were followed up for 6 months to determine ifthere was any change in their condition.
The 7 patients who underwent preoperative pulmonaryfunction tests that we were able to follow up over the longterm had a mean vital capacity (VC) of 57.2% predicted; thesame patients at last check-up had a mean VC of 60.7%predicted. This result, however, was not statistically signif-icant. Over the long term, no patient described havingexercise or respiration difficulties. At the last check-up, 6patients who had undergone a preoperative exercise toler-ance test and had been followed up over the long termunderwent a 6-minute walk test; none of them were seen tohave symptoms of effort dyspnea The test was performed ina similar manner, and a mean minimum SaO2 of 97.5% was
found. This figure represented an important increase overthe preoperative period.
In addition, we evaluated all tests assessing the restric-tion or obstruction of respiratory functions. According toVC, 7 patients had light restrictions (VC: 66%-80% pre-dicted), and 6 patients were shown to have medium restric-tive ventilation dysfunction (VC: 51%-65% predicted). Ofthe 7 patients with light restrictions, 6 had undergone pneu-monectomy before the age of 10 years, and the periodbetween the operation and the time of testing varied be-tween 2 and 12 years. None of the patients was shown tohave obstructed airways (forced expiratory volume in 1second/forced VC% � 70). One patient who underwent aright pneumonectomy displayed an excessive shift of themediastinum trachea and esophagus 1 year after the opera-tion (Figure 5), but the patient had no findings of compres-sion of the left main bronchus and was free of respiratorysymptoms, dysphagia, and reflux.
We noted important improvements in the children’s nu-tritional status. Of 4 patients estimated to be in the 3rd to10th percentile group preoperatively, 3 were now in the 10thto 25th percentile group, and 1 had moved into the 25th to50th percentile group. Of the 7 patients estimated to be inthe 10th to 25th percentile group preoperatively, 5 hadmoved into the 25th to 50th percentile group, whereas theremaining patients showed no change. Neither of the 2patients in the 25th to 50th percentile group showed anysigns of change in their status.
DiscussionDestroyed lung caused by benign inflammatory lung dis-eases is an end-stage phenomenon prone to serious compli-cations.2 For destroyed lung, pneumonectomy proved to bethe most expeditious and effective management for serious
Figure 3. Chest CT scan of an 8-year-old boy shows the right lunggoes into the left chest with displacement of the mediastinalstructures into the left hemithorax 4 years after pneumonectomy.
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complications such as massive hemoptysis, secondary fun-gal infections, secondary amyloidosis, suppurative infec-tions, and pulmonary-systemic shunting.2,5
The most common cause of destroyed lung in our pa-tients was bronchiectasis. In 2, the diagnosis was congenitalcystic bronchiectasis. The causes of bronchiectasis in chil-dren are numerous. Nevertheless, in our patients the mostcommon causative factor was frequent pulmonary infection.Most of our patients had histories of insufficient and irreg-ular antibiotic use. Enlarged parabronchial lymph nodesafter pulmonary infections or narrowing secondary to thick-
ening of the bronchial lumen augment the progression of thebronchiectasis with pneumonia and destruction and maylead to total pulmonary bronchiectasis.1,12,13 The same sit-uation is considered to occur in children with tuberculosis.7
There was thickening in the main bronchus in 4 patients asa result of external pressure and intraluminal thickening andnarrowing in the main bronchi of 5 patients. Foreign bodyaspirations can also lead to whole lung bronchiectasis overthe long term, as in 1 of our patients.
The destroyed lung is nonfunctional with demonstrableabsent perfusion and ventilation.2,14 Bronchiectasis is com-
TABLE 2. Data on 13 patients at last check-up
No.
Age atpneumonectomy
(y)Resected
side
Age atlast
checkup(y)
Follow-upperiod (y) Scoliosis
VC(% pr)
FVC(% pr)
FEV 1(% pr)
FEV1/FVC(%)
1 6 L 18 12 No 68 70 66 912 13 L 24 11 No 62 66 62 943 3 L 12 9 Yes (�10°) 73 75 71 954 16 L 22 6 No 66 68 65 955 4 L 8 4 Yes (�10°) 68 70 64 916 14 R 16 Died at
age 17Yes (13°) 52 56 50 89
7 4 L 7 3 Yes (�10°) 69 72 67 938 10 R 11 1 No 58 62 60 979 6 L 10 4 Yes (�10°) 70 72 65 90
10 8 L 10 2 No 67 67 55 8211 12 L 17 5 No 59 62 57 9212 4 L 6 2 Yes (�10°) 55 53 60 11313 14 R 21 7 No 61 65 58 89
Figure 4. A, Chest x-ray film of a 7-year-old boy shows a light degree of scoliosis with collapse of the leftintercostal space 3 years after pneumonectomy. B, Chest x-ray film of an 18-year-old man shows a light degree ofscoliosis with collapse of the left intercostal spaces 12 years after pneumonectomy.
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monly complicated by hemoptysis, abscess formation, sep-ticemia, chronic suppurative states, and amyloidosis.1 Thepersistence of major inflammatory lung disease, especiallypulmonary tuberculosis, presents an evolving global prob-lem.15,16 The lung is the portal of entry for this disease, andit is the organ most involved pathologically. In the lung,tuberculosis produces an inveterate, necrotizing, granulo-matous process that involves the pleura. The destroyedpost-tuberculosis lung is a pathologic term describing thecomplication of end-stage inflammatory residues that fol-lows gross pulmonary destruction by tuberculosis and othercauses. Post-tuberculosis acute suppurative secondary in-fections in destroyed lungs are common. These infectionsmay be bacterial or fungal with significant bronchiectasis orin a residue cavity.1,5 Surgery in patients with tuberculosisinfections is indicated for the treatment of a destroyedpost-tuberculosis lung.
Chronic infectious complications in patients with de-stroyed lung include recurrent low-grade infections andfrequent hospitalizations. Chronic and acute hemoptysis canbe both debilitating and life-threatening. The severe consti-tutional symptoms seen in this patient group include feverand inanition.1 Growth retardation was found in 58.8% ofour patients. Improved nutrition was given to all our patientsduring the preoperative period. Correct anti-tuberculosistreatment should be administered to patients in whom activetuberculosis is diagnosed histologically in the postoperativeperiod. We did not provide anti-tuberculosis chemotherapyto any of our post-tuberculosis patients because we did notidentify histologically active tuberculosis in the postopera-tive period. The presence of active tuberculosis should beexamined in the preoperative period and treated beforesurgery. Two of our patients had pneumonia that rapidlyprogressed to total lung destruction. The chest x-ray film of1 of these patients had shown no abnormalities 10 monthspreviously. The other patient reported pulmonary symptomsonly 2 months previously. Both patients had a history ofsevere pulmonary infection and inadequate treatment. Pul-monary infections that are not treated promptly or ade-quately may lead to the total loss of the lung on 1 side,particularly in children. We cultivated K. pneumoniae from1 of these patients. There are few studies about pneumoniasresulting in necrotizing pneumonia or pulmonary gan-grene.4,17,18 These studies note that in addition to late orinadequate treatment, some patients have histories of aspi-ration. However, in 3% to 5% of patients, despite adequatetherapy, the disease process may progress to irreversiblerespiratory failure and death.4 In such patients, the mostcommon agents are Streptococcus pneumoniae, K. pneu-moniae, Bacteroides fragilis, P. aeruginosa, Haemophilusinfluenza, Staphylococcus aureus, and Escherichia co-li.4,17-19 The enzymes and toxins released by bacteria are themost important factors in the development of rapid lung
injury.4,17,18 A history of aspiration was absent in 2 of ourpatients.
Left lung involvement was found in 14 of our patients(82.3%), and only 3 patients (17.6%) had right lung involve-ment. Left lung involvement was also more common inother series.2,5,13 There are a number of possible reasons forthis. The left main bronchus is considerably longer andapproximately 15% narrower than the right main bron-chus,13 and the peribronchial space is limited by its prox-imity to the aorta; thus, it is more prone to obstruction by theenlargement of adjacent lymph nodes. In addition, the morehorizontal course of the left main bronchus, compared withthe right main bronchus, may have an effect on the drainageof secretions.1,13
A bronchus blocker Fogarty embolectomy catheter isused for younger children and in those in whom a double-lumen intubation tube for the drainage of lung secretionscannot be used.20 We used a Fogarty catheter in 2 patients,but it was removed after ventilation difficulties were noted.It was difficult to properly position the catheter. This prob-lem occurred either because of the inexperience of theanesthetist or as a result of the catheter being disturbedwhen the patient was being moved. Furthermore, Fogartycatheters may become displaced during manipulation of thebronchus, causing spillage or airway obstruction. Someauthors advocate using the prone position to avoid contam-ination of the healthy lung, although a prone thoracotomy ismore challenging for both the surgeon and the anesthe-tist.7,20,21 We did not use the prone position for surgerybecause of the difficulty of the position and our inexperi-ence in using it, and because its use may have prolonged theoperation. We believe that preoperative aggressive chestphysiotherapy, adequate and prolonged preoperative prepa-ration, precise sputum control, frequent intraoperative aspi-
Figure 5. Chest CT scan of an 11-year-old boy shows the exces-sive shift of the mediastinum to the right hemithorax 1 year afterpneumonectomy.
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ration, and bronchoscopic aspiration of the side that will beresected before the introduction of the endotracheal tubewere sufficient to prevent spillage. We did not encounterintraoperative spillage in any of our patients as a result ofour precautionary measures.
Pneumonectomy for inflammatory lung disease is fre-quently associated with high morbidity rates, and the fre-quencies of postpneumonectomy space empyema and BPFare high. It is essential to treat underlying infections beforesurgery in an effort to minimize sputum production, maxi-mize the patient’s nutritional status, minimize the chance ofintraoperative spillage, and decrease the risk of postopera-tive BPFs and postpneumonectomy space empyemas. Thereis scarce literature available on pneumonectomies in chil-dren, with postpneumonectomy complication rates of ap-proximately 20% in the series we located.22,23 The compli-cation rate in our series was similar at 23.5%. It is reportedthat postoperative morbidity and BPF are more common inpatients with tuberculosis, preoperative empyema, comple-tion pneumonectomy, or right pneumonectomy.1,3,5 Duringthe postoperative period, BPF developed in only 1 patient.This patient had a history of tuberculosis and had undergonea right pneumonectomy, open-window thoracostomy, andmyoplasty. The other patient in whom and empyema devel-oped had undergone left pneumonectomy.
Children and adults have been evaluated together inmany reports detailing destroyed lung. In these series, themortality rate was between 1.2% and 25%.2 The mortalityrate in our series was 11.7% (2/17). One patient who hadundergone pneumonectomy died intraoperatively as the re-sult of respiratory insufficiency, and 1 died on postoperativeday 3 as the result of postpneumonectomy pulmonaryedema. The remaining lung after pneumonectomy is knownto be prone to pulmonary edema that can carry a mortalityrate of 100%.24 The mechanism suggested for its develop-ment is not totally clear but includes increased capillarypressure, altered endothelial permeability, reduced lym-phatic carrying capacity, and overaggressive postoperativefluid therapy.25 Because of the possibility of the latter,postoperative fluid administration should be performed withcaution, particularly when considering fresh frozen plasmatransfusion.26
Patients underwent follow-up for a median of 5.2 years.One of the patients was lost during the follow-up period,and no major problems were observed in the other patientsexcept for mild pulmonary infections. All of the childrenwere observed to grow and develop normally after pneu-monectomy. There was marked herniation of the remaininglung with a mediastinal shift to the opposite side on fol-low-up chest radiography or CT in all of the patients.Postpneumonectomy syndrome developed in some patients(described mainly in neonates and children when tissue ispliant), especially those who underwent right pneumonec-
tomy. A marked shift and counterclockwise rotation of themediastinum cause compression of the bronchus betweenthe aorta and pulmonary artery, leading to respiratory dis-tress and even death.20,24 Numerous methods aimed at pre-vention and treatment have been described, including theuse of expandable silicone or saline-filled prostheses thatcan be inflated as the child grows.20,24 We did not use anyprostheses for intraoperative prevention in our patients.None of our patients had postpneumonectomy syndromeduring the postoperative follow-up period. As in our pa-tients with long-standing inflammatory diseases, a gradualmediastinal shift and lung herniation have developed. As aresult of this, the possibility of postpneumonectomy syn-drome developing in these patients is weak. In addition, wedid not want to use a prosthesis in our patients, becauseaccording to Blyth and coworkers,20 a prophylaxis can leadto complications.
In young children subjected to pneumonectomy, the sizeof the remaining lung increases by partial compensatoryovergrowth.10,27 In the youngest patients (ages 3-14 years),Peters and colleagues28 observed that considerable lungherniation can be associated with low residual air volumesand excellent VC and maximum breathing capacity.
In our subjects, those with a single lung coped well, andaccording to long-term follow-ups, all of these patientsperformed routine activities without difficulty. The respira-tory function test results, according to the remaining lung’sfunctional volume, were considered good. A slight degreeof restricted respiratory dysfunction was present in a signif-icant number of cases. Similar findings have been reportedin other studies.24 Patients undergoing pneumonectomy at ayounger age have a better VC than those who undergo thesame procedure at an older age. It is believed that theremaining lung is better able to expand in younger patients.This finding is supported by a number of studies that havenoted the compensatory growth with hyperplasia in youngerchildren10,28 and hypertrophy and dilation in older chil-dren.10 Over the long term, the postoperative VC of patientswas higher for those who were older and who could performfunction tests (Table 2). However, our younger patients hada higher mean VC percent prediction than those who un-derwent pneumonectomy at an older age. In addition, theexercise tolerance level of the younger children also in-creased.
Lezama-del Valle and colleagues24 described the long-term complications of scoliosis after pneumonectomy. Inchildren aged 1 to 3 years, scoliosis progressed from 10° to30° in 3 children in 3 to 5 years. We were unable to locateother studies on the long-term effects of scoliosis in childrenwho had undergone pneumonectomy. We found that 6 of 13patients demonstrated light (�10°) scoliosis at an averageof 5.2 years after pneumonectomy (range 1-12 years). Fiveof those patients with scoliosis were aged less than 7 years
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of age at the time of surgery. Patients with light scoliosis donot require treatment, although they should be examined atincreasing intervals to establish whether scoliosis has pro-gressed or not.11 In 1 patient with 30° scoliosis, Lezama-delValle and colleagues24 used a Boston jacket to correct thedeformation to 16°. Although patients who underwent pneu-monectomy before the age of 10 years have the possibilityof developing scoliosis in the long term, we do not think thattreatment will be required or that their resting posture willbe significantly affected.
ConclusionThe insufficient and inadequate use of medications for pul-monary infections and tuberculosis in patients, and the lackof follow-up over time, create a background for lung de-struction. Destroyed lung describes a totally nonfunctioninglung. When destroyed lung is ascertained, resection shouldbe performed to prevent complications, even though somepatients do not report significant symptoms. Patients shouldbe well prepared during the preoperative period in regard tonutritional status and infective process to minimize postop-erative complications. Children can easily tolerate pneumo-nectomy with acceptable rates of morbidity and mortality.In time, the remaining lung expands to compensate for theloss of the removed lung. Children acquire good exercisetolerance and higher lung volumes as the result of partialcompensatory lung growth and better nutritional status inthe long term. Those who undergo pneumonectomy andhave a healthy remaining lung tend to have a regular family,social, and work life. In the short term, patients should nothave major skeletal deformation.
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Eren, Eren, Balcı General Thoracic Surgery
The Journal of Thoracic and Cardiovascular Surgery ● Volume 126, Number 2 581
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2003;126:574-581 J Thorac Cardiovasc SurgSevval Eren, Mehmet Nesimi Eren and Akin Eraslan Balci
Pneumonectomy in children for destroyed lung and the long-term consequences
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