Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.

OBJECTIVE: From January 1998 to February 1999, 160 patients undergoing lung resection for non-small cell lung cancer were studied to define factors that increase the risk of postoperative supraventricular arrhythmia (SA) and to assess the effectiveness of amiodarone as an antiarrhythmic drug. METHODS: All patients were monitored intraoperatively and postoperatively up to day 3. Onset of SA was documented with ECG. Amiodarone was administered to those who developed SA with a loading dose of 5 mg/kg in 30 min and a maintenance dose of 15 mg/kg in 24 h. RESULTS: Mean age was 64 years (range 27-83 years). There were nine wedge resections, six segmentectomies, 127 lobectomies and 18 pneumonectomies. Twenty-two patients (13%) had SA, all of which were atrial fibrillations. The incidence of supraventricular arrhythmia with pneumonectomy and lobectomy was 33 and 12%, respectively (P=0.02). None of the patients who had a minor resection developed SA. The peak incidence of onset of SA occurred on postoperative day 2 and lasted from 1 to 12 days (average 3.4 days). Sinus rhythm was achieved with amiodarone in 20 patients (90.9%) with no side effects. Two patients received electrical cardioversion because hemodynamically unstable. Mean preoperative pO(2) and pCO(2) were lower in patients with SA: pO(2) 80.8 vs. 85 mmHg (P=0.04); pCO(2) 35.5 vs. 38 mmHg (P=0.01). Patients with concomitant cardiopulmonary diseases presented an odds ratio for postoperative arrhythmia of 12.4 (confidence interval 4. 5-34.1) (P<0.0001). CONCLUSION: Concomitant cardiopulmonary diseases, lower pO(2), pCO(2) and extent of surgery increase the risk of postoperative SA after lung resection for non-small cell lung cancer. Cardiac monitoring in patients at risk is recommended. Amiodarone was both safe and effective in establishing and maintaining sinus rhythm.     

心包内全肺切除术83例报告

目的 探讨心包内全肺切除术的适应证，手术技术，心包缺损修补和心脏疝预防，术后心律失常的处理等问题。方法 回顾性分析自１９９３年１月至１９９９年３月施行的心包内全肺切除术８３例的７病例资料。结果 全部病例均术中修补心包，其中术中直接间断缝合心包缺损６５例，自体壁层胸膜修补心包１７例，涤纶片修补１例。术后无心脏疝发生。术后并发心律失常８例，均发生在术后１周内。结论 术中探查才能决定是否行心包内全肺切除     

Cardiac herniation and sub-herniation. Complication of intrapericardial pneumonectomy]

Two cases are reported of cardiac herniation complicating intrapericardial pneumonectomy in the early postoperative period. Both patients had a radical pneumonectomy for right-sided bronchial carcinoma invading, in one patient, the carina and the superior vena cava. The pericardial defect, made necessary by the surgical procedure, had not been closed in either patient. About two hours after the end of surgery, both patients, lying supine, developed a state of shock, with tachycardia and arterial hypotension. The diagnosis of cardiac herniation was made in both cases on the chest film. Placing the patient on his left side was only partly efficient in one patient, slowing the heart rate from 160 b.min-1 to 120 b.min-1 and increasing the systolic blood pressure (from 60 mmHg to 80 mmHg). Both patients therefore required to be operated on again. In one patient, the heart had completely herniated through the pericardial defect, and had turned to the right side about the vena caval axis; in the other patient, partly improved by being turned to his left, the heart had returned to its normal position. The pericardial defects were closed in both cases with a strip of dura mater previously treated with 2 (ethyl-mercurithiol-5-benzoxazol) carboxylic acid. The immediate postoperative course was uneventful. Unexpected symptoms and sign occurring in the early postoperative period after intrapericardial pneumonectomy must imperatively lead to carrying out a chest X-ray.     

Pneumonectomy for unilateral destroyed lung with pulmonary hypertension due to systemic blood flow through broncho-pulmonary shunts.

OBJECTIVE: Three decades ago, a few patients with pulmonary hypertension and respiratory failure associated with a unilateral destroyed lung were reported to have been treated by a pneumonectomy. In the present study, we investigated the clinical features, operative indications, and results of four cases with pulmonary hypertension that underwent a pneumonectomy for a unilateral destroyed lung. METHODS: Four patients (three males, one female) with a destroyed lung and pulmonary hypertension (mean pulmonary arterial pressure >25 mmHg) were treated by a pneumonectomy between 1999 and 2002 at our institution. Their mean age was 59 years old (range 42-68 years). The underlying lung disease, Medical Research Council (MRC) dyspnea scale, respiratory function, arterial blood gas analysis, pulmonary arterial pressure, preoperative management, operative procedure, and postoperative course for each were reviewed retrospectively. RESULTS: The underlying lung disease that caused the destroyed lung was bronchiectasis in two patients, chronic empyema with bronchopleural fistula in one, and necrotizing pneumonia in one. The average mean pulmonary artery pressure was 33 mmHg (range 25-42 mmHg), which decreased to 27 mmHg (range 19-36 mmHg) after occlusion of the pulmonary artery in the affected lung. Following the pneumonectomy, the average mean pulmonary artery pressure was decreased to 17 mmHg (range 11-25 mmHg). Chronic inflammatory symptoms and functional impairments (showed by blood gas analysis, pulmonary arterial pressure, or MRC dyspnea scale) improved post-pneumonectomy. There was no operative death, though postoperative cardiorespiratory failure occurred in one patient. All patients were discharged from the hospital. CONCLUSIONS: We concluded that a pneumonectomy procedure may be indicated for selected patients with a unilateral destroyed lung and pulmonary hypertension due to systemic blood flow though broncho-pulmonary shunts.     

Cardiac herniation following intrapericardial pneumonectomy

Deiraniya, A. K. (1974).Thorax, 29, 545-552. Cardiac herniation following intrapericardial pneumonectomy. Cardiac herniation is a rare and catastrophic complication of intrapericardial pneumonectomy. Untreated it is invariably fatal. This paper reports three cases of cardiac herniation following intrapericardial pneumonectomy. In two cases massive haemorrhage complicated the cardiac herniation. All three cases were re-explored with two immediate survivals. The diagnosis, aetiology, haemodynamic effects, and management of this complication are discussed, and previously reported cases are reviewed.     

Letter to the Editor

Background: Conventional pneumonectomy via posterolateral thoracotomy is not always possible in cases with T4 tumour with widespread pulmonary artery invasion. Our objective is to present our surgical experiments in cases with a hilar mass who were thought to have pulmonary artery invasion, in whom we performed intrapericardial pneumonectomy through median sternotomy.

Method: Nine cases who had undergone intrapericardial pneumonectomy via median sternotomy were included in this study and evaluated retrospectively. These cases were thought to have right or left pulmonary artery invasion in preoperative evaluation.

Results: Two cases had right and seven cases left pneumonectomy. Based on TNM classification, two patients were Stage IIB, two Stage IIIA and five Stage IIIB in postoperative histopathological examination. Either right or left main pulmonary artery invasion was seen in IIIB cases while invasion was limited to the pericardium in the others. Lymph node involvement was detected in seven cases while six cases were N1, and one case was N2. There was no operative mortality.

Conclusion: Standard posterolateral thoracotomy might not be possible in all cases, particularly in patients with hilar tumours invading the main pulmonary artery. In such patients an intrapericardial approach with median sternotomy provides an easier and safer alternative while making it possible to have wider lymph node dissection. Furthermore, if necessary, hemi-clamshell incision can easily be added to this approach.     

Factors associated with perioperative complications after pneumonectomy for primary carcinoma of the lung

According to the literature patient's age, nutrition and smoking status, cardiopulmonary comorbidity and surgeon's experience are the main factors associated with perioperative complications after pulmonary resection. The purpose of the study was to identify the correlation between pre- and intraoperative risk factors and complications after pneumonectomy for primary carcinoma of the lung. Between Sept. 11th 1999 and Dec. 20th 2003 121 standard pneumonectomies were performed in patients with non small-cell lung cancer. Sixteen risk factors noted in the patients before surgery were correlated with complications occurred after pneumonectomy. Overall mortality and morbidity rates were 3.3% and 30.6%, respectively. Twenty patients (16.5%) experienced cardiac rhythm disturbances, six (4.9%)--pleural haematomas, five (4.1%)--main bronchus stump fistulas, four (3.3%)--acute respiratory failure. Chronic obstructive pulmonary disease was correlated with broncho-pleural fistulas and acute respiratory failure after surgery. Chronic coronary disease was associated with postoperative cardiac arrhythmias, whereas postoperative bleeding was correlated with the overweight of the patients. Chronic obstructive pulmonary disease, chronic coronary disease and overweight are the risk factors associated with complications after pneumonectomy.     

Sudden cardiac herniation 6 months after right pneumonectomy

Cardiac herniation is a rare complication of intrapericardial pneumonectomy and has a high mortality. The condition has been reported only within 24 hours after surgery. In this report, a case is described in which a total cardiac herniation took place 6 months after right intrapericardial pneumonectomy. The patient presented with an acute vena cava superior syndrome and underwent thoracotomy to reposition the heart into the pericardial sac and to close the pericardium with a patch.     

Right ventricular morphology and function after pulmonary resection.

OBJECTIVE: To identify the effect of pulmonary resection on right ventricular performance and its possible contribution to mortality and morbidity. METHODS: Before and 2 days after pulmonary resection for primary lung cancer in 31 patients (21 males; ages 32-69 years), echocardiographic examinations of the right ventricle were performed. Systolic, diastolic and stroke volumes as well as right ventricular ejection fraction were estimated. Right ventricular volumes were calculated using the subtracting method. RESULTS: Right ventricular end-diastolic volume index increased significantly in patients after pneumonectomy: 80.4+/-7.2 ml/m2 versus preoperative evaluation: 66.1+/-5.2 ml/m2 (P = 0.031). In patients who underwent pneumonectomy right ventricular ejection fraction significantly decreased from 48+/-5.0% preoperatively to 39%+/-4.1% after surgery (P = 0.027). Fourteen patients after pneumonectomy had development of supraventricular arrhythmias postoperatively. These patients had much higher right ventricular end-diastolic volume index (76.3+/-6.4/82.1+/-7.4; P = 0.032) and lower right ventricular ejection fraction (42+/-4.3/37+/-3.9; P = 0.021) after surgery in comparison with patients who had normal sinus rhythm postoperatively. CONCLUSION: Pulmonary resection caused a significant dilatation and dysfunction of right ventricle in the early postoperative period. Early detection of deterioration in right ventricular function after pneumonectomy may provide the opportunity for interventional therapy.     

Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer.

We present in this paper a case of cardiac herniation following right intrapericardial pneumonectomy after induction chemotherapy. A 52-year-old man with advanced squamous cell carcinoma of the lung was admitted to our hospital suffering from a dry cough and chest pain. An intrapericardial pneumonectomy with partial pericardiectomy (4 x 4 cm) was performed. The pericardial defect was left open. Just prior to removal of the tracheal tube, cardiac herniation occurred with hypotension, arrhythmia and cardiac arrest. A chest X-ray revealed cardiac herniation into the right hemithorax. Re-thoracotomy was performed and the heart was returned to its normal position and the pericardial defect was immediately repaired with an expanded polytetrafluoroethylene (EPTFE) patch. The patient's postoperative course was uneventful. Unless prompt diagnosis and surgical treatment can be accomplished, cardiac herniation can be a fatal complication. We recommend that when pneumonectomy is performed, pericardial defects should be closed with a prosthetic patch, regardless of the defect's size.     

Determinants of perioperative morbidity and mortality after pneumonectomy

A total of 197 consecutive patients undergoing pneumonectomy at the M.D. Anderson Cancer Center from 1982 to 1987 were reviewed. Sixty-five variables were analyzed for the predictive value for perioperative risk. The operative mortality rate was 7% (14/197). Patients having a right pneumonectomy (n = 95) had a higher operative mortality rate (12%) than patients having a left pneumonectomy (1%, p less than 0.05). The extent of resection correlated with the operative mortality rate (chest wall resection or extrapleural pneumonectomy, n = 39, 15%; versus simple or intrapericardial pneumonectomy, n = 158, 5%; p less than 0.05). Patients whose predicted postoperative pulmonary function, by spirometry and xenon 133 regional pulmonary function studies, was a forced expiratory volume in 1 second greater than 1.65 L, forced expiratory volume in 1 second greater than 58% of the preoperative value, forced vital capacity greater than 2.5 L, or forced vital capacity greater than 60% of the preoperative value had a lower operative mortality rate (p less than 0.05). Atrial arrhythmia was the most common postoperative complication (23%). Xenon 133 regional pulmonary function studies are useful in predicting the risks of pneumonectomy.     

Study on the late effect of pneumonectomy on right heart pressures using Doppler echocardiography.

OBJECTIVE: Changes in the pulmonary artery systolic pressure (PASP) and the dimensions of the right ventricle (RV) of the heart, six months after pneumonectomy, were evaluated in order to detect the influence of pneumonectomy on right heart function. METHODS: 35 patients undergoing pneumonectomy (Group A) and 17 patients undergoing lobectomy or bilobectomy (Group B) were evaluated prospectively with spirometry, arterial blood gases determination and Doppler echocardiography at rest, preoperatively and six months postoperatively. Patients of both groups had normal preoperative PASP, RV dimensions and left ventricular ejection fraction. PASP was calculated using the equation: PASP=4x(maximal velocity of the tricuspid regurgitant jet)2+10 mmHg. FEV1, FVC, partial pressures of oxygen (pO2) and carbon dioxide in the arterial blood were considered as the main determinants of postoperative lung function. RESULTS: PASP increased significantly six months postoperatively in both groups (P<0.05). Mean PASP in Group A (40.51+/-12.52 mmHg) was significantly higher (P=0.012) than in Group B (32.88+/-5.25 mmHg). Mean PASP after right pneumonectomy (48.33+/-10.61 mmHg) was significantly higher (P=0.002) than after left pneumonectomy (35.26+/-10.83 mmHg). The incidence of RV dilatation was higher in Group A (60%) than in Group B (23.52%). RV dilatation was related with elevated PASP values in both groups (P<0.001 and P=0.034, respectively). Increased age (P<0.001), significant percent FVC reduction from preoperative values (P=0.012) and low pO2 values (P=0.001) were detected as strong predisposing factors for postpneumonectomy PASP elevation. CONCLUSIONS: Pneumonectomy is related with postoperative elevation of PASP and RV dilatation, especially right pneumonectomy. Significant percent FVC reduction, increased age and low pO2 values are the main responsible factors for elevation of the 6-month postoperative PASP values.     

Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.

OBJECTIVE: To investigate the incidence and management of postoperative complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma. METHODS: Patients with histologically proven mesothelioma of clinical stages T1-3, N0-2, M0 and considered to be completely resectable received neoadjuvant chemotherapy (cisplatin+gemcitabine or cisplatin+pemetrexed) followed by extrapleural pneumonectomy and postoperative radiotherapy. The incidence and management of postoperative complications in general and of bronchopleural fistula and postpneumonectomy-empyema in particular were analyzed. Univariate analysis was performed to identify prognostic factors [sex, age, side of operation, weight loss, smoking, chemotherapy, EORTC-score (European Organization for Research and Treatment of Cancer-classification) and duration of operation]. RESULTS: Between 1st May 1999 and 15th August 2005, 63 patients underwent complete extrapleural pneumonectomy after neoadjuvant chemotherapy. Postoperative complications were observed in 39 cases (62%) and 2 patients died within 30 days (3.2%). Postpneumonectomy-empyema occurred in 15.8% of the patients (n=10), six with a bronchopleural fistula on the right side. All empyemas were treated successfully. Five patients developed chylothorax (7.9%) and four patients had complications due to a patch failure: cardiac herniation (n=2), restriction of cardiac output (n=1) or gastric herniation (n=1). Patients with higher EORTC-score presented significantly more postoperative complications (p=0.03). A longer duration of surgery tended to be associated with a higher incidence of postoperative complications, especially of empyemas. CONCLUSIONS: Extrapleural pneumonectomy after neoadjuvant chemotherapy can be performed with mortality rates comparable to standard pneumonectomies. Complications are frequent but can be successfully managed; the EORTC-score seems to be a predictor for postoperative complications.     

Pneumonectomy for lung metastases: indications, risks, and outcome

Background. Resection of pulmonary metastases (PM) by pneumonectomy is infrequently performed and benefits are uncertain.

Methods. From 1985 to 1995, 42 patients underwent pneumonectomy for PM. Twenty-nine patients had PM from sarcomas, 12 patients from carcinomas, and 1 patient from melanoma. The indications for pneumonectomy were pulmonary recurrences in 12 patients, PM centrally located in 26 patients, and high number of PM in 4 patients. There were 11 intrapericardial and 6 extended pneumonectomies. The average number of PM resected was 3. Twenty-two patients (52%) had lymph nodes involvement.

Results. There were 2 postoperative deaths (4.8%) related to pneumonectomy and one death within 30 days for rapidly evolving disease; 4 patients (9.5%) had major postoperative complications that were medically treated. Five patients (12%) were operated on for recurrences on the residual lung. At the completion of the study, 12 patients were still alive, 8 without recurrences. The median survival was 6.5 months (range, 1 to 144 months); the 5-year survival was 16.8%.

Conclusions. Pneumonectomy should not be considered an absolute contraindication in patients with PM, but the poor outcome of our series suggests strict criteria of selection.     

Evaluation of superior transseptal approach for the removal of left atrial myxoma

We compared the operative outcomes among 14 patients who underwent the removal of left atrial myxoma with four different approaches; right lateral (n = 2), transseptal bi-atrial (Dubost, n = 4), conventional transseptal (n = 4) and superior transseptal approach (STA, n = 4). Concomitant operations were performed in 4 cases (CABG, two; aortic valvuloplasty, one; mitral valve replacement, one), and two out of 4 cases were in the STA group. The mean operation, cardiopulmonary bypass and aortic cross-clamp times were shorter in the STA group compared to the other three group. The total amount of postoperative drain discharge and the peak value of creatine kinase were also lower in the STA group compared to the other three groups. Among the patients in sinus rhythm before operation, the use of STA was associated with a greater incidence (100%) of postoperative atrial fibrillation or junctional rhythm. These rhythm disturbances were temporary, and all returned to sinus rhythms during hospital stay. We conclude that STA is an excellent approach with a nice surgical view to expose and remove the left atrial myxoma.     

Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Initial experience of video assisted thoracoscopic pneumonectomy.

BACKGROUND--Preliminary experience of video assisted thoracoscopic pneumonectomy in six patients with bronchogenic carcinoma is described. METHODS--Four left and two right pneumonectomies were performed under video thoracoscopic imaging. Thoracoscopic instruments were passed through two separate stab incisions on the lateral chest wall and a separate 6 cm submammary incision was also created to allow further access for instrumentation and removal of the resected lung. In this initial experience resection was restricted to patients with bronchogenic carcinomas of less than 6 cm in diameter who had no involvement of the mediastinum. RESULTS--There were no operative deaths and no complications attributable to the technique. One patient developed postoperative atrial fibrillation and a small sacral sore and one patient was readmitted with abdominal pain and pyrexia which settled following exclusion of post pneumonectomy empyema. The remaining four patients made a rapid uncomplicated postoperative recovery with less pain and discomfort than that normally associated with a standard posterolateral thoracotomy. Postoperatively the mean (SD) patient controlled morphine consumption was 1.36 (1.90) mg per hour in the first 36 hours compared with the unit mean for open thoracotomy of 1.73 (1.68) mg per hour. The mean linear visual analogue pain score was 15.4 (15.6) in the first 24 hours compared with the unit mean for open thoracotomy of 34.5 (8.5). CONCLUSIONS--Video assisted thoracoscopic pneumonectomy can be performed safely in patients who have stage I and stage II bronchogenic carcinomas, up to 6 cm in diameter, with no mediastinal involvement on mediastinoscopy and thoracic computed tomographic assessment. This technique may result in less postoperative pain and discomfort and should allow a quicker return to normal activities.     

Platypnea orthodeoxia syndrome and bronchopleural fistula following right pneumonectomy: The first case of double misfortune following pneumonectomy

We report a case of post-pneumonectomy right to left shunting via patent foramen ovale (PFO) and bronchopleural fistula (BPF). Although the latter complication is well-known following pneumonectomy, the former is quite rare. In terms of post-pneumonectomy complications, no case has been reported, in which right to left shunting via PFO and BPF were synchronous. Low awareness of post-pneumonectomy PFO often results in delay of the appropriate management, like in our experience. The rarity and the complexity of our case as well as literature review of the post-pneumonectomy right to left shunting via PFO are summarized.With our case of post-pneumonectomy right to left shunting via PFO and BPF reviewed, we would like to show the rarity of our case and to enlighten all of the thoracic surgeons for early detection of this hemodynamic complication following pneumonectomy.     

Supraventricular arrhythmias after resection surgery of the lung.

OBJECTIVE: Two hundred consecutive patients undergoing resection surgery of the lung during 1999 were retrospectively reviewed to define prevalence, type, clinical course and risk factors for postoperative supraventricular arrhythmias (SVA) with particular reference to atrial fibrillation or flutter (AF). METHODS: Records of 200 lung patients were collected and analysed with particular attention to preoperative physiologic values and associated pathologies, lung functional status, electrocardiogram registration, extent of surgical resection of the lung and were also analysed to confirm or exclude correlation between them and postoperative AF; three patients were excluded as they were affected preoperatively by SVA. RESULTS: Forty-five episodes of SVA, 41 of AF were identified in 197 patients (22%) and were more prevalent in several groups of patients such as those with increased age, pneumonectomy and superior lobectomy. Rhythm disturbances were most likely to develop on the second day after surgery. Ninety-eight percent of AF disappeared within a day of discharge and sinus rhythm was restored with digitalis or other antiarrhythmic drugs in all patients except one who was discharged with persistent atrial fibrillation. Arrhythmias were not direct causes of any in-hospital deaths. There is a tendency in the difference of the AF rate between pneumonectomy and upper lobectomy patients versus inferior lobectomy ones, probably related to the different anatomic structure of the proximal trunks of the upper and inferior veins of the lung, respectively. CONCLUSIONS: Statistical analysis revealed that increased age, extent and type of pulmonary resection, such as pneumonectomy and superior lobectomy were significant risk factors. Despite these factors, arrhythmias after lung surgery could be managed easily and were not closely related to higher mortality. Direct cause of AF after lung resection surgery remains unclear; anatomical substrate such as surgical damage to the cardiac plexus or to the proximal trunks of the pulmonary veins covered by myocardial sleeves with electrical properties are to be considered.     

Extrapleural completion pneumonectomy combined with chest wall resection for complex aspergilloma

Completion pneumonectomy for complex aspergilloma remains challenging for thoracic surgeons. This pneumonectomy procedure often requires extrapleural dissection. Although extrapleural dissection is effective in preventing intraoperative contamination of the operative field, it is associated with massive bleeding. In addition, when the pleura has been severely thickened, it is difficult to conduct extrapleural dissection. We herein report 2 patients who underwent an extrapleural completion pneumonectomy combined with chest wall resection. In this technique, we avoided extrapleural dissection where dense pleural adhesions existed. Instead, we performed an en-bloc chest wall resection. This technique can decrease the amount of bleeding and prevent contamination of the operative field. It can also reduce the size of post-pneumonectomy space, and decrease the chance of post-pneumonectomy empyema and bronchial stump fistula. We advocate that extrapleural completion pneumonectomy combined with chest wall resection be considered in case that extrapleural dissection is extremely difficult.