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J Thorac Cardiovasc Surg 2005;130:1219-1220
© 2005 The American Association for Thoracic Surgery

Brief Communication

Thoracoscopic operation with local and epidural anesthesia in the treatment of pneumothorax after lung transplantation

Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan

Received for publication May 17, 2005; accepted for publication June 30, 2005.

^_* Address for reprints: Hiroshi Date, MD, Department of Cancer and Thoracic Surgery (Surgery II), Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-Cho, Okayama 700-8558, Japan (Email: hdate{at}nigeka2.hospital.okayama-u.ac.jp).

Drs H. Date (left) and S. Sugimoto (right)

Intractable pneumothorax in the native or in the transplanted lung may occur after lung transplantation, and successful thoracoscopic repair with general anesthesia has been reported. ¹ For recipients after lung transplantation, however, the risks of general anesthesia itself cannot be negligible, especially during the early postoperative period. We report 2 cases of intractable pneumothorax after lung transplantation successfully treated by thoracoscopic operation with local and epidural anesthesia.

Clinical Summaries

Patient 1
A 47-year-old man with a history of multiple episodes of bilateral pneumothorax underwent right single-lung transplantation for interstitial pneumonia associated with rheumatoid arthritis. Soon after extubation on postoperative day (POD) 9, a significant ulcerative stricture developed in the right main bronchus and was treated with repeated bronchoscopic débridements. On POD 27, the patient had a pneumothorax develop in the native lung. The initial treatment consisted of chest tube drainage. Pleurography was performed through the chest tube, and a major air leak site was found in the left lower lobe. On POD 34, the patient underwent thoracoscopic operation with local and epidural anesthesia. A thoracic epidural catheter was placed immediately before the operation. Ropivacaine 0.2% (5-7 mL) was injected into the epidural space at induction and added as needed during the operation for analgesia. The patient maintained spontaneous breathing during the subsequent procedure, and oxygen was administered by facial mask as needed. He was then positioned in a right lateral decubitus position. After additional local anesthesia with 1% lidocaine, a thoracoscope was inserted through the seventh intercostal space at the midaxillary line. The source of the air leak was found to be a ruptured bulla in the left lower lobe. Significant pleural adhesion was seen, and we avoided unnecessary dissection that might create additional air leaks. Two additional ports were inserted carefully to avoid injuring the half-deflated lung. Aerosolized fibrin glue was injected around the hole of the leaking bulla. The bulla was then covered with a piece of polyglycolic acid sheet. We sprayed the sheet with aerosolized fibrin glue and obtained a complete air sealing. The postoperative course was uneventful, and the patient was discharged from the hospital 57 days after single-lung transplantation. Although he required a Dumont stent placement for the anastomotic stricture in the right main bronchus at 4 postoperative months, no pneumothorax has recurred at a follow-up of 40 months.

Patient 2
A 37-year-old woman underwent bilateral living-donor lobar lung transplantation with her elder sister's right lower lobe and her younger sister's left lower lobe for bronchiectasis associated with panbronchiolitis. The total forced vital capacity of the two grafts was estimated to be 53.9% of the recipient's predicted forced vital capacity. ² The postoperative course was complicated by two episodes of severe acute rejection in the right graft and prolonged mechanical ventilation for 25 days. She had a left hydropneumothorax develop and required chest tube drainage. Significant dead space remained, with persistent air leak (Figure 1). The patient underwent thoracoscopic operation with local and epidural anesthesia on POD 51 in the same manner as did patient 1. Her postoperative course was uneventful, and no pneumothorax has recurred at a follow-up of 23 months.

View larger version (109K): [in this window] [in a new window]   Figure 1. Left hydropneumothorax after bilateral living-donor lobar lung transplantation (patient 2).

After single-lung transplantation, the contralateral native lung may be the source of early and late pneumothorax related to the progression of the underlying disease in patients with emphysema, pulmonary fibrosis, and lymphangioleiomyomatosis. ¹ Bronchial stenosis in the transplanted lung may lead to preferential ventilation to the native lung, rendering it more susceptible to pneumothorax. ³ After living-donor lobar lung transplantation, a pleural space problem may increase the risk of pneumothorax, because a limited amount of lung tissue is transplanted. Prolonged mechanical ventilation may favor the onset of pneumothorax. ⁴

Successful thoracoscopic repair with general anesthesia has been reported for posttransplantation pneumothorax. However, we thought that it would be difficult to maintain single-lung ventilation in these 2 cases because of bronchial stenosis in patient 1 and a small graft (one lobe) in patient 2.

With local and epidural anesthesia, pain and cough were controllable. Patients maintained spontaneous breathing, with stable blood pressure and arterial blood gas values. The half-deflated lung provided a satisfactory view for the thoracoscopic operation. We simply covered the leaking area with a piece of polyglycolic acid sheet and sprayed the sheet with aerosolized fibrin glue, as described previously. ⁵ This method does not require pleural dissection and can shorten the operative time. We believe that thoracoscopic operation in the treatment of pneumothorax with local and epidural anesthesia is useful for lung transplantation recipients with immunosuppression and malnutrition.

References

1. Venuta F, Boehler A, Rendina EA, De Giacomo T, Speich R, Schmid R, et al. Complications in the native lung after single lung transplantation. Eur J Cardiothorac Surg 1999;16:54-58.[Abstract/Free Full Text]
   
2. Date H, Aoe M, Nagahiro I, Sano Y, Andou A, Matsubara H, et al. Living-donor lobar lung transplantation for various lung diseases. J Thorac Cardiovasc Surg 2003;126:476-481.[Abstract/Free Full Text]
   
3. Chhajed PN, Malouf MA, Tamm M, Hopkins PM, Plit M, Glanville AR. Resolution of native lung pneumothorax by insertion of a nitinol stent for bronchostenosis in the transplanted lung. Respirology 2002;7:377-379.[Medline]
   
4. Date H, Aoe M, Sano Y, Nagahiro I, Miyaji K, Goto K, et al. Improved survival after living-donor lobar lung transplantation. J Thorac Cardiovasc Surg 2004;128:933-940.[Abstract/Free Full Text]
   
5. Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:924-926.[Abstract/Free Full Text]
   

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