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J Thorac Cardiovasc Surg 1994;107:953-955
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Right pneumonectomy syndrome: Surgical correction with expandable implants

Robert J. Downey, MD, Victor F. Trastek, MD, R. P. Clay, MD

Sections of General Thoracic and Plastic Surgery
Mayo Clinic
Rochester, MN 55905

To the Editor:

Postpneumonectomy syndrome, a rare complication of right pneumonectomy, causes cough and exertional dyspnea because of progressive mediastinal shift, with compression of the left main stembronchus by the vertebral column. We recently successfully treated a severe case by implanting expandable double-lumen permanent breast prostheses into the empty right pleural cavity to reposition the mediastinum in the thoracic midline.

A previously healthy 40-year-old man sought treatment for worsening shortness of breath and cough. Nine months previously, he had undergone right pneumonectomy elsewhere for a lung mass, found on pathologic examination to be a granuloma caused by infection with Histoplasma capsulatum. After discharge, he did well initially but after 6 weeks had a cough, which worsened during the ensuing months. Shortness of breath progressed to the point that the patient could not walk on level ground. Retrosternal discomfort while swallowing solids developed, and the patient's weight fell from 170 to 145 pounds. Medical history was remarkable primarily for a diagnosis of Marfan's syndromebased on an upper-to-lower segment ratio of 0.82 and dilatation of the aortic root to 4 cm.

Chest roentgenogram revealed overexpansion of the left lung with displacement of the mediastinal structures into the right pleural space. Pulmonary function tests showed severely compromised function (GoTable I). Chest computed tomographic scan (Fig. 1) showed marked rotation and displacement of the heart and other mediastinal structures into theposterior right pleural space, with herniation of the left lung into the anterior right pleural space. The left main stem bronchus was tethered over the anterior vertebral body. Bronchoscopic examination confirmed extrinsic compression of the anteroposterior diameter of left main stembronchus to 5 mm and near occlusion of the superior segmental bronchus.


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  		Table 1. Pulmonary function test results
 


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  		Fig. 1. Preoperative computed tomographic scan of chest shows marked rotation and displacement of heart and other mediastinal structures into posterior right pleural space, with herniation of left lung into anterior right pleural space.

 
Operative correction was performed through the previous right posterolateral thoracotomy. Adhesions holding the mediastinal structures within the right pleural space were divided and pericardiopexy was performed by suturing the pericardium to the posterior sternum. Three Becker Siltex 800 ml tissue expanders (Becker Orthopedic Appliance Co., Troy, Mich.), containing a total of 1200 ml of saline solution, were placed in the right pleural space to further fix the mediastinum in the midline. Ports for the addition of saline solution to the implants were tunneled between ribs into the subcutaneous space. Before extubation, another bronchoscopic study was performed; the left main stem bronchus appeared to be restored to a normal diameter and was without evidence of tracheomalacia.

The postoperative period was notable for febrile episodes and elevations of serum amylase level and liver function tests, all of which resolved without a cause being established. Results of postoperativepulmonary function tests were moderately improved (GoTable I). Postoperative chest radiograph and computed tomographic scan (Fig. 2) confirmed midline positioning of the mediastinum and relief of left main stem bronchial obstruction. During the 6 months since surgical restoration of the mediastinum to the midline, the patient has had relief of his cough and shortness of breath, has gained 12 pounds, and is resuming physically demanding work as a fishing guide.



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  		Fig. 2. Postoperative computed tomographic scan of chest confirms midline positioning of mediastinum.

 
It is rare that pneumonectomy results in airway obstruction because of rotation of mediastinal structures and herniation of the contralateral lung into the emptied pleural space, causing compression of the main stem bronchus between the aorta, the pulmonary artery, a vertebral body,Go 1 and possibly the ligamentum arteriosum.Go 2 It is possible that lax elastic fibers and an increased length of the mediastinum in this patient with Marfan's syndrome predisposed him toward this complication by giving the mediastinal structures greater freedom to rotate into the empty chest.

Repair is directed toward repositioning and stabilizing the mediastinum in the thoracic midline by a combined procedure of cardiopexy and placement of pliable, variable-volume tissue implants into the empty pleural space.Go Go 3-6Cardiopexy alone probably provides an insufficient protection against recurrence. We tunneled the injection ports for the expanders into a subcutaneous position to allow postoperative insertion of additional saline solution should our intraoperative assessment of the volume needed for mediastinal alignment prove to be in error. With additional experience, and because postoperative injection carries a risk of contamination, providing access to the injection ports may not be necessary in the future. Before operative repositioning, it can be difficult to assess whether significant tracheomalacia exists in the compressed segment. Persistent airway narrowing and symptoms of obstruction after correction of mediastinal shift may necessitate reoperation for resection of the softened bronchus.

References

  1. Harrison MR, Hendren WH. Agenesis of the lung complicated by vascular compression and bronchomalacia. J Pediatr Surg 1975;10:813-7.[Medline]
  2. Stolar C, Berdon W, Reyes C, et al. Right pneumonectomy syndrome: a lethal complication of lung resection in a newborn with cystic adenomatoid malformation. J Pediatr Surg 1988;23:1180-3.[Medline]
  3. Powell RW, Luck SR, Raffensperger JG. Pneumonectomy in infants and children: the use of a prosthesis to prevent mediastinal shift and its complications. J Pediatr Surg 1979;14:231-7.[Medline]
  4. Wasserman K, Jamplis RW, Lash H, Brown HV, Cleary MG, Lafair J. Post-pneumonectomy syndrome: surgical correction using Silastic implants. Chest 1979;75:78-81.[Abstract/Free Full Text]
  5. Rasch DK, Grover FL, Schnapf BM, Clarke E, Pollard TG. Right pneumonectomy syndrome in infancy treated with an expandable prosthesis. Ann Thorac Surg 1990;59:127-9.[Abstract/Free Full Text]
  6. Riverson FA, Adams C, Lewis JW, Ochs D, Glines C, Popovich J. Silastic prosthesis plombage for right pneumonectomy syndrome. Ann Thorac Surg 1990;50:465-6.[Abstract]



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