JTCS KCI
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michael F. Reed
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Reed, M. F.
Right arrow Articles by Lewis, J. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Reed, M. F.
Right arrow Articles by Lewis, J. D.
Related Collections
Right arrow Minimally invasive surgery

J Thorac Cardiovasc Surg 2007;133:264-265
© 2007 The American Association for Thoracic Surgery

Brief Communication

Thoracoscopic mediastinal repositioning for postpneumonectomy syndrome

Michael F. Reed, MD*, Jaime D. Lewis, MD

Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH

Received for publication July 6, 2006; accepted for publication August 8, 2006.

* Address for reprints: Michael F. Reed, MD, University of Cincinnati Medical Center, Department of Surgery, Division of Thoracic Surgery, 231 Albert B. Sabin Way, ML 0558, Cincinnati, OH 45367-0558. (Email: michael.reed{at}uc.edu).

Postpneumonectomy syndrome is characterized by excessive mediastinal rotation and shift resulting in main bronchial obstruction.1Go More common in children, women, and those undergoing their first thoracic procedure, this entity of symptomatic airway compression may occur after right or left pneumonectomy.2,3Go Symptoms including stridor, dyspnea, and recurrent respiratory infections should be investigated by computed tomography (CT) and bronchoscopy. Patients found to have postpneumonectomy syndrome should undergo prompt therapy to alleviate their symptoms and prevent irreversible malacic changes of the airway. Here we report thoracoscopic mediastinal repositioning with intrapleural prostheses in a young woman in whom dyspnea and stridor developed after a right pneumonectomy.

Clinical Summary

A 20-year-old woman with Swyer–James (MacLeod) syndrome underwent thoracoscopic right pneumonectomy at 19 years of age. Her initial postoperative course was uneventful. However, mild dyspnea and stridor developed approximately 3 months after surgery. Over the ensuing 4 months, her symptoms of airway obstruction progressed. A CT scan of the chest demonstrated mediastinal shift to the right and narrowing of the left main bronchus as it crossed the descending aorta (Figure 1). Pulmonary function testing showed an obstructive defect with a forced expiratory volume in 1 second of 1.52 L (42% predicted) (Figure 2). Bronchoscopy verified left main bronchial narrowing.


Figure 1
View larger version (101K):
[in this window]
[in a new window]

  		Figure 1. Chest CT. A, Postpneumonectomy syndrome with rightward mediastinal shift and left main bronchial compression. B, Postoperative result with 2 saline implants in the right hemithorax, the mediastinum near midline, and improved left main bronchial diameter.

 

Figure 2
View larger version (16K):
[in this window]
[in a new window]

  		Figure 2. Pulmonary function testing. A, Preoperative flow-volume loop showing significant obstruction. B, Postoperative flow-volume loop demonstrating decreased obstruction. FEF, Forced expiratory flow.

 
Mediastinal repositioning was performed through a thoracoscopic approach. Two prior thoracoscopy port incisions were opened: a 12-mm site in the sixth intercostal space at the anterior axillary line and a 12-mm site in the eighth intercostal space at the posterior axillary line. Adhesions were lysed to facilitate replacement of the mediastinum centrally. A 6-cm access thoracotomy in the fourth intercostal space in the axilla was then reopened. At no time was rib spreading performed. Two saline breast implants were then placed through the access thoracotomy into the right hemithorax. As the left main bronchus was visualized with the flexible fiberoptic bronchoscopy, 1 implant (apical) was filled with 450 mL of saline and 1 implant (basilar) was filled with 700 mL of saline. Improved airway patency was demonstrated bronchoscopically. Her postoperative course was smooth, and she was discharged on the second postoperative day.

At follow-up in 3 months, she had returned to college and regular activities. She experienced neither dyspnea nor stridor. Chest CT demonstrated the mediastinum near midline and improved patency of the left mainstem bronchus (Figure 1). Her forced expiratory volume in 1 second increased to 2.23 L (62% predicted) (Figure 2).

Discussion

Postpneumonectomy syndrome is a rare complication after pneumonectomy. Several techniques have been described in an attempt to alleviate the symptoms and prevent or correct the malacic changes that may develop over time.4Go Methods include insufflation of air into the pleural space, insertion of Lucite balls into the empty thoracic cavity, and lysis of adhesions with phrenectomy on the postpneumonectomy side. In the largest series of patients, Grillo and colleagues2Go described repositioning with lysis of adhesions to allow the mediastinum to return to its former position, suturing the pericardium to the posterior sternum, and placing intrapleural prostheses in the majority of patients. Endobronchial stent placement has also been used.4Go Repositioning and placement of intrapleural prostheses seem to be superior to other methods of correction but require a second thoracotomy.

Adoption of less-invasive surgical techniques may improve outcomes by decreasing morbidity, shortening hospital stay, and providing a more desirable cosmetic result, particularly when comparing thoracotomy with thoracoscopy. However, it remains imperative that the fundamental principles that apply to an open approach are followed when performing minimally invasive surgery. In the case of mediastinal repositioning, key points are thorough lysis of adhesions to permit mobilization of the mediastinal structures, placement of prostheses to maintain mediastinal position, and intraoperative bronchoscopic verification of improved airway patency. Here we strictly adhered to these principles. We demonstrated that it is feasible to perform mediastinal repositioning for postpneumonectomy syndrome by using a minimally invasive approach.

References

  1. Adams HD, Junod F, Aberdeen E, Johnson J. Severe airway obstruction caused by mediastinal displacement after right pneumonectomy in a child. A case report. J Thorac Cardiovasc Surg 1972;63:534-539.[Medline]
  2. Grillo HC, Shepard JA, Mathisen DJ, Kanarek DJ. Postpneumonectomy syndrome: diagnosis, management, and results. Ann Thorac Surg 1992;54:638-650discussion 650-1.[Abstract/Free Full Text]
  3. Shamji FM, Deslauriers J, Daniel TM, et al. Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy. Ann Thorac Surg 1996;62:1627-1631.[Abstract/Free Full Text]
  4. Mehran RJ, Deslauriers J. Late complications. Postpneumonectomy syndrome. Chest Surg Clin North Am 1999;9:655-673.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
T. Ng, B. A. Ryder, D. E. Maziak, and F. M. Shamji
Thoracoscopic Approach for the Treatment of Postpneumonectomy Syndrome
Ann. Thorac. Surg., September 1, 2009; 88(3): 1015 - 1018.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
C. Soll, D. Hahnloser, T. Frauenfelder, E. W. Russi, W. Weder, and P. B. Kestenholz
The postpneumonectomy syndrome: clinical presentation and treatment
Eur J Cardiothorac Surg, February 1, 2009; 35(2): 319 - 324.
[Abstract] [Full Text] [PDF]

Home page
 MMCTSHome page
G. Rakovich, J. Bussieres, and E. Frechette
Postpneumonectomy syndrome
MMCTS, January 1, 2009; 2009(0831): mmcts.2008.003475 - mmcts.2008.003475.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michael F. Reed
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Reed, M. F.
Right arrow Articles by Lewis, J. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Reed, M. F.
Right arrow Articles by Lewis, J. D.
Related Collections
Right arrow Minimally invasive surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS