Why does lung cancer surgery bleed easily?
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Multiple large vessels entering and exiting the thoracic cavity are easily damaged during surgery
The more important vessels in the thoracic cavity are mainly the aorta, pulmonary artery, pulmonary vein, subclavian artery, upper and lower vena cava, odd vein, intercostal vessels, etc. These vessels are relatively large and are the central vessels of the circulatory system, which may lead to hemorrhage if they are injured.
Lobectomy requires the severance of several lobar arteries and veins, which are close to the heart, have high blood pressure and fast blood flow, and may bleed heavily in a short time if damaged.
In addition, some people have anatomical variants of blood vessels, and tumor invasion squeezes and adhesions shift the position of adjacent vessels, all of which increase the risk of vascular injury.
Another common cause is enlarged calcification of the lymph nodes. Lymph nodes are often associated with blood vessels, and enlargement and calcification of the lymph node can make it indistinguishable from a blood vessel or even invade it. There is a higher risk of bleeding when such lymph nodes are cleared during surgery.
Patients with cancer often have abnormal blood clotting
Patients with malignancy often have a combination of abnormal liver and kidney function and hematopoietic function, which can affect coagulation.
In addition, the risk of bleeding is even higher if patients with intermediate to advanced disease have received neoadjuvant radiotherapy first before surgery. This is because chemotherapy drugs directly affect the liver and bone marrow function, affecting the production of clotting factors and platelets, resulting in decreased coagulation, blood does not clot properly, the surgical wound cannot stop bleeding on its own, and the pleural cavity may “accumulate blood”.
Tumor invasion of blood vessels
When lung cancer is large and invades large blood vessels and the mediastinum, it can bleed a lot during surgery and cannot even be removed.
Thoracic adhesions
Under normal circumstances, the lung and chest wall in the chest cavity have a smooth surface (separated by the pleural cavity) and no adhesions. Due to factors such as inflammatory irritation, some patients may develop thoracic adhesions. On the one hand, the adhesive tissue carries many small blood vessels, and on the other hand, the adhesions can obscure the anatomy, and the surgeon may damage the blood vessels when separating the adhesions, leading to bleeding.
How to respond?
When bleeding occurs intraoperatively, physicians often use methods such as sutures to stop the bleeding. If the surgery is performed thoracoscopically, it may be difficult to stop the bleeding due to the limitations of the field of view and scope of operation, and the surgeon may add more incisions or convert to open surgery at any time to save lives.
Tearing bleeding from the pulmonary trunk often cannot be repaired, and the surgeon may expand the resection and convert to a total pneumonectomy.
Postoperative bleeding is often more urgent, and fluctuations in blood pressure may rebleed from intraoperatively sutured vessels. If there is a small amount of postoperative bleeding, it can be treated conservatively; if there is more bleeding, more than 200 mL in 3 hours, a second surgery is needed, and the surgeon will explore the bleeding in the chest cavity and do something to stop it.
Can the risk of bleeding be reduced preoperatively?
Before surgery, you and your family should tell your doctor what medications you have taken recently. If you have a combination of cardiovascular disease and often use anticoagulants (such as warfarin), remember to tell your doctor. During postoperative care, if you or a family member notice an increase in drainage fluid in the chest drainage bottle for a short period of time, or if you develop a dry mouth, wet and cold extremities, or a pale face, you should tell your doctor immediately.
Co-authors: Guangdong Provincial People’s Hospital Guangdong Lung Cancer Institute Dr. Shaopeng Zheng Dr. Jin Xia