Ann Thorac Surg 1996;62:1627-1631
© 1996 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Postpneumonectomy Syndrome With an Ipsilateral Aortic Arch After Left Pneumonectomy
Farid M. Shamji, MD,
Jean Deslauriers, MD,
Thomas M. Daniel, MD,
Frederick R. Matzinger, MD,
Reza J. Mehran, MD,
Thomas R. J. Todd, MD
Division of Thoracic Surgery and Department of Radiological Sciences Ottawa Civic Hospital, Ottawa, Ontario, Canada; Centre de Pneumologie de l'Hôpital Laval, Sainte-Foy, Quebec, Canada; and Department of Surgery, University of Virginia Health Sciences Centre, Charlottesville, Virginia
Accepted for publication July 8, 1996.
 |
Abstract
|
|---|
Background. Previous reports have described bronchial obstruction after left pneumonectomy (so-called postpneumonectomy syndrome) in the presence of a right aortic arch with the bronchus being compressed between the ascending aorta and thoracic spine. This study reports on 4 patients with left postpneumonectomy syndrome in the presence of a normally located left aortic arch and ascending thoracic aorta.
Methods. The case histories of 4 patients with this syndrome were reviewed and several features common to all 4 were noted. In each case, the obstruction was thought to be due to a clockwise rotation of the mediastinum with bronchial compression occurring between the right main pulmonary artery and thoracic spine.
Results. Three patients were treated by repositioning of the mediastinum, and all 3 obtained relief of their dyspnea. In these cases, permanent repositioning was ensured by the insertion of a prosthesis filled with saline solution. The fourth patient was successfully treated by resection of a portion of the adjacent thoracic vertebra.
Conclusions. Postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms.
|
Introduction
|
|---|
Bronchial obstruction after right pneumonectomy (so-called postpneumonectomy syndrome) occurs secondary to compression of the left main bronchus between the aortic arch and the pulmonary artery [1, 2]. The identical clinical situation has been reported to occur after left pneumonectomy only if there is a right aortic arch [3]. It is the combination of excessive shift of the mediastinum into the empty hemithorax and its subsequent either counterclockwise (after right pneumonectomy) or clockwise (after left pneumonectomy) rotation that leads to compression of the main bronchus. The resulting dyspnea may be progressive over months or years. The role of the aortic arch anomaly in producing airway obstruction after left pneumonectomy has been stressed in a recent review of a large experience [4]. We believe that this congenital anomaly is not a prerequisite and wish to report on 4 patients with left postpneumonectomy syndrome in the presence of normal left aortic arch and descending thoracic aorta.
|
Clinical Material
|
|---|
Patient 1
A 21-year-old man required left intrapericardial pneumonectomy in July 1991 for central locally advanced typical carcinoid tumor. Apart from early postpericardiotomy syndrome, he remained well for 3 months, but then began to complain of increasing shortness of breath on exertion. Clinical observation supported by chest radiograph (Fig 1A
), computed tomographic scanning (Fig 1B), and awake fiberoptic bronchoscopy confirmed the presence of marked narrowing of the distal right main bronchus that extended for the length of the bronchus intermedius. A left thoracotomy was undertaken in March 1992, and the mediastinum was repositioned by anterior pericardiorrhaphy and insertion of a 1,000-mL Dow Corning (Midland, MI) silicone prosthesis filled with saline solution.
View larger version (88K):
[in this window]
[in a new window]
|
Fig 1. . (Patient 1.) (A) A 21-year-old man 7 months after left pneumonectomy for carcinoid tumor in the left main bronchus. Chest roentgenogram demonstrates complete mediastinal shift into the pneumonectomy space. (B) Intravenous contrast-enhanced computed tomographic scan at the level of the right pulmonary artery and bronchus intermedius demonstrates narrowing of the airway due to extrinsic compression between the right pulmonary artery and spine (arrow). There is marked mediastinal shift and clockwise rotation.
|
|
Intraoperative bronchoscopy was used to monitor relief of airway obstruction. With continuous hemodynamic monitoring, overcorrection of the mediastinal shift was avoided. At operation, there was neither fluid nor any adhesions within the postpneumonectomy space. There was a distinct "sucking-in" of air when the chest was opened, causing the markedly displaced mediastinum to fall away from the left posterolateral chest wall. The radiologic assessment carried out soon after the operation showed that the mediastinum had returned to normal (Fig 2). The patient has remained symptom-free for 36 months since the corrective operation.
View larger version (92K):
[in this window]
[in a new window]
|
Fig 2. . (Patient 1.) (A) Chest roentgenogram 3 days after mediastinal repositioning. The trachea is midline, and the superior margin of the prosthesis is barely visible above the air-fluid level (short arrow). A radiopaque marker for the prosthetic valve is seen (long arrow). (B) Postop computed tomographic scan at 8 weeks demonstrates the prosthesis filled with saline solution in the pneumonectomy space. The mediastinum is midline and the bronchus intermedius is normal in caliber. The prosthetic valve is located outside the bony chest wall (between the two black markers).
|
|
Patient 2
A 44-year-old woman was treated by curative left intrapericardial pneumonectomy for stage IIIA squamous cell carcinoma in April 1991. Assisted ventilation for 6 weeks was required because of postoperative pulmonary edema. Over the next 12 months she complained of unexpected breathlessness on exertion. In June 1992, she required urgent medical attention for marked dyspnea and right lower lobe pneumonia. Assisted ventilation for severe hypoxemia (arterial oxygen tension, 35 mm Hg) became necessary. Diagnosis of postpneumonectomy airway obstruction was made by bronchoscopy and computed tomographic scanning (Fig 3). Five days later, left thoracotomy was carried out for repositioning the mediastinum using a 900-mL Dow Corning silicone prosthesis filled with saline solution. Pericardiorrhaphy was not done. The operative findings were identical to those seen in patient 1. Ventilatory assist was discontinued immediately after the operation. She has remained well for 30 months with a stabilized mediastinum (Fig 4).
View larger version (83K):
[in this window]
[in a new window]
|
Fig 3. . (Patient 2.) Preoperative computed tomographic scan: Note the mediastinal shift and severe narrowing of the right main bronchus (arrow). Also note the pleural effusion on the right side (secondary to obstructive pneumonia in the right lower lobe), indicated by an open circle.
|
|
View larger version (94K):
[in this window]
[in a new window]
|
Fig 4. . (Patient 2.) Postoperative computed tomographic scan shows satisfactory repositioning of the mediastinum using a prosthesis filled with saline solution.
|
|
Patient 3
A 63-year-old man was treated for stage I squamous cell carcinoma by left pneumonectomy in September 1992. He recovered uneventfully. Six months later, he noticed increasing shortness of breath particularly upon lying supine. The dyspnea worsened and he had to sit and lean forward with arms resting on a table to obtain relief. With awake fiberoptic bronchoscopy, shift of the trachea to the left and extrinsic compression of distal bronchus intermedius were seen. This was more pronounced with the patient supine; there was a marked reduction of forced expiratory volume at 1 second and of forced mid-expiratory flow rate (Fig 5). Diagnosis of postpneumonectomy airway obstruction was further confirmed with computed tomographic scanning (Fig 6). In September 1993, the patient underwent repositioning of the mediastinum using two breast prostheses filled with saline solution (total volume, 1,600 mL: superior prosthesis, 600 mL, and inferior, 1,000 mL.). At operation there were no adhesions and a small amount of fluid was found; a small defect in the pericardium was seen near the left atrial appendage. As well, redundant mediastinal pleura was present behind the heart where lung had herniated through from the other side. The pericardial defect was closed and the posterior pericardium was then sutured to the mediastinal pleura overlying the descending thoracic aorta to prevent retrocardiac lung herniation. Bronchoscopy after the operation was finished confirmed complete patency of the airway. Immediately after the operation, supraventricular tachyarrhythmia developed, believed to be secondary to overcorrection of the mediastinal shift and impaired atrial filling. Repeat lung function testing 5 days later showed further deterioration. A second operation was immediately performed to adjust the overcorrection of the mediastinum. The total volume of the prostheses was reduced to 980 with the superior prosthesis 500 mL and the inferior prosthesis 480 mL; as well, 470 mL of free fluid was removed. After the second procedure the patient had an uncomplicated recovery. He has remained symptom-free for 18 months without recurrence of the mediastinal shift (Fig 7).
View larger version (19K):
[in this window]
[in a new window]
|
Fig 5. . (Patient 3.) Flow-volume loops before and 4 weeks after the reoperation. There was a marked difference in lung function between sitting and supine positions before the operation, which was no longer seen after the mediastinum had been satisfactorily repositioned.
|
|
View larger version (87K):
[in this window]
[in a new window]
|
Fig 6. . (Patient 3.) Preoperative computed tomographic scan showing compressed bronchus intermedius (arrow) just proximal to the right middle lobe bronchus take-off.
|
|
View larger version (95K):
[in this window]
[in a new window]
|
Fig 7. . (Patient 3.) Note the change in position of the bronchus (arrow) with regard to the thoracic vertebra and the location of the descending aorta on the postoperative computed tomographic scan.
|
|
Patient 4
A 41-year-old woman required standard pneumonectomy in February 1982 for a non–small cell cancer of the left lung. In addition to the primary tumor, there were several satellite nodules in the lung. There were no postoperative complications. Ten months later, the cancer recurred as a solitary nodule in the middle lobe. Chemoradiotherapy was given after a positive needle aspiration biopsy. At the time, the forced expiratory volume in 1 second was measured at 1.37 L. The lung function started to deteriorate, and she required repeated hospitalization for dyspnea and purulent bronchitis over the next 4 years; the forced expiratory volume in 1 second ranged from 1.2 to 0.9 L. In September 1987 extrinsic obstruction of the bronchus intermedius was noted at bronchoscopy. Respiratory failure developed, and she was given high-dose corticosteroid therapy. Mechanical ventilatory assistance was required ten times over the next 12 months before a decision was made to relieve the bronchial obstruction surgically. The operation was undertaken through the right side of the chest and involved an osteotomy of the adjacent vertebral body; this was followed by tracheostomy. This resulted in immediate relief and cessation of ventilatory support. The bronchial obstruction was seen to be corrected. She died suddenly at home 4 months later, and the cause was never determined.
|
Radiologic Findings
|
|---|
Preoperative chest roentgenograms of all 4 patients demonstrated complete shift of the mediastinum into the left pneumonectomy space with hyperinflation of the right lung. Narrowing of the bronchus intermedius cannot be appreciated on either posteroanterior or lateral chest roentgenograms, but is well demonstrated with computed tomographic scanning. One patient presented acutely with right lower lobe pneumonia complicated by parapneumonic effusion. Preoperative computed tomographic scans demonstrated severe narrowing of the bronchus intermedius due to extrinsic compression between the right pulmonary artery and the thoracic spine. The right main bronchus was not affected. There was complete shift and clockwise rotation with posterior displacement of the mediastinum into the pneumonectomy space. There was no residual fluid in the pneumonectomy space. The aortic arch and descending thoracic aorta were left-sided. Postoperative chest roentgenograms and computed tomographic scans demonstrated that the trachea and mediastinum had been repositioned in the midline. Computed tomographic scanning confirmed repositioning of the right pulmonary artery and bronchus intermedius away from the spine and a normal caliber of the bronchus.
|
Comment
|
|---|
Several features common to these 4 patients should be noted. Contrary to previous reports, there was a normal left aortic arch. After pneumonectomy the mediastinum shifted excessively toward the left into the empty left hemithorax. This shift occurred with a clockwise rotation of the mediastinum, disturbing the normal spatial relationship of the structures in the mediastinum. The mediastinal trachea was thus no longer in the midline, and the origin of the right main bronchus was now well left of the midline and posterior to the bodies of the thoracic vertebrae. These mechanisms, functioning in combination, resulted in an apparent elongation and narrowing of the bronchus intermedius. The bronchial compression occurred between the right main pulmonary artery and the thoracic spine. The retrocardiac herniation of right lung in 1 patient was also believed to be important in bronchial compression. Previous reports of the syndrome after a left pneumonectomy have emphasized that it only occurred in the presence of a right aortic arch; the bronchus compressed between the ascending and descending thoracic aorta. The aortic arch anomaly was absent in our 4 patients.
It is possible that the syndrome is much more common than we realize. Mediastinal shift and exertional dyspnea are relatively frequent after pneumonectomy. The dyspnea is readily attributed to the extent of the pulmonary resection. We suggest that the combination of both dyspnea and mediastinal shift warrants a computed tomographic scan, an awake bronchoscopy, or both. The finding of bronchial obstruction should lead one to consider surgical intervention as described below.
All 3 patients with a repositioned mediastinum obtained relief of their dyspnea. Improvement in the measurements of lung function was documented in 2 patients (Table 1). At thoracotomy, 2 had very few adhesions and little or no pleural fluid. Where present, adhesions were divided to completely mobilize the mediastinum. Mediastinal position was assured by the insertion of a prosthesis filled with saline solution; final volumes in all 3 cases were approximately 1.0 L. In 1 case the use of greater than this amount led to excessive contralateral shift and the requirement of a second thoracotomy. This emphasizes the importance of continuous hemodynamic monitoring of both systemic and pulmonary pressures, particularly after closure of the chest and before the patient is extubated and moved to the recovery room. In 1 case the pericardium was sutured to the anterior chest wall to further ensure a midline mediastinal position. The importance of this maneuver is uncertain, but other authors have attempted similar fixation by more elaborate means [4]. The fourth case was successfully treated by resection of a portion of the adjacent thoracic vertebra. The sudden unexplained death at 4 months may have been due to recurrent bronchial obstruction, perhaps secondary to bone regeneration. Based on our experience with the other 3 left-sided cases and several right-sided cases not reported here, we believe that mediastinal repositioning is a superior operation.
We conclude from this clinical experience that postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. As with the syndrome that occurs after pneumonectomy with right-sided aortic arch excessive mediastinal shift is the basis for the pathology and should alert the surgeon to the presence of the syndrome when presented with a patient with dyspnea after pneumonectomy [5, 6]. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms. There have been other reviews of postpneumonectomy syndrome after a right pneumonectomy that have indicated the beneficial effects of mediastinal repositioning [4–6].
|
Footnotes
|
|---|
Address reprint requests to Dr Todd, Toronto General Hospital, 10 Eaton-226, 200 Elizabeth St, Toronto, Ont, Canada M5G 2C4.
|
References
|
|---|
- Whyte KF, McMahon G, Wightman AJ, Cameron EW. Bronchial compression as a result of lung herniation after pneumonectomy. Thorax 1991;46:855–7.
- Szarnicki R, Maurseth K, de Leval M, Stark J. Tracheal compression by the aortic arch following right pneumonectomy in infancy. Ann Thorac Surg 1978;25:231–5.[Abstract]
- Quillin SP, Shackelford GD. Postpneumonectomy syndrome after lung resection. Radiology 1991;179:100–2.
- Grillo HC, Shepard JO, Mathisen DJ. Postpneumonectomy syndrome: diagnosis, management, and results. Ann Thorac Surg 1992;54:638–51.[Abstract]
- Shepard JO, Grillo HC, McLoud TC, Dedrick CG, Spizarny DL. Right-pneumonectomy syndrome: radiologic findings and CT correlation. Radiology 1986;161:661–4.[Abstract/Free Full Text]
- Jansen JP, Brutel de la Riviere A, Alting MP, Westermann CJ, Bergstein PG, Duurkens VA. Postpneumonectomy syndrome in adulthood. Surgical correction using an expandable prosthesis. Chest 1992;101:1167–70.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
T. Ng, B. A. Ryder, D. E. Maziak, and F. M. Shamji
Thoracoscopic approach for the treatment of postpneumonectomy syndrome.
Ann. Thorac. Surg.,
September 1, 2009;
88(3):
1015 - 1018.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Soll, D. Hahnloser, T. Frauenfelder, E. W. Russi, W. Weder, and P. B. Kestenholz
The postpneumonectomy syndrome: clinical presentation and treatment
Eur. J. Cardiothorac. Surg.,
February 1, 2009;
35(2):
319 - 324.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Lee, H. K. Kim, S. Lee, H. Kim, and J. Kim
Surgical correction of postpneumonectomy-like syndrome in a patient with a tuberculosis-destroyed lung
J. Thorac. Cardiovasc. Surg.,
September 1, 2008;
136(3):
780 - 781.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. R. Shen, J. C. Wain, C. D. Wright, H. C. Grillo, and D. J. Mathisen
Postpneumonectomy syndrome: Surgical management and long-term results.
J. Thorac. Cardiovasc. Surg.,
June 1, 2008;
135(6):
1210 - 1219.e6.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. L.R. Bedard, K. Uy, and S. Keshavjee
Postpneumonectomy Syndrome: A Spectrum of Clinical Presentations
Ann. Thorac. Surg.,
March 1, 2007;
83(3):
1185 - 1188.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. F. Reed and J. D. Lewis
Thoracoscopic mediastinal repositioning for postpneumonectomy syndrome
J. Thorac. Cardiovasc. Surg.,
January 1, 2007;
133(1):
264 - 265.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Perigaud, O. Baron, J. C. Roussel, O. Al Habash, P. Despins, J. L. Michaud, and D. Duveau
Pneumothorax after left pneumonectomy: Implantation of an intrapleural prosthesis
Ann. Thorac. Surg.,
August 1, 2004;
78(2):
707 - 709.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. C. Grillo
Development of tracheal surgery: a historical review. Part 2: treatment of tracheal diseases
Ann. Thorac. Surg.,
March 1, 2003;
75(3):
1039 - 1047.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. C. Grillo
Development of tracheal surgery: a historical review. Part 1: techniques of tracheal surgery
Ann. Thorac. Surg.,
February 1, 2003;
75(2):
610 - 619.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. F. Kelly, D. W. Hunter, and M. A. Maddaus
Postpneumonectomy syndrome after left pneumonectomy
Ann. Thorac. Surg.,
February 1, 2001;
71(2):
701 - 703.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
