Ann Thorac Surg 2008;85:1436-1438. doi:10.1016/j.athoracsur.2007.09.002
© 2008 The Society of Thoracic Surgeons
Case Reports
Reimplantation of the Left Lung 17 Years After a Bronchial Rupture
Alper Toker, MD*,
Serhan Tanju, MD,
Sukru Dilege, MD
Department of Thoracic Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
Accepted for publication September 4, 2007.
* Address correspondence to Dr Toker, Inonu Cad, Yildiz Sok. STFA Bloklari, B/6 Blok No 13 81090 Kozyatagi, Istanbul, Turkey (Email: atoker{at}istanbul.edu.tr).
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Abstract
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We describe a 37-year-old female patient who had a major vehicle accident 17 years ago. A chest tube had been inserted through the left side of the chest to treat pneumothorax. She was readmitted to the hospital with dyspnea 17 years later. Her examinations, including fiberoptic bronchoscopy, revealed total atelectasis of the left lung with a blind-ending left main bronchus. Anastomosis of the left distal main bronchus to left main bronchus was performed. She had no complications and was discharged on postoperative day 8. Follow-up demonstrated a perfectly functioning left lung with nuclear and tomographic investigations performed on the first postoperative year.
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Introduction
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Total rupture of the bronchus can be overlooked in the absence of accompanying major pathologic disturbances. This condition may result in delayed diagnosis. Here we described a 37-year-old female patient who fell from a tractor on which she was sitting next to the driver’s seat and was hit by the attached trailer when she fell to the ground 17 years ago.
A 37-year-old female patient was referred to our clinic as a result of atelectasis of the left lung. Computerized chest tomography (Fig 1) revealed total atelectasis and hyperplasia of the left lung. Fiberoptic bronchoscopic examination of the left lung demonstrated a blind-ending left main bronchus. From the history of the patient, we learned that the she fell from a tractor on which she was sitting next to the driver’s seat on the side and was hit by the attached trailer when she fell to the ground 17 years earlier. She had been transported to a small hospital in a small town. An indeterminate injury of the left chest with a possible pneumothorax had ended with chest tube insertion. She had not exhibited hemoptysis, and although she did not remember how long her chest was drained, her family members agreed on a 1-week duration. Medical records were not available.
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Fig 1. Computerized thoracic tomography scans (A, B) revealed an atelectatic left lung, shifted mediastinum, and anteriorly herniated right lung. The patient compensated the situation and did not have a major chest wall deformity.
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Her physical examination revealed absent breathing sounds over the lateral part of the left hemithorax and shifted apical cardiac impulse. She was breathing easily at rest but she had difficulty while lying down. Her pulmonary function tests showed a forced expiratory flow in 1 second of 2,210 mL (70%). She had an oxygen consumption test of 21 mL · kg–1
· min–1. Routine laboratory examination was normal.
She was intubated with a single-lumen tube and placed in the right lateral decubitus position. The left chest was entered through a standard posterolateral thoracotomy incision with the resection of the sixth rib. There were tight adhesions, and the lung was freed. The left lung appeared hypoplastic, resembling that of a child. The left main pulmonary artery was dissected free and was retracted anteriorly with umbilical tape. Dissection of the tissue under the aortic arch showed the left main bronchus. However, it was very difficult to find the distal bronchus, which was located under the origin of the left lower lobe superior segmental artery.
We resected the distal bronchus transversely until we saw a healthy lumen, and aspirated a mucoid secretion from the lung. Anastomosis of the left distal main bronchus to the left main bronchus with 4-0 polydioxanone sutures (Ethicon Inc, Johnson & Johnson, Sommerville, NJ) showed that the lung was functioning. It required a peak pressure of less than 25 cm H2O to expand. No air leak was noticed. She was discharged on day 8 without any need of bronchoscopy. She underwent follow-up examinations in the 6th and 12th postoperative months. Her pulmonary function tests revealed a forced expiratory flow in 1 second of 2,555 mL (80%) in the 12th postoperative month. Her computerized chest tomographic (Fig 2) and scintigraphic scans (Fig 3) at the first postoperative year revealed a perfusing and ventilating lung. She was free of any symptoms and was performing her job successfully. She did not complain about lying down.
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Fig 2. Chest computerized tomographies (A, B) of the patient revealed a functioning lung at the 12th postoperative month.
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Comment
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In 1956, Mahaffey and associates [1] presented a case report showing that a lung could remain atelectatic after a bronchial rupture and could regain its functions after 11 years with a successful anastomosis. Other authors reported that it is not an absolute condition [2]. In a series presented recently, patients who remained atelectatic longer than a year underwent resection of the lung [2]. Our experiences with 8 patients who had bronchial rupture caused by vehicle accidents within the past 16 years were similar to those of Mahaffey and associates [1]. We believe that the bronchus may be reconstructed even after years. In this topic, diagnosis is important, and dissecting the old traumatized tissue without injuring major pulmonary vessels is the major point. Others who agree with us suggested that it is possible to repair tracheobronchial injuries successfully even many months after they occur [3].
Tracheobronchial rupture as a result of a blunt trauma is a different topic to debate. The patient we present here is unique in our series because she was diagnosed with total separation of the left main bronchus 17 years after the blunt trauma, and her left lung regained its functions.
Here, the effects of resection or reconstruction may be discussed preoperatively. A bronchial system ending blindly should make a surgeon think about delayed bronchial rupture. Then the surgeon should consider a possible pneumonectomy and investigate the expected pulmonary function after resection. The other point to debate: Is a pneumonectomy really necessary or should we just leave the lung there? Certainly, such a long time is an exception, but the case presented here shows that a lung can regain its functions even after 17 years. To evaluate the functions of the left lung, we have conducted pulmonary function tests and computerized tomographic and perfusion scans. These investigations showed a perfectly working left lung.
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References
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- Mahaffey DE, Creech Jr O, Boren HG, DeBakey ME. Traumatic rupture of left main bronchus successfully repaired 11 years after injury J Thorac Surg 1956;32:312-331.[Medline]
- Ozdulger A, Cetin G, Gulhan E, Topcu S, Tastepe I, Kaya S. A review of 24 patients with bronchial ruptures: is delay in diagnosis more common in children? Eur J Cardiothorac Surg 2003;23:379-383.[Abstract/Free Full Text]
- Kiser AC, O’Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes Ann Thorac Surg 2001;71:2059-2065.[Abstract/Free Full Text]
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Abstract
Introduction
