In lung cancer treatment, surgery provides the best chance for a cancer cure by precisely removing the tumor from the body. However, as an invasive treatment, surgical treatment often comes with some unforeseen risks while allowing lung cancer patients to achieve excellent outcomes.
Risks associated with surgery
Lung cancer surgery involves many vital organs and requires a high level of expertise, clinical experience, and surgical skill from the surgical team. In a small number of patients, appropriate complications can occur as a result of improper surgical procedures, commonly including persistent pulmonary air leak, postoperative bleeding, and bronchopleural fistula.
Persistent postoperative pulmonary air leak
A small amount of short-term postoperative air leak is more common after lung cancer surgery, but an air leak longer than 5 days is called a persistent air leak, and its occurrence is related to the quality of the lung tissue and the size of the surgical wound. Mild postoperative lung air leaks can be promoted by enhanced nutrition to promote wound healing, whereas severe air leaks may require surgical repair.
Postoperative bleeding
Small amounts of postoperative bleeding are common, and when bleeding is greater than 100 ml/h, it is called postoperative bleeding. Most of the bleeding is due to dislodgement of blood crusts from the dissected ends of small vessels or damage to the intercostal or bronchial arteries, and some patients require reoperation to stop the bleeding. Very few patients will have large pulmonary vascular hemorrhage with violent bleeding and high mortality, requiring emergency resuscitation.
Bronchopleural fistula
After lung surgery, the disconnected bronchial stump requires specialized closure, and in a few patients, due to poor healing, the bronchial stump splits and forms a bronchopleural fistula. At this point, serious chest infection and respiratory failure are triggered, which are among the more serious surgical complications. It is usually controlled by surgery or interventional therapy after adequate drainage and nutritional support.
Risks associated with anesthesia
Anesthesia can reduce pain and better maintain the stability of the patient’s body’s internal environment to ensure smooth lung cancer surgery. However, anesthesia comes with certain risks, such as airway obstruction, gastrointestinal reactions, and delayed awakening.
Respiratory obstruction
This is one of the most serious complications of anesthesia. Common causes include posterior tongue drop, laryngospasm, and laryngeal edema, which need to be identified early and removed promptly. In a small number of patients with severe disease, emergency endotracheal intubation or tracheotomy is required.
Gastrointestinal reactions
A common complication of anesthesia, often caused by anesthetic drugs or surgical medications. The patient should be shifted to the lateral position promptly to avoid asphyxia from inadvertent suction. In severe cases, antiemetic medications can be administered to relieve symptoms.
Delayed awakening
Often caused by residual effects of anesthetics, symptomatic treatment with antagonists of the appropriate anesthetics is indicated; appropriate ventilation and high-flow oxygenation may also allow rapid expulsion of inhaled anesthetics.
Vital system dysfunction
Lung cancer surgery involves many vital organs, and the patient’s physical condition, different surgical approaches, and the surgeon’s technical ability may lead to different degrees of organ damage, which affects the patient’s postoperative recovery and prognosis.
Respiratory injury
The most common complications of thoracic surgery include pulmonary infection, pulmonary atelectasis, pulmonary embolism, and respiratory failure.
- Pulmonary infection: Patients with postoperative reduced respiratory muscle tone, sluggish cough reflex, and tracheal intubation can cause varying degrees of pulmonary infection, which should be treated promptly with sensitive antibiotics.
- Postoperative pulmonary atelectasis: It often begins 24 to 48 hours after surgery and is mostly caused by bronchial secretions that are not easily drained and obstructed. Mild pulmonary atelectasis can be treated symptomatically by promoting sputum drainage. In a few patients with severe pulmonary atelectasis, respiratory function is affected and a tracheotomy is required to help drain the sputum.
- Pulmonary embolism: It is one of the most dangerous postoperative complications, mostly due to prolonged postoperative bed rest and dislodgement of deep vein thrombosis in the lower extremities of the patient. Pulmonary embolism has a high mortality rate and requires emergency resuscitation once it occurs.
- Respiratory failure: It is the end stage of respiratory complications. Respiratory infection and bronchial asthma are two common causes of respiratory failure after lung cancer surgery. Early diagnosis and treatment are the keys to successful resuscitation of postoperative respiratory failure.
Circulatory system
Common cardiac arrhythmias, hypovolemic circulatory disorders, and heart failure.
- Cardiac arrhythmias: the most common circulatory complication, mainly due to the effect of surgery on cardiac function. The incidence of postoperative arrhythmias in elderly patients with lung cancer is as high as 50% to 70%, with atrial fibrillation being more common; the incidence of severe arrhythmias is nearly 14%, occurring mainly on postoperative days 2 to 4.
- Low-volume circulatory disturbance: It occurs mostly within 2 days after surgery, mainly due to high surgical trauma, high and rapid intra-thoracic exudation, or intra-thoracic hemorrhage, and requires timely blood volume supplementation therapy.
- Heart failure: It is the end stage of circulatory complications. It is mainly due to the increased pressure and resistance of the pulmonary circulation and the progressive increase of the right heart load after pneumonectomy. Early in the disease, heart rate and cardiac output may increase compensatorily, but as the resistance of the pulmonary circulation increases, the right heart load is further increased, eventually leading to heart failure.
Cancer recurrence or metastasis
The aim of lung cancer surgery is mainly to completely remove the tumor and strive to achieve a curative effect. However, there are still some patients who inevitably develop recurrence or metastasis after surgery, which is the main reason for failure of lung cancer treatment.
Recurrence, in which residual cancer cells continue to grow and form new lesions, and metastasis, in which cancer cells spread to distant sites to form new tumors via blood vessels and lymphatic vessels. The key to reducing recurrence and metastasis of lung cancer lies in early surgical treatment. The earlier the staging, the easier it is to be completely removed by surgery. For patients with more advanced staging, the chance of radical resection needs to be improved by preoperative or postoperative combination of systemic therapy (chemotherapy, targeted and immunotherapy, etc.).