Patients presenting for thoracic surgery either acutely or chronically will always be demanding and require extensive planning for anaesthesia, surgery and recovery with many factors needing to be considered and resolved before beginning.
The most frequent thoracic surgeries are performed for the treatment of primary lung cancer and pleural mesothelioma. For lung cancer, the standard procedures are pneumonectomy and lobectomy with associated mediastinal lymphadenectomy. In order to avoid pneumonectomy, extended lobectomy with sleeve bronchoplasty and/or angioplasty can be done.
When adjacent organs are involved, extended resections are accepted (chest wall, vena cava…). For small lesions (<2 cm) without lymph nodes involvement and for patients with limited respiratory function, segmentectomy is an option (results under evaluation). For the treatment of pleural mesothelioma, the accepted oncologic resection is extra-pleural pneumonectomy extended to the diaphragm and pericardium. This surgical indication requires careful evaluation of tumour staging and patient’s capacities. The morbidity and mortality of these resections require comprehensive follow-up (clinical, biological (including blood gases) and radiological).
Smoking Cessation
Smoking irritates your lungs and may prolong your recovery. If you are a smoker, you will increase your lung function and efficiency each day that you are smoke-free before surgery. We recommend that you stop smoking immediately or at least three weeks before your surgery.
Swedish offers a smoking cessation program that lasts for eight weeks and provides participants with education and coaching to help them successfully stop smoking. The program involves a comprehensive approach to care. It focuses on not only the medical issues related to smoking, but also on the emotional and stress-management issues that help people to become successful non-smokers for life.
What can I expect?
Most patients will have met the consultant thoracic surgeon at the surgical outpatients at St George’s Hospital or at one of the district hospital the team covers. At that stage a full explanation of the condition and surgical treatment will be given.
Once you have been added to the waiting list, the thoracic surgery clinical nurse specialist (CNS) will be available to assist with your pre-procedure assessment and preparation. You may be invited to attend the hospital for a pre-operative visit to check that you are fit enough for the procedure. During your visit we will ask you some questions about your health and abilities.
The time of your admission will depend on various factors. You will either be offered admission on the day before your surgery or on the morning of your planned operation; the Pathway Co-ordinator or secretary to your consultant will discuss this with you by telephone. If it is not possible for your surgery to go ahead for any reason, you will be given another date for your operation as soon as possible.
On your admission, you will be seen by the surgical team where consent will be taken for your operation and you will be prepared for surgery by the nursing team on your ward.
What medications should I stop taking?
Certain types of medications may need to be stopped before your admission for surgery. You will be advised of these either at the clinic appointment with your surgeon or when you are given the date for your surgery. The leaflet “What medicines do I need to stop before my chest/lung surgery?” will be included with your admission letter to help clarify which medications you should continue to take.
The hospital will provide “non-emergency” transport for you but only if the doctor has said it is needed because of your medical condition.
Occasionally, in exceptional circumstances, it may be possible for someone to travel with you in the hospital transport. Your doctor will need to agree that this is needed before the journey.
The day of your operation
You must not eat anything for six hours before your operation but you can drink water until two hours before you go to the operating theatre. You will be told the planned time of your operation and when you must stop eating and drinking either in the letter you received before coming into hospital or by the nurses. The time of your operation may change and if this happens, perhaps because of an emergency, the nurses will tell you.
The nurses will go through a checklist with you on the morning of your operation to make sure everything needed has been done.
You must remove all make-up and nail varnish, and all jewellery except your wedding ring (this can be taped on your finger). You will also need to remove dentures, glasses and contact lenses but this can be done in the anaesthetic room if you prefer. They can be handed to the nurse to take back to the ward. In the hour before your operation, the theatre will call the ward to ask the nurses to make sure you are ready for surgery. You will be asked to empty your bladder, put on a theatre gown and get into bed.
Your nurse and a porter will take you to theatre on your bed. Once there you will be transferred on to a theatre trolley and taken into the anaesthetic room. You will be given your general anaesthetic before being transferred to the theatre.
Immediately after your operation
When you wake up from your operation, you will be in the recovery unit next to the theatre. The staff will watch you closely and take your pulse and blood pressure regularly. They will make sure that any pain is well controlled. When your condition is stable, a nurse will take you back to the ward and the nurses there will continue to check your observations.
After the operation you may have several attachments such as, an oxygen mask, a chest drain and intravenous fluids or medicines.
Oxygen: You will be given oxygen through a mask. This is to help your lungs get enough oxygen into your blood and also to help to remove the anaesthetic gases. The length of time people need oxygen varies and your nurse will tell you how long you will receive it. To increase your oxygen levels and to reduce the risk of a chest infection, you will be encouraged to do deep breathing exercises.
Chest drains: During the operation your lung will be collapsed. A chest drain will be inserted to help to remove the excess air and also any fluid or blood that is present in this space. This tube sits between the lung and the chest wall and is held in place by a stitch in the skin. The chest drain is attached to a drainage bottle. The nurses will explain this to you.
Your drain may be connected to a suction unit on the wall. This is to help your lung to expand quicker. If this is the case, you will be restricted to your bed space. The length of time your drain remains on suction depends on the results of chest x-rays which show how your lung is expanding.You will have x-rays regularly.
The chest drain will be removed when your lung has expanded and excess fluid has been drained off. This time varies and your nurses and doctors will tell you when this will be.
The chest drain will be removed on the ward by two nurses. The wound will be closed by the stitch that was put in during your operation. The nurses will tell you when it will need to be removed.
Intravenous fluid (“drip”): You will not be able to drink straight after your operation so you will be given the fluid you need by a “drip” directly into your bloodstream. You may drink as soon as you feel able. You should then drink as much as possible unless you are told not to by your doctor or nurse.
Pain control: Your pain may be controlled in different ways.
- Patient controlled analgesia (PCA): You may have a pump that delivers a small amount of morphine at the push of a button. The button is on a handset and you can press it when you have pain. The pump will not allow you to overdose, but if your pain is not well controlled, please tell your nurse. The pump, and how to use it will be explained to you in the recovery room and again on the ward.
- Intra pleural block: This is a thin catheter (tube) that is inserted into the chest cavity at the end of your operation. The tube is connected to a bag of local anaesthetic solution, via an infusion pump.The pump delivers a small amount of local anaesthetic continuously to numb the pain. The rate at which the anaesthetic is given will be reduced gradually. The catheter will then be removed on the ward two to three days after your operation.
Whatever form of pain control you receive, please tell your nurse if it doesn’t work. It is important that your pain is well controlled after your operation so that you can do your exercises.
Pain control medicines can cause nausea, vomiting and constipation. Please tell your nurse if you have any side effects. Drink plenty of fluids, keep as mobile as possible and eat a high fibre diet to prevent constipation.
Recovering from your operation & physiotherapy
After your operation you must follow the advice given by the staff looking after you. This will help you make a speedy recovery. If you have had a thoracotomy incision, VATS lobectomy or need extra assistance you will be seen by the physiotherapist. This will help you make a speedy recovery, helping to re-inflate your lung after the surgery and help get you home as soon as possible.
Deep breathing exercises
After the operation your breathing is often shallow, which means only the upper part of your lungs expands. As the lower areas don’t expand enough, there is an increased risk of you developing a chest infection. To prevent this you must do regular deep breathing and supported coughing to expand the lower parts of your lungs and clear out secretions. Normally five deep breaths every half an hour is sufficient.
Supported cough
It is very important that you are able to cough. After an anaesthetic, phlegm may collect in your lungs. It is important to clear this as this may also cause a chest infection in the first few days after your operation. Your chest wound may be uncomfortable when coughing. Supporting the wound when coughing will make this far more comfortable. To support your wound place your hands around your chest. Your pain should be controlled to allow you to cough. If you are unable to cough because of pain, you need to speak to the nurse looking after you. Please remember that coughing will cause no damage to your chest wound.
Shoulder exercises and posture
After your surgery it is quite normal to not want to move your arm on the side where the surgery has been done. It is important you start to move your shoulder and upper body normally, adopting a good posture. This will help prevent joint stiffness on the side of your operation. A good posture is also important to prevent back problems later on. You are advised to do the following exercises:
1. Sit or stand:
Lift your arm up in front of you, until you feel a gentle stretch, hold for a few seconds and then release. Repeat 3 times, 5 times per day.
2. Sit or stand:
Lift your arm up out to the side until you feel a gentle stretch, hold for a few seconds and then release. Repeat 3 times, 5 times per day.
3. Sitting or Standing:
Bend sideways at the waist, until you feel a gentle stretch on the side you are stretching away from. Repeat 3 times, 5 times per day.
4. In sitting cross your arms over your chest:
Rotate your trunk to one side, hold for a few seconds and then repeat to the other side. Repeat 3 times, 5 times per day.
Walking and getting moving
It is extremely important that you sit out of bed and start moving around as soon as possible. By doing this you will help loosen any secretions in your lungs and prevent other problems such as:
- Pressure sores
- Deep vein thrombosis (DVT)
- Constipation
This is vital for everyone who has had lung surgery no matter how small or large the operation. If you still have a chest drain in you may be instructed by a physiotherapist to do stepping or marching on the spot, or walking regularly throughout the day. By getting moving again this will help to re-inflate your lung so the chest drain can be removed. Which means you can go home sooner.
Nutrition
It is important that you are well nourished before your operation so that your body has resources to help it to heal well.
If, before you come into hospital, you have lost weight without trying to do so or feel your appetite is poor, please tell the nurses. They can arrange for you to see a dietician.
Most people find that they lose their appetite or feel sick for a couple of days after an operation. Tell your nurse if you are having problems with this. The dietician will be able to give advice about foods that you may be able to manage or supplements. If nausea is a problem, your doctor can prescribe some anti-sickness medicines.
Wound care
Your wound and the dressing will be checked daily by the nurses. While you still have a chest drain you will not be able to have a bath or shower. Once the drain is removed you may bathe but it is still important to keep the wound clean and dry. If you are concerned about your wound or dressings, please tell the nurses.
Going home; your “discharge”
The length of time you stay in hospital will vary depending on your type of operation and speed of recovery. The nurse-in-charge will discuss with you when you will be able to go home.
Sometimes you may need further convalescence (time and help to recover) at your local hospital. The medical team will discuss this with you, if necessary.
You may not be able to do physical activities, such as housework or shopping, for two to six weeks after your operation. Ask family or friends to help with these when you go home. If you think you might need extra support, speak to your nurse as soon as you come into hospital. There are various services to help you at home that can be provided by your local social services department. The aim is to make sure all the help you need is in place before you leave hospital.
You will be given a two week supply of your medicines, including pain control tablets, at the time you leave hospital. The pharmacist and your nurse will discuss with you what they are for and when to take them. After you finish this supply, you should go to your GP (family doctor) for a new prescription.
On the day you go home your nurse will give you a rough idea of what time you will be able to leave. We ask that you arrange your own transport home. If you think you will need hospital transport, please discuss this with your nurse.
How often you have to come back to the hospital will vary depending on the type of operation you have had. The nurse-in-charge will tell you the date of your first follow-up appointment before you leave hospital or will send it to you by post.
It can take 10 to 14 days for the results of biopsies (samples of tissue for examination under the microscope) to be available. These results will be given to you at your follow-up appointment.
What to expect at home
Your recovery can take between six and 12 weeks depending on the type of operation you have had. The surgical team will be able to advice the likely length of recovery for your particular operation.
You may feel tired and experience some discomfort when you get home. This is perfectly normal and is part of the healing process.
Exercise
Everyone recovers at a different rate. You must continue to do the exercises to help your breathing and posture that you have been taught by the physiotherapist or nurses. You will be given personal exercise advice depending on what operation you have had.
As soon as you feel well enough you may want to do more physical exercise. Go ahead but if you feel tired or have pain, slow down and rest. Your recovery is a gradual process. You should ask the doctor at your outpatient appointment before doing any strenuous exercise such as lifting heavy weights.
Monitoring for infection
After any lung surgery you are at a higher risk of developing a chest infection. If you have a temperature, feel generally unwell and are coughing up discoloured sputum (phlegm), go to your GP. You may need antibiotics.
Pain control
In the first few months after surgery, it is usual to have:
- mild aches and pains
- numbness
- pins and needles
These are normal and part of healing. Muscular pain in your neck, shoulders, arms and back is also very common for up to six weeks after your operation.
Continue with the pain control you were given when you left hospital and visit your GP for a repeat prescription, if necessary.
Your wound
Check your wound daily. If you notice any of the following signs, you will need to go to your GP as it may be infected:
- oozing (weeping) after previously being dry
- inflammation (redness and swelling)
- feeling hot to the touch
Try to avoid tight clothing while your wound is healing. The nurses will tell you when to have your stitches, clips or staples removed. This will be done by a district nurse at home or the practice nurse at your GP’s surgery. The nurses will arrange this before you go home. After the stitches have been removed you can wash your wound as normal.
“What NOT to Do” Before Surgery
Any medication that may cause bleeding will be stopped before surgery. Please be sure to stop taking these medications as directed by your surgeon or anesthesiologist.
1 Week Before Surgery
- NO Aspirin
- NO Plavix
- NO Ticlid
- NO All medicines containing aspirin such as Anacin, Excedrin, Fiorinol, Aggrenox and Alka-Seltzer
5 Days Before Surgery
- NO Coumadin
2 Days Before Surgery
NO all non-steroidal anti-inflammatory (NSAIDs) medications, which include:
- NO Celebrex
- NO Diclofenac
- NO Ibuprofen (Motrin, Advil)
- NO Meloxicam (Mobic)
- NO Nabumetone (Relafen)
- NO Naproxen (Aleve, Naprosyn, Anaprox)
- NO Piroxicam (Feldene)
Discontinue all supplements at least 48 hours before surgery. If not dissolved properly, they can make your surgeon’s job more difficult. Some nutritional supplements and foods can interfere with anesthesia and healing and should be avoided for one week before surgery. The most common (but not all) include:
- NO Vitamin E
- NO Gingko bilboa
- NO Fish oils
- NO Couramin
- NO White willow bark
- NO Garlic extract
- NO Onion extract
- NO Ginger root
- NO Ginseng
- NO Nightshades (tomato, potato, pepper and eggplant)
For more information, you can call the Northwest Natural Health Specialty Care Clinic at Swedish at (206) 386-3015.
1 Day Before Surgery
- NO Lovenox
Tylenol may safely used at any time as long as you follow the directions on the label.
Smoking
Stop smoking, if you have not already done so. Cigarette smoking is proven to be closely linked to lung disease. Continuing to smoke following an operation on your lung can cause complications. Smoking is a major factor in developing bronchitis, emphysema and is a major cause of heart disease.
If you are finding it difficult to stop smoking, you may find it helpful to join a smoking cessation group or contact your local stop smoking service. Your nurse can tell you about these and give you some booklets with advice on how to stop. You can also contact the national NHS Smoking Helpline.
Diet
Eat a well balanced diet. This can speed up the healing process and your overall recovery. If you want more information, your nurse can give you leaflets on how to eat a healthy diet
If your appetite remains poor at home, try having:
- small meals
- regular snacks
- milky drinks
If you continue to have problems, you can get “build-up” drinks from your local chemist that provide you with extra nutrients and calories. Your GP can also refer you to a dietitian, if necessary.
Alcohol
You may drink alcohol but check with your doctor that it does not affect any medicines you may be taking, for example antibiotics. Alcohol may also improve your appetite if you are having problems eating, but do drink sensibly.
Your feelings
Your feelings may change from day to day. It may take several weeks or months for you to adjust physically and emotionally to what has happened. You may find it helps to talk about how you are feeling with your GP or specialist nurse.
Sex
You may start or resume sexual activity as soon as you feel able. After your operation you may need to try different positions until you find one that is comfortable for you and your partner.
If you are tired, you may want to set aside time for sex after a period of rest. Do talk to your partner about how you are feeling.
If you have any concerns, you may find it helpful to talk to your GP or specialist nurse.
Work
When you go back to work will depend on:
- the type of job you do
- the operation you have had
- how quickly you are recovering from it.
Your doctor can advise you about how soon this might be.
Driving
You should not drive until you feel able to do an emergency stop without feeling any discomfort. If you have had a thoracotomy, this may be up to six weeks. If in doubt, talk to your doctor – if you drive before you are told you can, your insurance may not be valid.
Flying
You must not fly for six weeks from the date of your operation, whatever it was, as changes in air pressure may affect the expansion of your lung.
Maintain or Increase Your Physical Activity Before Surgery
- General Exercise/Rehabilitation: If you are participating in an exercise or rehabilitation program, you should continue this until you arrive at the hospital for surgery. Daily activity will help condition your muscles and make it easier for you to move after your operation. Walking is generally an easy and effective way to maintain your physical conditioning before your admission to the hospital.
- Breathing Exercise: Breathing exercises are an important part of your recovery, especially after lung surgery. Deep breathing and coughing will help you to clear secretions after surgery and can help you relax before and after surgery.
If you develop a fever, a persistent cough, or discolored sputum (green or gold) prior to surgery, please call our office immediately.
Diet Instruction
- Eat a balanced diet prior to surgery: You will be permitted to eat and drink up until midnight before your surgery date. Do not eat or drink anything after midnight.
- Bowel Preparation: Some patients will be required to complete a bowel preparation prior to the day of surgery. Your surgeon will discuss this with you when scheduling your surgery. Detailed instructions will also be provided to you in writing at that time.
Relaxation
As much as possible, relax the day before surgery, spend time with your family and get a good night’s sleep.
References
- Thoracic surgery patient information
- Thoracic Surgery Preparation
- Preparing, monitoring and recovering the thoracic surgery patient
- Thoracic surgery: the major surgical procedures
- Featured Image Credit: My Health Turkey