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J Thorac Cardiovasc Surg 2004;127:1836-1838
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Division of Thoracic Surgery, Department of Cardiac and Thoracic Surgery, University of Pisa, Pisa, Italy
Received for publication November 28, 2003; revisions received January 7, 2004; accepted for publication January 13, 2004.
* Address for reprints: Marco Lucchi, MD, Division of Thoracic Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
m.lucchi{at}med.unipi.it
Extended resections are considered a valid therapeutic option in cases of selected locally advanced lung cancer in reason of an acceptable morbidity.1-3 Multimodality treatment, including chemotherapy, radiotherapy, and surgical intervention, has proved to improve the results in terms of disease-free and overall survival,4-6 despite a major postoperative morbidity.7
Pneumoencephalus is a rare complication of important cranial trauma8 or neurosurgery,9 but to our knowledge, it was never reported after thoracic surgery. We report a case of massive pneumoencephalus appearing late after an en bloc upper right lobectomy for lung cancer in a patient who previously underwent chemoradiotherapy. Thoracic surgeons should be aware of this possible complication when an extended lung resection involving the ribs and the vertebral bodies is performed.
Clinical summary
A 76-year-old man was referred for surgical treatment of right upper lobe squamous carcinoma infiltrating the chest wall. Previously, the patient underwent 3 cycles of neoadjuvant chemotherapy (carboplatin and paclitaxol) and radiotherapy (40 Gy) with a partial response (<50%). At the operation, we performed an en bloc right upper lobectomy with the posterior arches of the first 4 ribs and the transverse process of D2.
The postoperative course was uneventful, and the patient was discharged on the ninth day. The pathologic examination showed a poorly differentiated lung carcinoma that was widely necrotic and infiltrating the chest wall. The results of biopsy on the vertebral bodies, as well as on the hilar and mediastinal nodes, were negative for neoplastic cells, and consequently, the pTNM was T3 N0 (stage IIb).
Five days later, the patient complained of dyplopia, headache, and decrease of bilateral sight. He went to the first aid department, where a brain computed tomographic scan was performed, showing a massive hypotensive pneumoencephalus (Figure 1). At chest radiography, a remarkable right hydropneumothorax was present (Figure 2, A). The patient was referred to our department, where a chest tube was positioned on the middle axillary line at the VI space, evacuating about 2000 mL of sero-hematic pleural fluid and air. We placed the bed of the patient in the Trendelenburg position and the drainage in aspiration.
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Afterward, the chest tube was removed, and the patient's clinical state progressively improved. On the 15th day, the patient was discharged.
Discussion
Randomized trials, as well as meta-analysis, show the benefit of neoadjuvant treatments in selected patients with locally advanced stage III non–small cell lung cancer. However, a combined modality treatment can increase morbidity and mortality after surgical intervention in patients with stage III non–small cell lung cancer7 because it is associated with more postoperative complications, especially when extended resections have been performed. Up to now, pneumoencephalus after a thoracic operation was never documented. Speculating about its pathogenesis, we can hypothesize that the pneumoencephalus was imputable to a dura mater lesion, determined during the disarticulation of the transverse process of D2, and a hypertensive hydropneumothorax, which complicated the late postoperative course and generated a pressure gradient allowing the air to go inside the liquoral space. The chest tube, which solved the pneumothorax, and the Trendelenburg position of the patient, which allowed the air to go out of the liquoral space, were necessary and sufficient to take care of the pneumoencephalus. The dura mater lesion was small and unknown by the surgeons, who otherwise could appreciate the cerebrospinal fluid leak and attempt to repair or protect it with a pleural-muscle flap or use of fibrin glue. Moreover, if the dura mater lesion had been substantial, the pneumoencephalus could have been of early and not late onset.
This report, emphasizing a possible complication of en bloc resections involving the vertebral bodies, especially after chemotherapy, radiotherapy, or both, might prompt the thoracic surgeon to evaluate a possible solution of continuity of the dura mater during extended lung resections.
References
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