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Ann Thorac Surg 2008;85:1434-1436. doi:10.1016/j.athoracsur.2007.10.033
© 2008 The Society of Thoracic Surgeons
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Case Reports

Simultaneous Bilateral Spontaneous Pneumothorax With Pleural Window Communicating With Bilateral Pleural Spaces

Shunsuke Yamada, MDa,*, Kazuho Yoshino, MDa, Hiroshi Inoue, MDb

a Department of Thoracic Surgery, Tokai University Hachioji Hospital, Hachioji, Tokyo, Japan
b Tokai University School of Medicine, Hachioji, Tokyo, Japan

Accepted for publication October 8, 2007.

* Address correspondence to Dr Yamada, Department of Thoracic Surgery, Tokai University Hachioji Hospital, 1838 Isikawa, Hachioji, Tokyo, 192-0032, Japan (Email: yamada.shunsuke{at}hachioji-hosp.tokai.ac.jp).


   Abstract
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 Abstract
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A pleural window communicating between bilateral pleural cavities is a serious condition in patients with pneumothorax, allowing air to leak from the affected lung into the contralateral pleural cavity and resulting in bilateral spontaneous pneumothorax. We treated a patient with a history of right-sided bullectomy for simultaneous bilateral spontaneous pneumothorax that subsequently recurred. A pleural window (1 cm long) was detected in the mid-mediastinum, and direct suture closure with localized pleural abrasion using argon beam coagulation on the circumference of the lesion was performed at video-assisted thoracoscopic surgery.


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Simultaneous bilateral spontaneous pneumothorax (SBSP) is rare but can be a critical clinical event. Almost all reported cases have involved underlying pulmonary disease such as chronic obstructive pulmonary disease, malignant neoplasm, or tuberculosis. In the present case, a congenital pleural window communicating between bilateral pleural cavities allowed air to leak from the affected lung into the contralateral pleural cavity, causing SBSP. Reports of surgical SBSP associated with congenital pleural communication are extremely rare. We report the case of a patient with SBSP associated with a congenital pleural window that was treated using video-assisted thoracoscopic surgery.

A 21-year-old man was transferred to our hospital for surgical treatment of recurrent SBSP. Two months earlier he had been transferred to the emergency department of another hospital because of clinically critical complete collapse of both lungs and had undergone urgent bilateral tube thoracostomy. He subsequently underwent right-sided bullectomy with pleural abrasion using dry gauze in a right-sided axial thoracotomy as a procedure to prevent right-sided pneumothorax. After 2 months, SBSP developed again and the patient was admitted to another hospital. Unilateral tube drainage was performed because of complete collapse of the left lung. A small right-sided pneumothorax was observed. The patient was transferred to our hospital the next day. Plain chest radiographs obtained at our hospital showed resolution of pneumothorax on both the drained and contralateral sides. Before surgery, the chest tube was inserted into the right side in the operating room and video-assisted thoracoscopic surgery was performed to treat left-sided pneumothorax. At inspection of the anterior mediastinum along the sternum and the middle mediastinum along the descending aorta, a 1-cm long pleural window was detected at the caudal margin of the inferior pulmonary ligament, between the aorta and the esophagus (Fig 1). The lesion was closed by direct pleural suture, and localized pleural abrasion was performed using argon beam coagulation along the circumference of the sutured lesion. No ruptured bullae were apparent in the lung parenchyma. Wedge resection of a small bulla in the left lung apex was performed using an end stapler. The postoperative course was uneventful, and the bilateral chest tubes were removed 1 day after surgery.


Figure 1
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  		Fig 1. Video image shows orifice of pleural defect (1 cm long) at caudal margin of inferior pulmonary ligament, between aorta and esophagus.

 

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Simultaneous bilateral spontaneous pneumothorax associated with pleural communication between bilateral pleural cavities is considered a possible postoperative complication after major thoracic or cardiovascular surgery. However, congenital pleural communication is not well known. What is its frequency? What are its likely locations? How many communications are there, and how large are they? The presence of a congenital pleural communication may even go unnoticed.

In the embryogenesis of the pleura, from week 5 the pleuropericardial folds fuse in the midline, with separation of the pleural cavity from the pericardial sac. Plural communication might occur after some adverse influence on the fetus during this period. This anomaly is a critical problem in patients with spontaneous pneumothorax. Pneumatic flow from the affected lung to the contralateral pleural cavity through a pleural window causes bilateral pneumothorax. In our patient, the degree of pulmonary collapse differed, but SBSP developed twice despite surgery to treat right-sided pneumothorax. A unilateral chest tube was inserted to resolve pneumothorax on the contralateral side, as in ipsilateral pneumothorax. This led to a suspicion of continuity between bilateral pleural spaces.

As treatment of SBSP, early definitive surgery must be performed to reduce the risk of recurrence [1]. Bullectomy is most effective in preventing recurrence, and recurrence is further reduced with the addition of apical pleurodesis. The recurrence rate of pneumothorax is less than 5%. Because recurrence of SBSP is life-threatening, obliteration of this communication is clearly essential. The pleural window in our patient was small (1 cm) and could be closed by direct pleural suture, and pleural abrasion using argon beam coagulation on the circumference of the sutured lesion was performed for further obliteration of the lesion by localized pleural adhesions.

As for the surgical approach to pneumothorax, most bullae are present in the lung apex. As a result, surgeons concentrate attention on the apical lung area during surgery. Small transaxillary thoracotomy is chosen as the surgical procedure for apical lesions, rather than standard thoracotomy [2]. However, this surgical approach may result in pleural communications being missed. The pleural window in our patient, which was located far from the apical lesion, could not be detected at right-sided axillary thoracotomy. Congenital pleural communication treated surgically has previously been reported in only 2 patients with SBSP [3, 4]. The communication was located at the front of the thymus in the anterior mediastinum in 1 patient and from the tracheal carina to the diaphragm (10-cm long) in the middle mediastinum in the other patient. Right-sided posterolateral or bilateral axillary thoracotomies were performed. However, in both patients, existence of pleural communications was confirmed and identified when water was poured in to test for air leakage or for irrigation that had escaped to the opposite pleural cavity. Meticulous attention should be paid to detecting the pleural window.

Video-assisted thoracoscopic surgery is now a standard approach in treating spontaneous pneumothorax in many institutions. This surgical procedure produces a cosmetically small scar. Reduction of postoperative pain is expected compared with open thoracotomy. However, few controlled studies have been performed to correctly compare these methods [2, 5]. As an important advantage, videoscopy enables wide-view inspection of all thoracic fields. When performing surgical treatment of SBSP without underlying pulmonary disease, the existence of pleural communications must always be considered, and the mediastinal pleura must be carefully examined, particularly where bilateral pleura come into contact with each other.


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  1. Minami H, Senda K, Horio Y, Iwahara T, Shibagaki T, Sakai S. Simultaneous bilateral spontaneous pneumothoraces[in Japanese] Nihon Kyobu Shikkan Gakkai Zasshi 1990;10:1321-1325.
  2. Kim KH, Kim HK, Han JY, Won YS, Choi SS. Transaxillary minithoracotomy versus video-assisted thoracic surgery for spontaneous pneumothorax Ann Thoracic Surg 1996;61:1510-1512.[Abstract/Free Full Text]
  3. Nomori H, Kaseda T, Ishihara T, Iseki M. A case of bilateral pneumothorax due to the intrathoracic communication through the defect of the mediastinal pleura Kyobu Geka 1988;41:761-763.[Medline]
  4. Juvonen T, Martti L, Pokela R, Juvinen J, Kairaluoma MI. Mediastinal window: a case of simultaneous bilateral spontaneous pneumothorax Ann Thoracic Surg 1992;54:560-561.[Abstract/Free Full Text]
  5. Freixinet JL, Canalis E, Julia G, Rodriguez P, Santana N, Castro FR. Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax Ann Thoracic Surg 2004;78:417-420.[Abstract/Free Full Text]



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This Article
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Hiroshi Inoue
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