Completion pneumonectomy across distinct ischemic, septic, and oncologic scenarios: a single-center experience

Objective: Completion pneumonectomy (CP), defined as removal of the remaining lung after prior ipsilateral resection, is a high-risk procedure associated with significant morbidity and mortality, most commonly performed for benign lung disease, recurrent malignancy, or post-resection complications. This study aimed to investigate the impact of surgical timing and indication on short-term outcomes (morbidity and mortality) and long-term survival after CP. Methods: Prospective observational study at a high-volume thoracic surgery center (2014-2024). Among 286 pneumonectomies, 38 were completion pneumonectomies. Patients were classified as Rescue CP (< 90 days from initial resection) or Elective CP (> 90 days), with subgroups "Very Early" (< 10 days) and "Early" (11-90 days). Primary endpoint: 30- and 90-day mortality. Secondary endpoints: postoperative complications (Clavien-Dindo ≥ II), bronchopleural fistula (BPF), and long-term survival. Statistical analysis included Chi-square/Fisher's test and Kaplan-Meier/log-rank test. Results: Indications differed by surgical timing (p < 0.0001). Very early and early CP were mainly performed for residual lobe infarction and BPF, while late CP was for oncological relapse or bronchial stenosis. Rescue CP was associated with higher morbidity and 90-day mortality compared with elective CP (45% vs. 5.5%). The worst outcomes were observed in the 11-90 day interval, whereas very early CP (< 10 days) showed better survival. Long-term survival was significantly better after elective CP. Conclusion: Completion pneumonectomy should be considered a spectrum of operations performed under distinct clinical conditions. Surgical timing reflects the underlying clinical scenario and is strongly associated with perioperative risk and long-term survival.