Ann Thorac Surg 2004;78:707-709
© 2004 The Society of Thoracic Surgeons
Case report
Pneumothorax after left pneumonectomy: Implantation of an intrapleural prosthesis
Christian Perigaud, MDa,
Olivier Baron, MDa*,
Jean Christian Roussel, MDa,
Ousama Al Habash, MD,
Philippe Despins, MDa,
Jean Luc Michaud, MDa,a,
Daniel Duveau, MDa
a Thoracic and Cardiovascular Department, Hôpital G and R Laënnec, Nantes, France
Accepted for publication June 23, 2003.
* Address reprint requests to Dr Baron, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital G et R Laënnec, Boulevard J. Monod, 44093 Nantes Cedex 01, France
e-mail: olivier.baron{at}chu-nantes.fr
 |
Abstract
|
|---|
Postpneumonectomy syndrome is defined as an airway obstruction due to mediastinal shift and rotation after pneumonectomy. A patient who had undergone a left pneumonectomy for bronchial carcinoma 13 years before presented with tension pneumothorax of her remaining lung. Although all factors relevant to the development of postpneumonectomy syndrome were ascertained, the patient had a pneumothorax rather than an airway obstruction. This pneumothorax was treated surgically. The goal of this operation was to reduce the right pleural cavity volume by implanting an intrapleural prosthesis in the pneumonectomy cavity. This treatment is identical to that used for postpneumonectomy syndrome, which allows the right lung to be rejoined with the thoracic wall.
|
Introduction
|
|---|
Postpneumonectomy syndrome is a rare complication after right or left pneumonectomy. Jansen and coworkers [1] reported only 1 of 640 patients who had undergone pneumonectomies (incidence of 0.2%). It is an airway obstruction secondary to a mediastinum shift and rotation. A hernia of the functional and greatly distended lung is associated with this mediastinal deviation.
Over the past 10 years, treatment of this syndrome has greatly improved. Currently, it consists of a surgical approach that involves mediastinal repositioning with the insertion of a prosthesis in the pneumonectomy cavity.
This case concerns a female patient who presented with all factors associated with the development of postpneumonectomy syndrome but with a tension pneumothorax rather than an airway obstruction. We attempt to both explain the physiopathology of this event and specify its very particular management, which is similar to postpneumonectomy syndrome treatment.
In 1989, a female patient aged 51 years underwent a left pneumonectomy for a stage II bronchopulmonary epidermoid carcinoma (T2N0M0). Thirteen years later, this woman was admitted to the emergency department with acute respiratory distress. Thorax roentgenograms revealed an important pneumothorax over the remaining right lung, requiring emergency thoracic drainage. During her hospital stay, several tension pneumothorax recurrences required emergency drainage (Fig 1). On hospital day 14, an additional right pneumothorax recurrence after a symphysis attempt with an intrapleural cyclin injection led to the patient's transfer to intensive care unit for placement of a new thoracic drain. Two thoracic computed tomographic scans at days 15 and 22, respectively (Fig 2), showed heart displacement and large mediastinal vessels within the left hemithorax as well as a clockwise rotation. The right lung was distended, producing a large hernia in the left hemithorax. A gaseous effusion was observed on the thorax anterior side, identical on both scans. Both the trachea and right bronchus did not show any compression. No recurrence of the neoplastic pathology was observed.
View larger version (137K):
[in this window]
[in a new window]
|
Fig 1. Roentgenogram of the thorax at day 23 shows a distended right lung, the mediastinum shifted to the left, and two thoracic drains.
|
|
At day 29, because of the persisting pneumothorax and despite two active suction drains with persistent air leakage, the patient was operated on. The left thoracotomy incision was reopened, and adhesions were carefully released without opening the right pleura, thus revealing a pleural cavity free of any tumor recurrence. The mediastinum, heart, and right lung were repositioned with the insertion of a prosthesis filled with 450 mL physiologic solution in the left hemithorax. At the end of the operation, a thoracic roentgenogram was obtained in the operating room (Fig 3), revealing a repositioned mediastinum and a less distended right lung with no hernia protrusion in the left hemithorax. The prosthesis was well in place. No bubbling was observed from the drains that were removed at the end of the surgical procedure. The patient was extubated during the immediate postoperative period. She left the hospital on postoperative day 6. At 1 month follow-up, monitoring thoracic computed tomography confirmed the absence of recurrent pneumothorax and the mediastinal repositioning and a partial, but clearly less distended, right lung with no more herniation in the left hemithorax. The prosthesis was well positioned.
View larger version (142K):
[in this window]
[in a new window]
|
Fig 3. Roentgenogram of the thorax in the operating room at the end of the operation under respiratory assistance shows mediastinal recentering and a less distended right lung with no more herniation in left hemithorax. The prosthesis ( ) is in the left hemithorax.
|
|
|
Comment
|
|---|
The occurrence of a pneumothorax in one lung after pneumonectomy for bronchopulmonary cancer is a rare and potentially lethal complication. In this female patient, the distended right lung filled up both the right and left hemithorax. The mediastinum was deviated in the left hemithorax. This case is very similar to one of postpneumonectomy syndrome, defined by Grillo and colleagues [2] as an airway obstruction caused by a mediastinal shift and rotation after right or left pneumonectomy. However, this clinical case varies from postpneumonectomy syndrome because the right remaining lung distention associated with the mediastinum shift in the left hemithorax is complicated by a pneumothorax instead of an airway obstruction. Actually, the greatly distended right lung is unable to occupy the right hemithorax and part of the left one. Thus, repeat drainages over 1 month were ineffective, and the right lung did not rejoin the thoracic wall. This medical treatment failure led to the need for surgical management. We believed that an identical treatment for the spontaneous pneumothorax by surgical pleural avivement was insufficient, and pleural symphysis could not be achieved in this patient by a mere pleura inflammatory reaction. The aim of the suggested treatment was to insert a prosthesis in the left hemithorax to reduce the right pleural cavity volume and therefore allow the right lung to rejoin the thoracic wall. Our team used a treatment similar to the one proposed by some authors for postpneumonectomy syndrome. In this syndrome, one of the techniques to eliminate airway obstruction consists of repositioning the mediastinum with a prosthesis filled with physiologic solution [2–5]. Other authors use expandable prostheses whose volume can be altered by an injection access placed inside the subcutaneous tissue [1, 6]. Most teams implant the prosthesis in the pneumonectomy cavity. Grillo and colleagues [2] suggest a subcostal positioning by placing a band of intercostal muscles and periosteum between the prosthesis and pericardium to facilitate prosthesis explantation if the need for reintervention arises. Implantation of the prosthesis can be associated with suturing of the pericardium onto the sternum posterior side [4, 5]. In our case, the goal was not mediastinal recentering but filling the pneumonectomy cavity to allow the remaining distended lung to rejoin the thoracic wall. We therefore chose an inelastic prosthesis filled with physiologic solution. Our management of this particular case resulted in a favorable outcome because the patient was quickly discharged from the hospital. At 1-month follow-up, computed tomography showed the right lung adjoining the thoracic wall without a pneumothorax recurrence.
|
References
|
|---|
- Jansen J.P., Brutel de la Rivière A., Carpentier Alting M.P., et al. Postpneumonectomy syndrome in adulthood. Surgical correction using an expandable prosthesis. Chest 1992;101:1167-1170.[Abstract/Free Full Text]
- Grillo H.C., Shepard J.A.O., Mathisen D.J., Kanarek D.J. Postpneumonectomy syndrome: diagnosis, managements and results. Ann Thorac Surg 1992;54:638-651.[Abstract]
- Kelly R.F., Hunter D.W., Maddaus M.A. Postpneumonectomy syndrome after left pneumonectomy. Ann Thorac Surg 2001;71:701-703.[Abstract/Free Full Text]
- 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]
- Riveron F.A., Adams C., Lewis J.W., Ochs D., Glines C., Popovich J. Silastic prosthesis plombage for right postpneumonectomy syndrome. Ann Thorac Surg 1990;50:465-466.[Abstract]
- Audry G., Balquet P., Vazquez M.P., et al. Expandable prosthesis in right postpneumonectomy syndrome in childhood and adolescence. Ann Thorac Surg 1993;56:323-327.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
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]
|
|
|
Top
Abstract
Introduction
) in the left hemithorax, pulmonary distention, pneumothorax (
).