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Ann Thorac Surg 2005;80:e13
© 2005 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Massive Pneumoperitoneum: A Late Complication of the Denver Pleuroperitoneal Shunt

Christophoros N. Foroulis, MD, PhD * , Nikolaos A. Desimonas, MD

Larissa University Hospital, Department of Thoracic Surgery, Larissa, Greece

* Address reprint requests to Dr Foroulis, Larissa University Hospital, Department of Thoracic Surgery, Larissa, 41110 Greece (Email: foroulis{at}internet.gr).

A 72-year-old man presented with progressive dyspnea as the result of a massive right-sided pleural effusion. Figure 1 shows his chest roentgenogram at admission. Thoracocentesis and pleural fluid cytology established the diagnosis of malignant pleural effusion (ie, non-small cell lung carcinoma). The lung was found unexpandable after fluid evacuation and bronchoscopy was negative for bronchial obstruction. A pleuroperitoneal shunt was then inserted and chemotherapy (docetaxel [Taxotere, Rhone Poulenc, France] plus vinorelbine [Navelbine, Pierre Fabre Farmaka, Milan, Italy]) was administrated to the patient. Twelve days after the first chemotherapy session the patient presented with epigastric discomfort and a distended abdomen. Chest roentgenogram confirmed the diagnosis of limited pneumothorax and massive pneumoperitoneum after pleuroperitoneal shunting of the effusion (Fig 2). A chest drain was inserted to treat the complication. The abdominal symptoms were resolved within 7 days after chest drainage. The patient died 20 days after the second chemotherapy session because of exhaustion.



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  		Fig 1.
 


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  		Fig 2.
 
Pleuroperitoneal shunt (Denver Biomedical, Inc, Denver, CO) is an effective palliative treatment for malignant pleural effusions and underlying trapped lung. The main, reported complications of pleuroperitoneal shunting are shunt occlusion by fibrin clots, infection and fracture of the shunt, skin erosion by the shunt, and malignant deposits in the abdomen. Pneumoperitoneum has also been twice reported in the past to be a rare complication of the shunt [1, 2]. High negative intrapleural pressure due to extreme shunt pumping, lung surface errosion by the shunt and post-chemotherapy necrosis of visceral pleura deposits are the main suggested factors that lead to late pneumothorax and consequently to pneumoperitoneum through the shunt.


   References
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 References
 

  1. Lopez-Viego MA, Cornell JM. Pneumoperitoneum and signs of peritonitis from a pleuroperitoneal shunt Surgery 1992;111:228-229.[Medline]
  2. Beshay M, Schmid RA. Spontaneous pneumoperitoneum after pleuroperitoneal shunt Eur J Cardiothorac Surg 2003;23:239.[Free Full Text]




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