Re-operation through the same approach after thoracic surgery excepting postoperative clotted hemothorax: retrospective study about 20 patients

Re-operation through the same approach after thoracic surgery excepting postoperative clotted hemothorax: retrospective study about 20 patients

Harmouchi Hicham^1,&, Ammor Fatimazahra¹, Belliraj Layla¹, Lakranbi Marouane^1,2, Ouadnouni Yassine^1,2, Smahi Mohamed^1,2

¹Department of Thoracic Surgery, CHU Hassan II of Fez, Fez, Morocco, ²Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdallah University, Fez, Morocco

^&Corresponding author
Harmouchi Hicham, Department of Thoracic Surgery, CHU Hassan II of Fez, Fez, Morocco

Introduction    

Thoracic surgery has undergone a tremendous development due to introduction of minimally invasive surgery and advances in techniques of general anesthesia and analgesia. This has allowed a decrease in rates of morbidity and mortality. Postoperative complications can occur following each thoracic surgical procedure. The most feared complications remain atelectasis, postoperative hemothorax, postoperative pyothorax, prolonged aerial leakage and bronchopleural fistula especially after pneumonectomy or pulmonary lobectomy. Most complications are managed by conservative methods such as fibroaspiration, mobilization or addition of a chest tube [1,2]. Sirbu and colleagues in their article published in 1998 about re-exploration for complications after lung surgery, they found that postoperative bleeding is the frequent complication for re-operation [3]. In different series, the rate of this complication is varied between 25 to 75% [3-5]. In this manuscript, we excluded the postoperative clotted hemothorax, since it was devoted in another article. The particularity in this manuscript according to the title, we treat patients who were re-operated through the same approach of the first surgery. Several articles discuss reoperation in a general way, which explain the frequency of postoperative clotted hemothorax and bronchopleural fistula [4,5].

Methods     

It was a descriptive and monocentric study with a retrospective collections of data, concerning 20 patients who were re-operated in our department of thoracic surgery over a period of ten years (from 1 January 2009 to 31 December 2018). We have included all patients who were benefited of a thoracic surgery in the past time in our department or outside it and who were operated from the same first surgical incision, whatever the period between the two interventions. Also, patients who were approached from the same first incision with addition of another approach were included in this study. Our exclusion criteria were patients benefiting of a re-exploration for postoperative clotted hemothorax and patients operated from another approach other than the first approach. Also, patients with incomplete medical records were excluded. We have collected data from the operative report, especially age, sex, indications for the first intervention and approach, the period between the two surgical procedures, informations concerning the second intervention (approach, extrapleural plan, exploration, chest tube) and finally postoperative complications. Our aim is to specify the indications for re-operations of these patients and to characterize the difficulties and comlplications that are accompanied to this reintervention through the same approach.

Results     

Among 20 patients, it was 9 men (45%) and 11 women (55%). The median age was 50.55 years old with extreme ages between 24 and 74 years old. Table 1 summarizes data of all patients. The first surgical procedure was carried out outside of our department in 9 patients (45%) against 11 patients (55%) was managed by our thoracic surgeons. Duration between the first and second surgery was varied from 4 days to 30 years. The etiologies indicating the first surgery were: hydatidosis all form combined in 7 patients (35%) (hydatid cyst of liver broken in the thorax in 2 patients 10%), chest wall disease in 3 patients (15%), post-trauma affections in 2 patients (10%), mediastinal pathology in 2 patients (10%), undocumented problem in 1 patient (5%), tuberculosis pyothorax in 1 patient (5%), goiter in 1 patient (5%), diaphragmatic hernia in 1 patient (5%), cavitary lesion in 1 patient (5%) and aspergilloma in 1 patient (5%). The approach for the first intervention were thoracotomy in 12 patients (60%), elective incision in 3 patients (15%), cervicotomy in 2 patients (10%), sternotomy in 1 patient (5%), mediastinoscopy in 1 patient (5%) and anterior mediastinotomy in 1 patient (5%). The reasons why a re-operation was indicated were: recurrence of hydatidosis in 3 patients (15%) and recurrence of elastofibroma dorsi in 1 patient (5%), recurrence of hemoptysis in 1 patient (5%), inconclusive anatomopathological study in 2 patients (10%), fortuitous adenorcacinoma discovery in 2 patients (10%), postoperative empyema in 4 patients (20%), infection of the chest wall in 3 patients (15%), chest wall hematoma in 1 patient (5%), diaphragmatic hernia in 1 patient (5%), cervical and mediastinal lymph nodes after an operated goiter in 1 patient (5%) and finally lachage of tracheal sutures in 1 patient (5%). For postoperative complications, 3 patients needed transfusion of the red blood cells (15%) and the rate of mortality was 15% in 3 patients. No patient in our study was operated for a persistent prolonged air leakage.

Discussion     

In recent years, various evolutions have been observed which can influence the surgical follow-up in thoracic surgery. These evolutions concern surgical techniques by the rise of video-assisted thoracoscopic surgery (VATS) and the optimization of anesthetic techniques and postoperative management in intensive care unit, including the use of non-invasive ventilation [6]. Some complications after thoracic surgery are common to any surgical procedure, and some depend on the type of intervention. The frequent reason for early reoperation in different series remains postoperative clotted hemothorax. According to Table 1, there are patients who were re-operated in the early period after the first surgery and patients who were stayed years before benefited of a second intervention. In the first case and especially after thoracotomy, there is no difficult since the pleura-pulmonary adhesions are not yet constituted. Unlike the second case where the pulmonary release is laborious and difficult, associated with bleeding. The recurrence of hydatid cyst is related to patients who have been operated by general surgeons who don´t know the particularities of hydatidosis surgery (especially the notion of avoiding pleural contamination), since thoracic surgery has not been recognized at the time in our country.

Surgical revision for wall infection is also common in our study, due to the predominance of infectious diseases in our context [7]. Normally, infection of the wall is managed by the daily dressing and the antibiotic treatment oriented by the antibiogram after sampling. However, a patient who does not respond to these procedures and in case of deep infections, sometimes associated with pleural empyema, surgical revision is indicated. No patient in our series was re-operated for persistent prolonged air leakage. Our procedure in this complication is to mobilize the chest tube or add another. Cristophoros and colleagues according to their article published in 2014, they have reoperated 6 patients among 719 patients for control of a prolonged air leakage [8]. For postoperative atelectasis, especially in children who cannot do their respiratory physiotherapy properly, our managment is to perform fiberoptic with bronchial aspiration and no patient was reoperated for this complication. Otherwise, the patient is urged to do his respiratory physiotherapy after leaving the hospital with spontaneous cough and incentive spirometry. When the surgical procedure is done for patients in order to have a diagnosis (mediastinotomy or mediastinoscopy) and the pathological study is inconclusive, we can propose to reoperate the patient to have a diagnosis especially if there are no other alternatives to get the diagnosis and the surgical procedure is not aggresive.

Likewise, the fortuitous discovery of lung cancer on the operative specimen was noted in two patients in this study who were chronic smokers; the first was operated firstly for a pulmonary hydatid cyst and the other for an aspergilloma. In this cases, an anatomical lung resection with mediastinal lymph nodes dissection remain mandatory. The mortality rate was low in the Christophoros series and colleagues (6.1%), with variable rates ranging from 13.3-37.7% [3,4,9]. In our series, the mortality rate was 15%. the limitations of this study is that it is retrospective, including a small number of patients and excluding patients with postoperative clot hemothorax and bronchopleural fistula with the most common complications indicative of reoperation. The advantage is that this study included all approaches that were performed, thoracotomies and others.

Conclusion     

The surgical reintervention after thoracic surgery through the same incision, especially a thoracotomy, presents a surgical difficulty that associates in the postoperative period with prolonged air leakage and bleeding following laborious release of the lung. Recurrence of primary disease, inconclusive anatomopathological study and the fortuitous discovery of lung cancer also present indications for reoperation.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Table     

Table 1: characteristics of patients

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