Geç Postoperatif Komplikasyonlar
Özet
Torasik cerrahi sonrasında birinci aydan itibaren görülen geç postoperatif komplikasyonlar, hastaların morbidite ve mortalite oranlarını önemli ölçüde etkilemektedir. Cerrahi insizyonlara bağlı olarak brakial pleksus ve ulnar sinir hasarı, kronik ağrı (posttorakotomi ağrı sendromu), kanat skapula, göğüs duvarı fıtıkları, seroma ve sternal dehisens gibi komplikasyonlar gelişebilir. Akciğer rezeksiyonları sonrasında ise özellikle sağ pnömonektomilerde mortalitesi yüksek olan bronkoplevral fistül (BPF), postpnömonektomi pulmoner ödemi ve mediastinal şifte bağlı gelişen postpnömonektomi sendromu gibi kritik tablolar izlenebilir. Trakeobronşiyal cerrahilerde anastomoz stenozu ve ölümcül trakeoinnominate arter fistülleri görülebilirken, akciğer nakli sonrasında fırsatçı enfeksiyonlar, bronşiyal stenoz ve en sık ölüm nedeni olan kronik allograft disfonksiyonu (BOS ve RAS) ön plana çıkar. Özofagus cerrahilerinde anastomoz darlığı, diyafragmatik herniasyon ve boşalma gecikmesi yaşanabilir; ayrıca cerrahi sahada yabancı cisim unutulması (gossiboma) da nadir bir komplikasyondur. Bu komplikasyonların önlenmesinde dokulara maksimum özen gösterilmesi, etkili analjezi ve yakın postoperatif takip kritik öneme sahiptir.
Late postoperative complications occurring after the first month of thoracic surgery significantly impact patient morbidity and mortality. Incision-related complications include brachial plexus and ulnar nerve injuries, chronic pain (post-thoracotomy pain syndrome), winged scapula, chest wall hernias, seroma, and sternal dehisence. Following lung resections, critical conditions such as bronchopleural fistula (BPF)—which carries high mortality, especially after right pneumonectomy—post-pneumonectomy pulmonary edema, and post-pneumonectomy syndrome due to mediastinal shift can occur. Tracheobronchial surgeries may lead to anastomotic stenosis and fatal tracheoinnominate artery fistulas, whereas lung transplantation carries risks of opportunistic infections, bronchial stenosis, and chronic allograft dysfunction (BOS and RAS), which represents the leading long-term cause of death. Esophageal procedures can result in anastomotic strictures, diaphragmatic herniation, and delayed gastric emptying; additionally, retained foreign bodies (gossiboma) remain a rare risk. Preventing these complications requires meticulous tissue handling, optimized multi-modal analgesia, and rigorous postoperative follow-up.
Referanslar
Kaiser D. Early and late postoperative complications in thoracic surgery interventions. Pneumologie 1991;45:147-52.
Heitmiller RF (1996). Thoracic incisions. Baue AE, Geha AS, Hammond GL, et al. In Glenn’s Thoracic and Cardiovascular Surgery, 6th edn (73-89). Stanford:Appleton and Lange.
Berry MF, Friedberg J. Chest wall/diaphragmatic complications. Thorac Surg Clin 2006;16:277-285.
Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin 2004;14:345-352.
Grogan EL, Jones DR. VATS lobectomy is better than open thoracotomy: what is the evidence for short-term outcomes? Thorac Surg Clin 2008;18:249-258.
Reuben SS, Yalavarthy L. Preventing the development of chronic pain after thoracic surgery. J Cardiothorac Vasc Anesth 2008;22:890-903.
Kelsheimer B, Williams C, Kelsheimer C. New Emerging Modalities to Treat Post-Thoracotomy Pain Syndrome: A Review. Mo Med. 2019 Jan-Feb;116(1):41-44.
Koehler RP, Kenan RJ. Management of postthoracotomy pain: acute and chronic. Thorac Surg Clin 2006; 16:287-297.
Salazar JD, Doty JR, Tseng EE et al. Relationship of the long thoracic nerve to the scapular tip : an aid to prevention of proximal nerve injury. J Thorac Cardiovasc Surg 1998;116:960-964.
Mitchell RL. The lateral limited thoracotomy incision: standard for pulmonary operations. J Thorac Cardiovasc Surg 1990;99:590-595.
Demmy TL, Park SB, Liebler GA et al. Recent experience with major sternal wound complications. Ann Thorac 1990;49:458-462.
Davidson BR, Bailey JS. Incisional herniae following median sternotomy incision: their incidence and aetiology. Br J Surg 1986;73:995-996.
Rostad H, Strand TE, Naalsund A, et al. Lung cancer surgery:the first 60 days. A population-based study. Eur J Cardiothorac Surg 2006;29:824-828.
Ginsberg RJ. Lung cancer surgery: acceptable morbidity and mortality, expected results and quality control. Surg Oncol. 2002 Dec;11(4):263-6
Wada H, Nakamura T, Nakamoto K, et al. Thirty-day operative mortality for thoracotomy in lung cancer. J Thorac Cardiovasc Surg. 1998 Jan;115(1):70-3.
İnan K, Şengül İnan M, Bıçakçıoğlu P, et al. The surgical management in pneumonectomy cases for lung cancer treatment. Curr Thorac Surg. 2020; 5(2): 064-070
Bernard A, Deschamps C, Allen MS, et al. Pneumonectomy for malignant disease:factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 2001;121:1076-1082.
Sonobe M, Nakagawa M, Ichinose M, et al. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000;18:518-523
Sirbu H, Busch T, Aleksic I, et al. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001;7:330-336.
Sarkar P, Chandak T, Shah R, et al. Diagnosis and management bronchopleural fistula. Indian J Chest Dis Allied Sci 2010;52:97-104.
Ginsberg RJ, Pearson FG, Cooper JD, et al.: Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach. Ann Thorac Surg 1989;47:231-235
Deslauriers J, Aucoin A, Gregoire J. Postpneumonectomy pulmonary edema. Chest Surg Clin North Am 1998;8:611-631.
Ponn RB (2005). Complication of Pulmonary Resection. In:Shields TW, Lo Cicero J, Ponn RB, Rusch V.,et all editors. In General Thoracic Surgery 6th ed. (554-586.) Philadelphia:Lippincot Williams and Wilkins.
Deslauriers J, Ferraro P (2002). Late Complications. In:Pearson FG, Cooper JD, Deslauriers J, et all editors. In Thoracic Surgery 2nd ed (189-207). Philadelphia:Churchill Livingstone.
Grillo HC, Shepard JA, Mathisen DJ, et al. Postpneumonectomy syndrome: diagnosis, management, and results. Ann Thorac Surg 1992;54:638-50
Kelly RF, Hunter DW, Maddaus MA: Postpneumonectomy syndrome after left pneumonectomy. Ann Thorac Surg 2001;71:701.
Tedder M, Anstadt MP, Tedder SD, et al. Current morbidity, mortality and survival after bronchoplastic prosedures for malignancy. Ann Thorac Surg 1992;54:387-391.
Mathisen DJ. Complications of tracheal surgery. Chest Surg Clin N Am 1996;6: 853.
Machuzak M, Santacruz J.F, Gildea T, et al. Airway complications after lung transplantation. Thorac Surg Clin 25 (2015) 55–75
Wright D. Management of tracheoinnominate fistula. Chest Surg Clin N Am 1996;6:865.
Kıyan E. Akciğer naklinde geç dönem medikal komplikasyonlar. Güncel Göğüs Hastalıkları Serisi 2020;8: 127-135.
Nosotti M, Tarsia P, Morlacchi LC. Infections after lung transplantation. J Thorac Dis 2018; 10: 3849-68.
Pappas PG, Alexander BD, Andes DR, et al. Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Ne twork (TRANSNET). Clin Infect Dis 2010; 50: 1101-11
Türkkan S, Yekeler E. Akciğer nakli sonrası hava yolu komplikasyonları ve yönetimi. Güncel Göğüs Hastalıkları Serisi 2020;8:61-67.
Torre M.D, Fernandez R, Fieira E. et al. Postoperative surgical complications after lung transplantation Rev Port Pneumol. 2015; 21(1):36-40.
Weigt SS, Der Hovanessian A, Wallace WD,et al. Bronchiolitis obliterans syndrome: the Achilles’ heel of lung transplantation. Semin Respir Crit Care Med 2013; 34: 336-51.
Belle-van Meerkerk G, van de Graaf EA, Kwakkel-van Erp JM, et al. Diabetes before and after lung transplantation in patients with cystic fibrosis and other lung diseases. Diabet Med 2012; 29: e159-62
Nagle SJ, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38: 771-83.
Luskin MR, Heil DS, Tan KS, et al. The Impact of EBV Status on Characteristics and Outcomes of Posttransplantation Lymphoproliferative Disorder. Am J Transplant 2015; 15: 2665-73.
Orringer MB, Marshall B, Iannettoni MD. Transhiatal esopagectomy:clinical experience and refinements. Ann Surg 1999;230:392-400
Barthel JS, Kelley ST, Klapman JB. Management of persistent gastroosophageal anastomotic strictures with removable self-expandable polyester silicon-covered stents: an alternative to serial dilation. Gastrointest Endosc 2008;67:546-552.
Vallbohmer D, Holscher AH, Herbold T, et al. Diaphragmatic hernia after conventional or laparoscopic-assisted transthorasic esophagectomy. Ann Thorac Surg 2007;84:1847-1852.
