Ann Thorac Surg 2009;88:1015-1018. doi:10.1016/j.athoracsur.2009.02.021
© 2009 The Society of Thoracic Surgeons
Case Reports
Thoracoscopic Approach for the Treatment of Postpneumonectomy Syndrome
Thomas Ng, MDa,*,
Beth A. Ryder, MDa,
Donna E. Maziak, MDCMb,
Farid M. Shamji, MDb
a Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
b Division of Thoracic Surgery, University of Ottawa, Ottawa, Ontario, Canada
Accepted for publication February 9, 2009.
* Address correspondence to Dr Ng, 2 Dudley St, Ste 470, Providence, RI 02905 (Email: tng{at}usasurg.org).
Presented at the Surgical Motion Picture session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract
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Postpneumonectomy syndrome develops after pneumonectomy when excessive mediastinal shifting leads to compression of the contralateral main bronchus. This case report describes a total thoracoscopic approach for the treatment of postpneumonectomy syndrome.
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Introduction
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Postpneumonectomy syndrome (PPS) is an uncommon complication of pneumonectomy, with a reported incidence of less than 1% [1]. Excessive lateral shifting and posterior rotational displacement of the mediastinum postoperatively leads to compression of the contralateral main bronchus by the pulmonary artery anteriorly and the vertebral body and aorta posteriorly. PPS commonly occurs after right pneumonectomy, but can occur after left pneumonectomy, with or without the presence of a right-sided aortic arch [1–3]. Mediastinal repositioning with expandable saline prostheses has become the treatment of choice for PPS [1–4]. We present a patient who underwent thoracoscopic placement of saline prostheses for the treatment of PPS. This was achieved using a 2-port total thoracoscopic approach, without an access incision.
Our patient is a 41-year-old woman who underwent right pneumonectomy for a central atypical carcinoid tumor. Seven months later, she presented with worsening dyspnea, wheeze, and orthopnea. A chest roentgenogram showed extensive shifting of the mediastinum, with significant deviation of the trachea from the midline and a lack of cardiac silhouette within the left thoracic space.
Pulmonary function tests showed significant air flow obstruction with diminished forced expiratory volume in 1 second (FEV1) of 0.96 L (36% predicted), FEV1/forced vital capacity (FVC) ratio of 0.57 (70% predicted), and peak expiratory flow of 1.35 L/s (22% predicted). Her flow-volume loop showed significant compromise during inspiration and expiration, suggesting a fixed airway obstruction (Fig 1A).
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Fig 1. (A) The preoperative flow-volume loop shows significant impairment during inspiration and expiration. (B) The postoperative study shows dramatic improvement after mediastinal repositioning.
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A computed tomography (CT) scan revealed severe compression of the left main bronchus and left lower lobe bronchus between the pulmonary artery anteriorly and both the vertebral body and aorta posteriorly (Fig 2A). Awake bronchoscopy confirmed the presence of airway compression, without evidence of airway malacia (Fig 3A).
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Fig 2. (A) A preoperative computed tomography scan reveals significant compression of the left main bronchus (arrow). (B) The postoperative scan shows resolution of the airway compression (arrow).
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Fig 3. (A) A preoperative bronchoscopy shows significant compression of the left main bronchus. (B) The postoperative view shows a widely patent left main bronchus.
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With the diagnosis of PPS, right thoracoscopy was performed using 2 ports, 1 sized 12 mm and the other, 5 mm. The initial 12-mm port was placed by open technique. The closed trocar technique was avoided because this method risks injuring the shifted mediastinum. At thoracoscopy, the adhesions were easily lysed to ensure mediastinal mobility for repositioning.
Two smooth-shell saline mammary prostheses (Mentor, Irving, TX) were deflated and inserted through the 12-mm port. They were placed into the pneumonectomy space and filled with 770 mL and 450 mL of saline, respectively, which was achieved with a syringe extracorporeally using the tubing attachment. The adequacy of mediastinal repositioning was monitored with intraoperative bronchoscopy to confirm relief of airway compression. Central venous pressure was monitored to avoid overcorrection of the mediastinal repositioning.
The patient tolerated the procedure well and was discharged on postoperative day 2 without complication. Six months after the procedure, the patient reported complete resolution of her presenting symptoms. A chest roentgenogram showed improvement in the mediastinal shifting. Follow-up pulmonary function tests showed significant improvements in her FEV1 of 1.50 L (58% predicted), FEV1/FVC ratio of 0.82 (99% predicted), and peak expiratory flow of 2.47 L/s (42% predicted) compared with the preoperative values. The flow-volume loop also showed a dramatic improvement during both inspiration and expiration (Fig 1B). A repeat CT scan showed the mediastinum was in a satisfactory position, with complete resolution of the airway compression (Fig 2B). Postoperative awake bronchoscopy confirmed normal airway patency without airway malacia (Fig 3B).
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Comment
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PPS should be considered in the differential diagnosis when a patient presents with progressive disabling dyspnea after pneumonectomy. The diagnosis is made with pulmonary function tests, flow-volume loops, dynamic inspiratory and expiratory CT scan, and awake bronchoscopy. Other causes of dyspnea after pneumonectomy that should be ruled out include inadequate remaining pulmonary reserve, new-onset congestive heart failure, unrecognized prior pulmonary hypertension, late progressive decline in lung function, recurrent cancer, and pulmonary embolism. Once the diagnosis is made, treatment is indicated not only to relieve symptoms such as dyspnea or recurrent infection but also to prevent airway malacia, progression to respiratory failure, and sudden death [3, 5].
Various treatments have been described for PPS, but the most effective method is by mediastinal repositioning using expandable saline prostheses, with or without anterior pericardiorrhaphy [1–3]. The important steps of this procedure include lysis of adhesions to allow for mediastinal mobility during repositioning, intraoperative bronchoscopy to assure relief of airway compression, and central venous pressure monitoring to avoid over correction of the mediastinum [1–3]. Once normal patency of the airway is seen with intraoperative bronchoscopy, no further volume is added to the prostheses, thus preventing over correction of the mediastinum, which may lead to a decrease in venous return or compression of the contralateral lung [1–3].
Similar to this report, Reed and colleagues [5] also described a video-assisted approach. They, however, used a 6-cm access incision, whereas our total thoracoscopic approach used 2 ports. Although mediastinal repositioning with saline prostheses is often performed by open thoracotomy, we believe this procedure lends itself very well to a minimally invasive approach. All the important operative steps described in this article can be safely and effectively performed by thoracoscopy, thereby conferring to the patient the benefits of a minimally invasive operation.
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References
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- Shen KR, Wain JC, Wright CD, Grillo HC, Mathisen DJ. Postpneumonectomy syndrome: surgical management and long-term results J Thorac Cardiovasc Surg 2008;135:1210-1216.[Abstract/Free Full Text]
- Shamji FM, Deslauriers J, Daniel TM, Matzinger FR, Mehran RJ, Todd TR. Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy Ann Thorac Surg 1996;62:1627-1631.[Abstract/Free Full Text]
- Macare van Maurik AF, Stubenitsky BM, van Swieten HA, Duurkens VA, Laban E, Kon M. Use of tissue expanders in adult postpneumonectomy syndrome J Thorac Cardiovasc Surg 2007;134:608-612.[Abstract/Free Full Text]
- Mehran RJ, Deslauriers J. Late complications. Postpneumonectomy syndrome. Chest Surg Clin N Am 1999;9:655-673.[Medline]
- Reed MF, Lewis JD. Thoracoscopic mediastinal repositioning for postpneumonectomy syndrome J Thorac Cardiovasc Surg 2007;133:264-265.[Free Full Text]
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Abstract
Introduction
