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Ann Thorac Surg 2001;71:1704-1706
© 2001 The Society of Thoracic Surgeons

Case report

Surgical correction of postpneumonectomy stridor by saline breast implantation

Inderpaul Birdi, FRCSa,*, Max Baghai, FRCSa, Francis C Wells, FRCSa

a Papworth Hospital NHS Trust, Cambridge, England, United Kingdom

Accepted for publication June 6, 2000.

* Address reprint requests to Dr Birdi, Department of Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, England (Email: inderuk{at}hotmail.com).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Postpneumonectomy syndrome is a rare complication of pneumonectomy and is characterized by progressive dyspnea, stridor, and repeated chest infections. It is caused by displacement and rotation of the mediastinal structures into the pneumonectomy space, producing compression and malacic changes in the trachea and remaining bronchus. We report the successful long-term results of mediastinal correction, cardiopexy and plombage with saline breast prostheses in a 59-year-old man after right pneumonectomy for carcinoma of the lung


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
The postpneumonectomy syndrome is a rare problem that is usually seen after right pneumonectomy. It is characterized by counter-clockwise rotation and rightward displacement of the heart, great vessels, and trachea into the pneumonectomy space, leading to stretching and narrowing of the left main bronchus between the aorta and the pulmonary artery. Tracheomalacia or bronchomalacia may complicate the clinical picture, making treatment extremely difficult. The syndrome often manifests with progressive dyspnea, stridor, and recurrent pulmonary infection, leading ultimately to respiratory failure and death without intervention.

A 59-year-old man underwent surgery for squamous cell carcinoma involving the right lower lobe bronchus on October 13, 1985. Pneumonectomy was required because the tumor involved the right main bronchus. Initial recovery was uncomplicated.

He returned 8 months postoperatively with minimal stridor. Chest radiography showed some deviation of the mediastinum to the right. Rigid bronchoscopy performed at this stage was unremarkable.

The patient did not attend his routine outpatient appointments until he was re-referred 6 years later with progressive stridor, dyspnea on exertion, and repeated chest infections. He had chosen to neglect his symptoms until this time. A chest radiograph at this time demonstrated gross deviation of the mediastinum to the right, with hyperexpansion of the left lung. Computed tomography (Fig 1) showed rotation of the heart into the right posterior thorax. The trachea was very tortuous as it crossed the midline, and the left main bronchus was distorted in its course across the vertebral column. The left lung was herniating across the midline, virtually filling the entire chest. At bronchoscopy, the left main bronchus was slit-like over the vertebral column and would not admit a flexible scope. There were no malacic features. It was felt that simple endoscopic stent insertion would not be successful, and surgical correction of the deviation followed by plombage was therefore performed on December 14, 1992.


Figure 1
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  		Fig 1. Preoperative computed tomogram showing gross mediastinal shift and compression of the left main bronchus

 
The previous thoracotomy was reopened and the pneumonectomy space was found to be clean and unobliterated. The left lung and mediastinum were mobilized and the pericardium was secured to the back of the sternum using ethibond sutures. Three saline breast implants (Mentor Corporation, Santa Barbara, CA) were then placed into the right hemithorax to obliterate the remaining space and to prevent recurrent displacement of the mediastinal structures.

The patient experienced considerable improvement in his stridor immediately postoperatively, and at 6-week follow-up he was symptom free. Computed tomography performed 6 years after plombage demonstrated complete integrity of the saline implants (Fig 2). The patient was participating in circuit training exercise at that time.


Figure 2
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  		Fig 2. Computed tomogram 6 years after plombage. The sialastic implants remain intact and tesselate well.

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
The surgical treatment of postpneumonectomy syndrome is directed toward correction of the distortion of the left main bronchus after displacement of the mediastinal structures into the right hemothorax. Advances in endoscopic bronchial stent insertion can sometimes allow the correction of stridor, particularly in the presence of malacic changes in the remaining bronchus. The appropriate positioning of the stent is not always possible, particularly in the presence of gross distortion and mediastinal repositioning and plombage of the empty hemithorax has been reported to be a relatively successful alternative [1–3]. In 1949, Johnson and colleagues [4] used methyl-methacrylate spheres in the thoracic space but the spheres occasionally led to tracheal erosion or pseudoaneurysm formation.

The use of an expandable silicone prosthesis, as used in plastic surgery, was first described by Rasch and colleagues [5] in a 5-month old child who had previously undergone right pneumonectomy for total pulmonary sequestration. The ability to gradually increase the volume of the prosthesis is useful in children to accommodate changes in intrathoracic size as a result of growth. In adults, this has also been of value in graduating mediastinal correction by progressive injection of saline through a subcutaneous port [2]. Conversely, there are reports of leakage of the prosthesis caused by overinflation and injury [5, 6] and therefore the shape and size of the prosthesis must be determined carefully.

Some workers have combined mediastinal correction and cardiopexy, with the implantation of prosthetic breast [1, 7]. We believe that this method has a number of advantages over other plombage techniques. After correction of mediastinal position, a varying number of saline breast implants can be inserted into the chest. The ability of these implants to alter their shape in relation to the inside of the chest wall and also to one another make them advantageous to other plombage devices. In addition, the relatively low pressure of the contents of these prostheses as well as the durability of their walls may make them less likely to rupture. In our patient, CT scanning was repeated 6 years after saline prosthesis plombage. This confirmed the integrity of the implants.

Our patient showed no clinically important evidence of bronchomalacia despite the fact that he was clearly symptomatic over the 7-year period between his right pneumonectomy and surgical plombage. In a series of 11 patients with this syndrome, Grillo and colleagues [1] observed bronchomalacia only in patients in whom the bronchus was interposed between the pulmonary artery and aorta and not in those where the bronchus lay between the pulmonary artery and the spine as was the situation in our case.

The development of stridor after pneumonectomy needs to be carefully assessed by bronchoscopy and CT in order to exclude the early manifestations of postpneumonectomy syndrome. Mediastinal correction and cardiopexy combined with plombage of the pneumonectomy space with saline breast prostheses can be an effective long term treatment option. The occurrence of bronchomalacia is not invariably present in those with a protracted postpneumonectomy history suggestive of this syndrome and may be more closely related to the anatomical position of the bronchus in relation to neighboring vascular structures.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Grillo H, Shepard J, Mathisen D, et al. Post-pneumonectomy syndrome. Diagnosis, management and results Ann Thorac Surg 1992;54:638-651.[Abstract/Free Full Text]
  2. Tsunezuka Y, Sato H, Watanabe S, et al. Improved expandable prosthesis in postpneumonectomy syndrome with deformed thorax J Thorac Cardiovasc Surg 1998;116:526-528.[Free Full Text]
  3. Regnard JF, Pouliquen E, Magdeleinat P, et al. Postpneumonectomy syndrome in adults. description therapeutic propositions apropos of 8 cases. [French] Rev Mal Respir 1999;16:1113-1119.[Medline]
  4. Johnson J, Kirby C, Lazatin C, et al. The clinical use of a prosthesis to prevent overdistention of the remaining lung following pneumonectomy J Thorac Surg 1949;18:164-172.[Medline]
  5. Rasch D, Grover F, Schnapf B, et al. Right pneumonectomy syndrome in infancy treated with an expandable prosthesis Ann Thorac Surg 1990;50:127-129.[Abstract/Free Full Text]
  6. Audry G, Balquet P, Vazquex M, et al. Expandable prosthesis in right pneumonectomy syndrome in childhood and adolescence Ann Thorac Surg 1993;56:323-327.[Abstract/Free Full Text]
  7. Riveron F, Adams C, Lewis J, et al. Sialastic prosthesis plombage for right postpneumonectomy syndrome Ann Thorac Surg 1990;50:465-466.[Abstract/Free Full Text]



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This Article
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Max Baghai
Francis C Wells
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