Optimal Management for Right Upper and Intermediate Lobectomy with Tumor Proximity to Pulmonary Vein and Lower Lobe Abscess

Preoperative Evaluation and Planning

The American College of Chest Physicians recommends comprehensive preoperative pulmonary function assessment with calculation of predicted postoperative values for patients undergoing right upper and intermediate lobectomy, especially those with recent pneumonia and lower lobe abscess, to determine the risk of postoperative pulmonary complications 1, 2, 3.
For patients with post-bronchodilator FEV₁ <1.5 liters, calculate predicted postoperative FEV₁ (ppoFEV₁) using the formula: ppoFEV₁ = preFEV₁ × (19 - 5)/19 = preFEV₁ × 0.74, considering any obstructed segments in the calculation 1, 2, 3.
The American College of Chest Physicians notes that patients with severe COPD may demonstrate smaller postoperative FEV₁ decline than predicted and may even show improvement due to "lung volume reduction" effect, but this should not be relied upon when making the initial surgical decision 6.

The lower lobe abscess must be completely treated and resolved before proceeding with upper and intermediate lobectomy, with administration of appropriate antibiotics for at least 4-6 weeks and confirmation of radiographic resolution with repeat CT imaging 1, 2.
Formal liaison between the referring chest physician and thoracic surgical team is essential for coordinating the timing of surgery after abscess resolution 1, 2, 5.

Preoperative 3D-CT angiography is essential to map pulmonary vein anatomy and identify any anomalies before attempting resection near the pulmonary vein, to minimize the risk of vascular injury 1, 2, 3.
The American College of Chest Physicians recommends preferring video-assisted thoracoscopic surgery (VATS) over thoracotomy whenever possible, as it reduces postoperative complications and improves recovery, but tumor proximity to the pulmonary vein may necessitate open thoracotomy for adequate exposure and safe vascular control 7.

If ppoFEV₁ or ppoTLCO approaches 40% predicted, strongly consider less extensive resection, such as sublobar resection (segmentectomy or wedge) for peripheral tumors <2 cm, or sleeve resection of the upper lobe alone (preserving the intermediate lobe) for larger tumors 1, 2, 4.
The American College of Chest Physicians reports that patients with severe COPD can undergo limited resections with acceptable morbidity (15-25%) and mortality (1-15%) rates 6.

Mandate smoking cessation immediately, regardless of planned surgery date, as even short-term cessation (4-8 weeks) reduces postoperative pulmonary complications, and consider formal prehabilitation program for high-risk patients 7.
Use protective one-lung ventilation with tidal volume 6 mL/kg predicted body weight, PEEP 5-8 cmH₂O, and recruitment maneuvers to minimize postoperative pulmonary complications, and maintain restrictive fluid management at 2-6 mL/kg/hour baseline rate 7, 9.
Implement multimodal physiotherapy immediately postoperatively, combining deep breathing exercises, early mobilization (within 24 hours), incentive spirometry, and supported coughing with incision splinting, to reduce postoperative pulmonary complications 7, 9.