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Ann Thorac Surg 2001;71:701-703
© 2001 The Society of Thoracic Surgeons

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Case report

Postpneumonectomy syndrome after left pneumonectomy

^a Section of General Thoracic Surgery, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
^b Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA

Accepted for publication January 9, 2000.

Address reprint requests to Dr Maddaus, University of Minnesota, Box 207, 420 Delaware St SE, Minneapolis, MN 55455
e-mail: madda001{at}tc.umn.edu

	Abstract

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Postpneumonectomy syndrome, a late complication of pneumonectomy, is secondary to shift of the mediastinum and remaining lung toward the pneumonectomy side, leading to tracheobronchial compression between the vertebral body and the aorta or pulmonary artery. Obstructive airway symptoms are usually due to tracheobronchial tree compression, however, secondary airway malacia may develop. We report herein a case of postpneumonectomy syndrome with secondary bronchomalacia after left pneumonectomy in a patient with normal mediastinal vascular anatomy.

	Introduction

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Postpneumonectomy syndrome, a late complication of pneumonectomy, is secondary to a shift of the mediastinum and remaining lung toward the pneumonectomy side, leading to tracheobronchial compression between the vertebral body and the aorta or pulmonary artery. Obstructive airway symptoms are usually due to tracheobronchial tree compression. However, secondary airway malacai may develop.

A 38-year-old woman initially underwent segmental left mainstem bronchus sleeve resection at 30 years of age for bronchus stricture secondary to histoplasmosis-induced mediastinal fibrosis. Recurrent stenosis led to left pneumonectomy 6 months later. Six years later, she developed progressive exertional dyspnea and difficulty clearing secretions and at referral was unable to walk one block without severe dyspnea. Physical examination showed only significant expiratory stridor. Pulmonary function testing showed a forced expiratory volume in 1 second (FEV₁) of 1.33 L (40% of predicted) and an FVC of 2.92 L (73% of predicted). Chest roentgenogram showed shift of the heart and mediastinal structures into the left hemithorax with right lung hyperexpansion and no fluid in the left hemithorax. Chest computed tomography (CT) confirmed these findings and also demonstrated compression of the right mainstem bronchus and the bronchus intermedius between the vertebral body and the right pulmonary artery (Fig 1). Flexible bronchoscopy showed marked narrowing of the right mainstem bronchus and bronchus intermedius, independent of respiration. The narrowing was not a stricture, but was an anterior-posterior narrowing with a fish-mouth appearance felt to be secondary to external compression between the vertebral body and pulmonary artery.

View larger version (76K): [in this window] [in a new window]   Fig 1. CT scan shows transition from a patent airway (A) to compression of the right mainstem bronchus (B) between the vertebral body and pulmonary artery. (Ao = aorta; PA = pulmonary artery; RMB = right mainstem bronchus; RULB = right upper lobe bronchus; SVC = superior vena cava.)

View larger version (89K): [in this window] [in a new window]   Fig 2. Dynamic CT scan shows patency of the right mainstem bronchus (arrow) with inspiration (A) and near complete collapse with exhalation (B). (RMB = right mainstem bronchus.)

	Comment

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This report reinforced two features of postpneumonectomy syndrome. First, the clinical radiographic presentation was classic with dyspnea on exertion, ineffective cough, expiratory stridor, and difficulty clearing secretions; chest roentgenogram showed complete shift of the heart and mediastinum into a hemithorax devoid of fluid. Chest CT clearly demonstrated compression of the right mainstem bronchus and the bronchus intermedius between the vertebral body and the right pulmonary artery. Second, consistent with other reports [1–4], left thoracotomy with lysis of adhesions and implantation of breast prostheses was successful in achieving and maintaining mediastinal repositioning. However, the mediastinal repositioning failed to give her significant relief, because of her underlying bronchomalacia, the extent of which became evident only after the mediastinal repositioning.

Tracheobronchial malacia has been described in conjunction with postpneumonectomy syndrome. It is likely caused by prolonged compression of the cartilage rings between a great vessel (aorta or pulmonary artery) and the vertebral body [5, 6], leading to thinning and softening of the cartilage rings to a degree that may be related to the length of time the airway was compressed. Our patient likely had compression for as long as 6 years. Grillo and associates [5], in their experience with 11 patients with postpneumonectomy syndrome, found that 4 demonstrated significant tracheobronchial malacia after surgical relief of airway compression. In these 4 patients, the interval between the pneumonectomy and the surgical relief of airway compression was 1.5, 8, 17, and 20 years. Five of the remaining 7 patients without malacia had an interval of 2 years or less.

In summary, postpneumonectomy syndrome has now been documented after left pneumonectomy in 5 patients [1, 7], including ours, with normal mediastinal vascular anatomy. Airway compression between the pulmonary artery and the vertebral body leads to mechanical obstruction, which, if prolonged, may lead to bronchomalacia. The initial treatment should be operative mediastinal repositioning with saline prostheses. If bronchomalacia becomes apparent, endobronchial stenting with an expandable wire stent should be performed. Resection of the malacic segment should be reserved for patients with stent placement failure or related complications.

	References

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1. Shamji F.M., Deslauriers J., Daniel T.M., Matzinger F.R., Mehran R.J., Todd T.R.J. Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy. Ann Thorac Surg 1996;62:1627-1631.[Abstract/Free Full Text]
2. Riveron F.A., Adams C., Lewis J.W., Jr, Ochs D., Glines C., Popovich J., Jr Silastic prosthesis plombage for right postpneumonectomy syndrome. Ann Thorac Surg 1990;50:465-466.[Abstract]
3. Wasserman K., Jamplis R.W., Lash H., Brown H.V., Clearly M.G., Lafair J. Post-pneumonectomy syndrome. Surgical correction using silatic implants. Chest 1979;75:78-80.[Abstract/Free Full Text]
4. Downey R.J., Trastek V.F., Clay R.P. Right pneumonectomy syndrome: surgical correction with expandable implants. J Thorac Cardiovasc Surg 1994;107:953-955.[Free Full Text]
5. Grillo H.C., Shepard J.A.O., Mathisen D.J., Kanarek D.J. Postpneumonectomy syndrome: diagnosis, management and results. Ann Thorac Surg 1992;54:638-651.[Abstract]
6. Rasch D.K., Grover F.L., Schnapf B.M., Clarke E., Pollard R.G. Right pneumonectomy syndrome in infancy treated with expandable prosthesis. Ann Thorac Surg 1990;50:127-129.[Abstract]
7. Quillin S.P., Shackelfort G.D. Postpneumonectomy syndrome after left lung resection. Radiology 1991;179:100-102.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rosemary F. Kelly Michael A. Maddaus Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kelly, R. F. Articles by Maddaus, M. A. Search for Related Content PubMed PubMed Citation Articles by Kelly, R. F. Articles by Maddaus, M. A. Related Collections Lung - basic science