Ann Thorac Surg 2002;74:929-931
© 2002 The Society of Thoracic Surgeons
Case report
Spontaneous rupture of the right hemidiaphragm after video-assisted lung volume reduction operation
Serban C. Stoica, AFRCSEda,
Stewart R. Craig, FRCS (C-Th)a,
Sing Yang Soon, MRCSEda,
William S. Walker, FRCSEd*a
a Department of Cardiothoracic Surgery, The Royal Infirmary, Edinburgh, United Kingdom
Accepted for publication January 23, 2002.
* Correspondence to Mr Walker, Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW, UK
e-mail: wsw{at}holyrood.ed.ac.uk
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Abstract
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Lung volume reduction operation is an important therapeutic option in patients with advanced emphysema. We report a case of spontaneous rupture of the right diaphragm after a video-assisted thoracoscopic surgical procedure for emphysema. The pathophysiology of this complication is also discussed, along with practical points for perioperative management of emphysematous patients.
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Introduction
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Lung volume reduction surgical procedure (LVRS) is an established form of treatment for advanced emphysema. The mortality rate ranges between 4% and 10% [1, 2], and it appears that a video-assisted thoracoscopic surgical approach results in less morbidity compared with a median sternotomy [3].
A 62-year-old woman with severe dyspnea from diffuse emphysema was referred for LVRS assessment. She was an ex-smoker whose treatment had included steroids for 9 years. The patient was managing well on inhalers, but her frequent exacerbations required parenteral and oral steroids. Investigations included respirometry, thoracic imaging, and cardiovascular assessment. The forced expiratory volume in 1 second (FEV1) was 0.25 L (2.0 L predicted), the vital capacity (VC) was 1.25 L (2.6 L predicted), and FEV1/VC was 20% (73% predicted). Her functional residual capacity was 5.00 L (2.8 L predicted), the total lung capacity was 6.00 L (4.5 L predicted), and gas transfer was also impaired; thus, she fulfilled our criteria for the procedure. An interval operation was offered, with the right side scheduled first. The upper lobe and the apical segment of the lower lobe were severely affected by emphysema, and a nonanatomic video-assisted thoracoscopic surgical resection was performed. Extubation was performed in the recovery area.
Fourteen hours later the patient suddenly described epigastric pain, vomited, and possibly aspirated into the airway. Clinical examination showed tachypnea, epigastric tenderness, and reduced air entry to the base of the right lung, which was dull to percussion. The intercostal drain was not bubbling, and there was marked surgical emphysema over the right hemithorax. The pulse was irregular at 140 beats per minute, but the patient was hemodynamically stable. When another chest drain was introduced in a more anterior site, air was released under pressure, and the respiratory measurements improved. An early postoperative chest radiograph and a repeat film are presented in Figures 1 and 2.
Investigations confirmed fast atrial fibrillation and a new inferior myocardial infarction. The patient spiraled into respiratory failure and was reintubated.
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Fig 2. Chest radiograph after the early clinical deterioration. Note the massive opacity in the lower right hemithorax and the significant surgical emphysema.
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A contrast thoracic computed tomographic scan performed on day 1 postoperatively revealed extensive surgical emphysema, collapse of the right lung base, and the anterior-most chest drain anterior to the liver, which was high in the thoracic cage. Gas was seen around the gallbladder, but there was no specific indication about the anatomy of the diaphragm. The patient was returned to the operating room for a thoracoscopy through the anterior video-assisted thoracoscopic surgical port. This procedure was difficult, and thus the video-assisted thoracoscopic surgical ports were converted into an anterolateral thoracotomy. The dome of the liver was herniating through a large diaphragmatic rupture, and the muscle was friable, retracted, and had virtually lost its insertion at the anterior costal margin. Reattachment of the diaphragm to the anterior costal margin was performed, and the repair was reinforced with a polyester stretch patch (MEADOX). Postoperatively the patient was labile and required high doses of inotropic agents. Swabs from multiple skin sites, including the drain sites, demonstrated colonization with methicillin-resistant Staphylococcus aureus. Methicillin-resistant S aureus septicemia ensued, and the patient ultimately died of multiple-organ system failure on day 29.
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Comment
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Spontaneous, nontraumatic rupture of the diaphragm is extremely rare, with only a handful of cases described in the world literature. The condition is associated with events that increase intraabdominal pressure and was described sporadically in relation to physical exercise, pertussis, psychiatric illness, and complicating labor. Bisgaard and colleagues [4] reviewed the cases reported up to 1985. They pointed out that the condition carries a significant mortality, with two deaths in 13 cases. The prognosis is clearly influenced by age and comorbidity.
Of 51 cases of thoracoscopic LVRS performed until the end of 1999, this was the first procedure-related death, giving us a procedure-related mortality of 2% and a 30-day mortality of 4%. The sequence of events is easier to understand retrospectively. An inferior myocardial infarction caused epigastric pain, retching, and inhalation of gastric contents. This facilitated the nontraumatic, severe rupture of the right diaphragm. Our differential diagnosis on the second postoperative chest radiograph, discussed in fact with radiologists in a multidisciplinary meeting, was basal atelectasis, subpulmonary hemorrhagic effusion, intraparenchymal hemorrhage, aspiration pneumonitis, and pulmonary embolism. The computed tomographic scan provided only indirect clues to the true diagnosis. Computed tomography is regarded as a good investigative tool for detecting rupture of the diaphragm after blunt abdominal trauma, with a sensitivity of 61% and a specificity of 87% [5]. However, this complication is well recognized in association with trauma. This emphasizes the point that the pretest likelihood ratio directly influences the accuracy of the investigation. In our case the clinical and radiologic index of suspicion for diaphragmatic rupture was understandably low. Finally, after early diagnosis and repair of the ruptured diaphragm, methicillin-resistant S aureus septicemia in a patient with minimal functional reserve turned out to be a fatal event.
Other authors reported wound complications after LVRS, and it can be speculated that long-term steroid treatment leads to poor quality of tissue [6]. In emphysematous patients other factors may contribute significantly to diaphragmatic rupture: the muscle is flat and atrophied from loss of respiratory excursion, and the buttress effect of the lung is immediately reduced after resection. In conclusion, LVRS cases have a number of risk factors for this complication. Discontinuing oral steroids a few weeks before planned operation and avoiding any increases in abdominal pressure in the postoperative period appear to be desirable goals. Finally, in the presence of postoperative respiratory distress, a lower index of suspecting diaphragmatic rupture is needed.
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References
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- Utz J.P., Hubmayr R.D., Deschamps C. Lung volume reduction surgery for emphysema: out on a limb without a NETT. Mayo Clin Proc 1998;73:552-566.[Abstract]
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- Kotloff R.M., Tino G., Bavaria J.E., et al. Bilateral lung volume reduction surgery for advanced emphysema. A comparison of median sternotomy and thoracoscopic approaches. Chest 1996;110:1399-1406.[Abstract/Free Full Text]
- Bisgaard C., Rodenberg J.C., Lundgaard J. Spontaneous rupture of the diaphragm. Scand J Thorac Cardiovasc Surg 1985;19:177-180.[Medline]
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Abstract
Introduction
