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J Thorac Cardiovasc Surg 1998;116:526-528
© 1998 Mosby, Inc.

Brief Communications

Improved expandable prosthesis in postpneumonectomy syndrome with deformed thorax

Kanazawa, Japan

From the Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan.

Received for publication March 4, 1998. Accepted for publication April 9, 1998. Address for reprints: Yoshio Tsunezuka, MD, Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, 153-Nu, Minamishinbomachi, Kanazawa, 920, Japan.

Postpneumonectomy syndrome is a rare complication of pneumonectomy. The mediastinum, heart, and lung shift into the postoperative thoracic space, and the trachea deviates to the posterior contralaterally after pneumonectomy, causing symptomatic airway compression. Prevention or treatment of postpneumonectomy syndrome with various procedures has been reported. We report the case of a patient in whom the right thorax was deformed and right pneumonectomy was performed because of laceration of the right main bronchus as a result of a traffic accident that led to progressive exertional dyspnea. It was successfully managed with an improved expandable prosthesis.

Clinical summary

A 37-year-old man underwent reconstruction of the right chest wall and trachea and right pneumonectomy for laceration of the right main bronchus as the result of a traffic accident on August 21, 1994. Approximately 1 year later, he complained of exertional dyspnea, an increased cough, and sputum production. Bronchoscopy revealed tracheal stenosis caused by postinflammatory change; there was no stenosis of the left main bronchus, and the right main bronchial stump was clear. A Dumon stent (16 mm x 70 mm) was positioned in the trachea. Two years after the operation, he experienced frequent pulmonary infections and bronchitis. Computed tomography showed gross herniation of the left lung into the right hemithorax and rightward mediastinal shift with compression of the left main bronchus stretched over the vertebral column and aorta (Fig. 1). Arterial blood gases showed moderate hypoxemia, and pulmonary function tests showed a moderate reduction in pulmonary overdistention (forced vital capacity [FVC] 2.05 L; forced expiratory volume in 1 second/forced vital capacity (FEV₁/FVC) ratio, 0.87; peak expiratory flow rate, 3.88 L/s; maximum mid-expiratory flow rate, 2.39 L/s; Paco₂, 51.2 mm Hg; Pao₂, 88.8 mm Hg). Analyzing the shape and capacity of the right deformed thorax from 3-dimensional computed tomography, a silicone rubber expandable prosthesis (820 ml, 130 L x 190 Wmax x 50 mm H) was made to occupy the intrathoracic space as much as possible (Koken Corp Ltd, Tokyo, Japan). In the upper space of the right thorax including the deformed area, a dead space was made to prevent damaging the prosthesis by contact with fractured ribs' edges. This silicone prosthesis was an improved tissue expander used in the field of plastic surgery. It consisted of a balloon-like expandable bag, a connecter, and a remote reservoir dome (injection port; Fig. 2).

View larger version (120K): [in this window] [in a new window]   Fig. 1. Computed tomography of the chest after right pneumonectomy: Before (top) and after (bottom) implantation of the prosthesis. Before operation, there is marked mediastinal shift, counterclockwise rotation, and herniation of the left lung. After implantation, the mediastinum was recentered with a prosthesis filled with saline solution.

View larger version (125K): [in this window] [in a new window]   Fig. 2. Photograph of the new expandable prosthesis: P, silicone bag prosthesis; B, tube and connector; A, reservoir dome (injection port).

Discussion

Surgical treatment for pneumonectomy syndrome diminishes the severe mediastinal shift and rotation and corrects the tracheobronchial compression. Various treatments for prevention of this syndrome have been reported. To prevent postpneumonectomy syndrome, it had been reported that a sulfur hexafluoride, SF6, injection into the thoracic cavity was performed after the operation. However, this procedure is not effective to recenter the mediastinum because of the subcutaneous escape of injected gas. ¹ Horvath and colleagues ² reported that, in children, the insertion of a Dacron graft between the ascending and descending aorta with separation of the aortic arch between the left carotid and subclavian arteries was performed. This bypass procedure is effective to improve compression of the main bronchus adhered to the aortic arch but is invasive. Johnson and colleagues. ³ used methyl-methacrylate spheres in the thoracic space in 1946, but their spheres occasionally led to tracheal erosion or pseudoaneurysm. Intrathoracic expandable prosthesis was first reported by Rasch and colleagues ⁴ in 1990. The patient was a 5-month-old infant who demonstrated severe respiratory distress after right pneumonectomy for total pulmonary sequestration. Intrathoracic expandable prosthesis has an advantage because the volume of the bag can be varied. This advantage is particularly useful in children because the volume can be increased according to growth. Another advantage is that the mediastinum can be recentered slowly and progressively by increasing the material volume of the bag, which is useful in postpneumonectomy in adult patients. Our expandable prosthesis is an improved tissue expander used to expand skin and subcutaneous tissue in the plastic surgery field. This expander has an injection port, into which we can inject saline solution in the subcutaneous tissue of the subclavicular region. The tube between the injection port and the silicone bag is laid subcutaneously through the intercostal space from the intrathoracic space. The right thorax of this patient was deformed because of a traffic accident, and it was doubtful whether an existing expandable prosthesis could be useful to fill the shape and volume. There was also a risk of damaging the prosthesis by contact with the incised ribs' edges, so we made a specially shaped expandable prosthesis without the upper part of the right thorax. The prosthesis was made egg-shell or ball-shaped to equalize the pressure of the internal wall of the silicone bag. Because it is important that the prosthesis not be able to move in the thoracic space and not collapse as the result of a leak caused by overinflation and injury, the shape and volume must be determined carefully. Two cases have been reported in which the prosthesis collapsed because of a leak. One was a valve set–type, and the prosthesis leaked near 1 of the fixation points. ⁵ The other was a 5 month-old infant, and the device developed a leak 8 months after the operation. ⁴ It may be necessary to improve the intensity of the bag's wall in the future.

In conclusion, our new expandable prosthesis is characterized by the proper thoracic shape, a subcutaneous remote injection port, and the advantage of easy volume management. The insertion of a new expandable prosthesis can improve the clinical symptoms of postpneumonectomy syndrome, even with a deformed thorax.

References

1. Harada K, Hamaguchi N, Shimada Y, Sayoyama N, Minamimoto T, Inoue K. Use of sulfer hexafluoride, SF6, in the management of the postpneumonectomy pleural space. Respiration 1984;46:201-8.[Medline]
   
2. Horvath P, Dinwiddie R, Stark J. Successful surgical treatment of tracheal compression following right pneumonectomy in infancy. Eur J Cardiothorac Surg 1990;4:351-4.[Abstract]
   
3. Johnson J, Kirby CK, Lazatin CS, Cocke JA. The clinical use of a prosthesis to prevent overdistension of the remaining lung following pneumonectomy. J Thorac Surg 1949;18:164-72.
   
4. Rasch DK, Grover FL, Schnapf BM, Clarke E, Polard TG. Right pneumonectomy syndrome in infancy treated with an expandable prosthesis. Ann Thorac Surg 190;50:465-6.
   
5. Audry G, Balquet P, Vazquex MP, Dejerine ES, Baculard A, Boule M, et al. Expandable prosthesis in right postpneumonectomy syndrome in childhood and adolescence. Ann Thorac Surg 1993;56:323-7.[Abstract]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshio Tsunezuka Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tsunezuka, Y. Articles by Seki, M. Search for Related Content PubMed PubMed Citation Articles by Tsunezuka, Y. Articles by Seki, M.