Having an Operation?
Patient Information

Chest Drains

Chest Drain

When the chest is opened air is let in and after the chest is closed, this air must be let out for lung re-expansion. Drains which go to bottles on the floor with water in to seal the tubing, are used routinely after chest surgery for this purpose. When draining is minimal and no air leaks out with coughing, the drains are removed. This is done by the nurse, in the ward. A dressing is placed over the exit hole of the drain to seal it for 1-2 days, then the dressings are changed. When the dressings on the drain sites are removed on the second day it is possible to have a shower. Don't scrub the wounds but let water run over them,pat them dry, don't put powder on and redress with an ordinary bandaid daily until they are dry and don't rub on the clothing. If there is redness or pain or a discharge, it needs to be reviewed.

Pulse Oximeter - finger measure of oxygen level

Physiotherapy
It is important to continue with breathing exercises, to help lung expansion, and walking also helps breathing as well as improve general strength.

Sequencial Compression Device used during operation.

Stockings
A deep vein thrombosis is a serious complication of surgery and wearing stockings helps minimize the risk. The stockings need only be on during the day and need to be kept on until full mobility - usually several weeks after going home.

Bleeding
Of over 200 patients being operated on, only 10-15% needed a transfusion in the operative stay in hospital. If you have a reason you do not want a blood transfusion, please let the doctor know, and they will act accordingly. It is most likely that blood will not be needed and the operation will go safely without any problems.

Epidural Catheter.

Post Operative Pain
Immediate post operative pain can be controlled in several ways:

• Thoracic epidural (see image on right)
• Patient controlled analgesia (PCA)
• Narcotic infusion
• Intermittent injections.
• Walking and swinging the arms is critical to limber up and aid in reducing long term pain.
• If taking codeine preparations (e.g. Panadeine or Panadeine forte), it may be best to take Lactulose or other aperient for the bowels to minimize straining and discomfort.

Going Home
When you're ready to go home you should be fairly pain free, able to look after yourself going to the bathroom and be free of any temperature or other problem.

Pain
It takes several weeks for healing to take place and pain should dissipate over this time as activity increases. Sleeping well during the night is crucial to good progress - sleeping in the day time means being awake at night, with a night/day cycle reversal which leads to anxiety, pain, etc...

Complications of Surgery

Examples:

• Bleeding
• Infections
• Air leaking from the lung
• Deep vein thrombosis
• Atrial fibrillation - palpitations
• Pulmonary embolus - blood clot in the lungs
• Heart attack
• Adult respiratory distress syndrome

1. Bronchial - these are treated with antibiotics and chest physiotherapy.
2. Pneumonia
3. Pleural space infections with or without an air leak from the lung or bronchial stump.

Pneumonia is very uncommon post operatively. It is recommended that smokers stop smoking totally for 2 weeks prior to chest surgery to enable all the defense mechanisms against infection of the airways be given a chance to recover. On the lining of the wind passages are cells with tiny brushes called cilia. These propel mucus upward and collect dust particles inhaled, and when it reaches the top it is swallowed or coughed out. Smokes lose these cilia and so have to cough to clear pooling mucous in the air passage, but with time off smoking, they are regenerated and start working again to help clear the airways. Sometimes infected dung cancers have to be removed, and the sudden improvement after the operation is associated with an increase in the body's ability to clear infections, consequently infections are rare. If mucus becomes trapped in the airways after surgery and just cannot be coughed out, a Bronchoscopy needs to be done. This is usually done in the operating theatre using a rigid bronchoscope to look down into the airways and suck the tenacious mucus out. If infection occurs with dropping off of the gas transfer of the lung, then ventilation is sometimes required. Of a series of 200 patients operated on, 6 needed to be ventilated postoperatively, with complete recovery. No preoperative predictors were present for this need other than the patients may have had more secretions in the airways than normal, but on analysis of their respiratory function, they had better than the average. Air leaks from the divided edges of the lung can be associated with infections, if there is inadequate coughing of secretions because of the air leak out of the lung.  


Pleural Space Infections:
Antibiotics are routinely given post operatively and as a result any form of infection in the chest is rare. The surgical principle to minimise infections around the lung, in the pleural space, is that if the remaining lung is fully expanded at the end of the operation, then there is no space for fluid to accumulate in that may get infected. However, as the windpipe is cut across, organisms from the airway can enter the cavity and cause infections. If an air leak occurs from where the lung is divided and this has contributed to the space infection, continued drainage of the chest while waiting for the air leaks to close off is the treatment. If the windpipe is suspected of having a leak, a Bronchoscopy to confirm it is necessary, followed by an operations to repair it. The infected pleural space is then either drained or irrigated or an opening is made in the chest as a window to allow proper drainage. This may be necessary if the whole lung is removed because the space cannot be taken up by any lung tissue. Open drainage may be a permanent requirement - occasionally closure of the chest again is possible.

Air Leaks:
Since the early 70's when the Russian surgeons developed the staplers, and the USA marketed the reloadable ones, use of staplers has become routine in thoracic surgery, and with a wide range of different sizes and types, most patients would have their bronchus or edge of lung stapled to seal them. All staples used now are Titanium - a non ferrous metal which are almost too small to see on the X ray, remain for ever and are not removed, don't rust and don't trigger off airport alarms.  One can have an MRI scan with these staples in place.   The staples close like  capital "B" rather than flat like paper staples and so crimp the surfaces together.  Because they don't actually crush the lung completely, air can leak out around the tiny holes they create.  These air leaks usually settle down as healing occurs, and drains are left in so air does not build up in the chest and stop lung expansion - this may take up to 2 weeks.  For unknown reasons, the bronchus can leak late on during recovery - this usually needs a Bronchoscopy to diagnose its location and assist in planning a repair.  When it needs repairing, it usually requires support with adjacent muscle being swung like a flap, over the surface to give its edge a good blood supply, or omental tissue from the stomach being rotated into the chest to give it coverage by healthy well vascularized tissue.  More and more commonly now, patients are sent home with the drain in place connected to a Heimlich valve connected, to wait for closure of the air leak.  This valve developed as long ago as the 1920's is extremely simple and allows patients god mobility whilst healing takes place.

Risks Of Not Coming Through The Surgery:
With such major surgery as this, risks are always there of having an unexpected problem, which can mean not coming through, such as an unexpected heat attack, blood clot landing in the artery to the lungs cutting of blood supply through the lungs and out to the body, or major congestion and infection which can't resolve despite treatment. The overall risk is 3 in 100 operations, but predictors are hard to determine because preoperative evaluation is very thorough.  In the assessment, evaluation of extent and operability of the cancer go hand in hand with medical evaluation.  Blood pressure control, diabetes control, evaluation of chest pain to exclude untreated cardiac disease as well as stabilisation of any other medical conditions ensure that the risks are kept low. Every so often when risks against benefits seem high, it is better to opt for radiation/chemotherapy to treat the cancer rather than have the increased risk of not coming through an operation.  This is why however multidisciplinary groups have become established in the major centres between surgeons, oncologists, radiotherapist and physicians to discuss treatment and risks individually. 

Heart Rhythm Disturbances - Atrial Fibrillation:
It is not known why the heart goes into atrial fibrillation following lung surgery, but it has been known to occur ever since lung surgery was first performed.  In fact, 20 years ago, patients would be admitted 4 days prior to lung surgery to start Digoxin so that they would have a therapeutic level in the blood at the time of the surgery and minimise the onset of this rhythm disturbance.  Nowadays the rate of needing this medication is around 15% of patients at the most - most patients going into this rhythm do so several days after the operation and may feel a "bump" in the chest and become sweaty.  Most of the time blood pressure doesn't drop, and Digoxin or similar medication is started which controls the rate and hopefully helps it switch back to normal sinus rhythm.  Digoxin once started is usually kept going for 6 or so week after going home, and if back in normal rhythm when reviewed, stopped.

Example of Atrial Fibrillation on chart.

Link: Smoking, Lung Cancer, Operations, and Giving Up Smoking.