Timing Between Bilateral Wedge Resections
There is no established guideline-recommended time interval between wedge resections from left to right lung. The decision to proceed with contralateral lung resection should be based on physiologic recovery, pulmonary function testing, and assessment of predicted postoperative lung function rather than an arbitrary time interval.
Physiologic Assessment Framework
The approach to bilateral lung resections should follow the same rigorous preoperative evaluation used for any lung resection, with particular attention to cumulative lung tissue loss 1:
Step 1: Baseline Pulmonary Function Assessment
- Measure current FEV1 and DLCO after the first wedge resection to establish the new baseline 1
- Calculate predicted postoperative (ppo) values for the planned second resection using the formula: ppoFEV1 = current FEV1 × (1 - fraction of total perfusion for lung to be resected) 2
- Obtain quantitative perfusion scan to accurately determine the functional contribution of the lung segments to be resected 1
Step 2: Risk Stratification
Low Risk (Proceed with surgery):
Intermediate Risk (Perform exercise testing):
- ppoFEV1 or ppoDLCO between 30-60% predicted 2
- Consider shuttle walk test or cardiopulmonary exercise testing 1
High Risk (Requires specialized evaluation):
- ppoFEV1 <40% predicted AND ppoDLCO <40% predicted 1
- ppoFEV1 or ppoDLCO <30% predicted indicates very high risk 2
Practical Timing Considerations
Minimum Recovery Period
While no specific interval is mandated, several physiologic factors should guide timing:
- Allow complete wound healing and resolution of postoperative inflammation, typically requiring several weeks 3
- Ensure return to baseline functional status with stable pulmonary function tests 1
- Verify absence of complications from the first resection, including air leaks, infections, or pleural issues 4
Cardiovascular Considerations
If there are cardiac risk factors, additional precautions apply 1:
- Wait at least 6 weeks after myocardial infarction before proceeding with the second resection 1
- Obtain cardiology consultation if MI occurred within 6 months of planned surgery 1
- Perform preoperative ECG on all patients 1
Surgical Approach Optimization
For patients with borderline pulmonary function after the first wedge resection:
- Consider VATS approach for the second resection, as it is associated with smaller postoperative decline in lung function compared to open thoracotomy 1
- Limit resection extent to the minimum necessary (wedge rather than anatomic resection) when pulmonary reserve is compromised 1, 5
- Ensure margin-free resection with frozen section confirmation to avoid need for re-resection 6
Critical Pitfalls to Avoid
Do not proceed with the second resection if:
- Current FEV1 is <1.5 liters, as this indicates insufficient reserve 2
- Predicted postoperative FEV1 would fall below 30% predicted (associated with mortality rates up to 60%) 2
- Patient has not returned to baseline performance status after the first resection 1
- Oxygen saturation is <90% on room air at rest 1
Common error: Assuming that because the first wedge resection was well-tolerated, the second can proceed immediately. Each resection cumulatively reduces pulmonary reserve, and formal reassessment is mandatory 1, 2.
Multidisciplinary Discussion
Patients with multiple adverse factors should have formal multidisciplinary review before proceeding with the second resection, including chest physician, surgeon, and oncologist 1. This is particularly important when:
- Performance status is WHO 2 or worse 1
- Weight loss >10% has occurred 1
- Multiple comorbidities are present 1
The key principle is that timing should be determined by physiologic readiness rather than calendar time, with the overriding goal of ensuring predicted postoperative lung function remains adequate to support acceptable quality of life and minimize mortality risk 2.