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Breathlessness After Pneumonectomy: Consider Postpneumonectomy Syndrome
Case Report
Breathlessness After Pneumonectomy: Consider Postpneumonectomy Syndrome Anthony J. Bastin,1,2 Jayenthan Karunanantham,3 Eric Lim2,3 Abstract A 59-year-old woman presented with increasing breathlessness several weeks after right pneumonectomy. Imaging confirmed features of postpneumonectomy syndrome with marked mediastinal shift, and compression of the left main bronchus and pulmonary vein. The mediastinum was repositioned by insertion of saline-filled prostheses into the pneumonectomy space with symptomatic and radiologic improvement. Clinicians caring for patients after pneumonectomy should be aware of this rare but treatable complication. Clinical Lung Cancer, Vol. 11, No. 6, 423-425, 2010; DOI: 10.3816/CLC.2010.n.054 Keywords: Right thoracotomy, Saline-filled prostheses, Venous compression
Case Report
Discussion
A previously fit and well 59-year-old woman with a 13 pack-year smoking history underwent a right pneumonectomy for primary lung adenocarcinoma involving all 3 lobes. Resection margins, visceral pleura, and lymph nodes were free of tumor. Her preoperative forced expiratory volume in 1 second (FEV1) was 2.33 L (93% predicted). At routine clinical review 6 weeks after surgery, she reported a 2-week history of increasing breathlessness on minimal exertion. Plain chest radiography demonstrated marked mediastinal shift to the right (Figure 1A). A computed tomography pulmonary angiogram excluded pulmonary embolism, and confirmed rightward shift of the mediastinum, with mild kinking of the left lower lobe bronchus against the aorta but severe narrowing of the pulmonary vein (Figure 1B and 1C). Flexible bronchoscopy was performed which did not reveal significant compression of the airway. Postpneumonectomy syndrome because of venous compression was diagnosed, and she underwent a repeat right thoracotomy with insertion of saline-filled silicone prostheses into the pneumonectomy space to reposition the mediastinum centrally (Figure 2A). The required volume of the saline-filled implants was estimated at the time of surgery by instilling a measured amount of saline into the hemithorax. Recovery was uneventful and at follow-up (1 month later) she had excellent symptomatic and radiologic improvement (Figure 2B and 2C).
Usually after pneumonectomy, air in the postpneumonectomy space is reabsorbed and fluid accumulation occurs over days to weeks, with total obliteration of the space taking weeks to months. Postpneumonectomy syndrome (PPS) is a rare complication following pneumonectomy with an incidence of up to 2%.1 Postpneumonectomy syndrome is characterized by marked shift of the mediastinum toward the side of the pneumonectomy with compression of the main bronchus over the descending aorta causing breathlessness. More rarely, other mediastinal structures such as the esophagus can become compromised.2 Postpneumonectomy syndrome is more common in children and after right pneumonectomy. Patients usually present several months after pneumonectomy with insidious onset of breathlessness, with or without stridor. Postpneumonectomy syndrome occurring many years after surgery has been described, and some patients are asymptomatic. The differential diagnosis of breathlessness after pneumonectomy includes pulmonary embolism, heart failure, pulmonary hypertension, and disease in the remaining lung. Echocardiography or cardiac magnetic resonance imaging, not performed in our case, may show evidence of compression of cardiac and vascular structures. Left untreated, PPS can result in progressive obstruction of the main bronchus with ongoing symptoms, recurrent lower respiratory tract infection, and tracheobronchomalacia. There are no widely accepted maneuvers to prevent the development of PPS. Our practice is to insert a chest drain into the pneumonectomy space which is clamped immediately before tracheal extubation. Chest radiography is performed postoperatively to evaluate the position of the mediastinum, and the drain is unclamped to release air if necessary. The treatment of choice for PPS is insertion of prostheses into the pneumonectomy space3 usually via an open procedure, although thoracoscopic insertion has been reported.4 Over time, the mediastinum may become ‘fixed’, necessitating division of adhesions and scars to release and mo-
1Unit
of Critical Care, Royal Brompton Hospital, London, UK Heart and Lung Institute, Imperial College London, UK 3Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK 2National
Submitted: Feb 13, 2010; Revised: Apr 2, 2010; Accepted: Apr 28, 2010 Address for correspondence: Mr. Eric Lim, Consultant Thoracic Surgeon, Academic Division of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP Fax: 44-20-7351-8560; e-mail: [email protected]
This article might include the discussion of investigational and/or unlabeled uses of drugs and/or devices that might not be approved by the FDA. Electronic forwarding or copying is a violation of US and international copyright laws. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by CIG Media Group, LP, ISSN #1525-7304, provided the appropriate fee is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 USA. www.copyright.com 978-750-8400.
Clinical Lung Cancer November 2010
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423
Postpneumonectomy Syndrome and Breathlessness Figure 1 Chest Radiograph and Computed Tomography Scan of a Patient With Postpneumonectomy Syndrome
Figure 2 Chest Radiograph and Computed Tomography Scan After Insertion of Saline-Filled Silicone Prostheses Into the Postpneumonectomy Space
A A
B
B
C C
(A) Rightward displacement of trachea and left heart border. (B) Mediastinal shift with rightward displacement of carina (arrow) and ascending aorta. (C) Narrowed left inferior pulmonary vein (arrow) because of the rightward displacement of the heart. Abbreviations: AA = ascending aorta; DA = descending aorta
424
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Clinical Lung Cancer November 2010
(A) Restored position of trachea and left heart border. (B) Restored position of carina (arrow) and ascending aorta. (C) Normal caliber of pulmonary vein (arrow). Abbreviations: AA = ascending aorta; DA = descending aorta; P = prostheses
Anthony J Bastin et al bilize the mediastinum before implantation of saline-filled implants. Other less commonly used options include tracheobronchial stenting5 and surgical fixation of the mediastinum to the sternum. Operative morbidity and mortality are low, and longer-term outcomes are generally good.6 Our patient developed symptoms relatively early after surgery. Computed tomography imaging demonstrated features of PPS with evidence of marked venous compression. Pulmonary vein compression after pneumonectomy has been rarely described in the literature7 and may have contributed additionally to breathlessness.
Conclusion Recognition of PPS followed by appropriate surgical reintervention with implantation of prostheses leads to good short and longer-term outcomes in the majority of patients. Clinicians caring for patients after pneumonectomy should be aware of this rare but treatable complication.
Disclosures Eric Lim has served as a paid consultant or been on the Advisory Board of Strategen.
References 1. Soll C, Hahnloser D, Frauenfelder T, et al. The postpneumonectomy syndrome: clinical presentation and treatment. Eur J Cardiothorac Surg 2009; 35:319-24. 2. Yüksel M, Yildizeli B, Evman S, et al. Postpneumonectomy oesophageal compression: an unusual complication. Eur J Cardiothorac Surg 2005; 28:180-1. 3. Macaré van Maurik AF, Stubenitsky BM, van Swieten HA, et al. Use of tissue expanders in postpneumonectomy syndrome. J Thorac Cardiovasc Surg 2007; 134:608-12. 4. Reed MF, Lewis JD. Thoracoscopic mediastinal repositioning for postpneumonectomy syndrome. J Thorac Cardiovasc Surg 2007; 133:264-5. 5. Nakamura Y, Ohata M, Kawabe K, et al. Left pneumonectomy syndrome successfully treated with endobronchial stent. Intern Med 1998; 37:880-3. 6. Shen KR, Wain JC, Wright CD, et al. Postpneumonectomy syndrome: surgical management and long term results. J Thorac Cardiovasc Surg 2008; 135:1210-9. 7. Smulders SA, Marcus JT, Holverda S, et al. Images in cardiovascular medicine. Compression of the pulmonary vein after right pneumonectomy. Circulation 2006; 113:e743-4.
Clinical Lung Cancer November 2010
|
425
Breathlessness After Pneumonectomy: Consider Postpneumonectomy Syndrome Anthony J. Bastin,1,2 Jayenthan Karunanantham,3 Eric Lim2,3 Abstract A 59-year-old woman presented with increasing breathlessness several weeks after right pneumonectomy. Imaging confirmed features of postpneumonectomy syndrome with marked mediastinal shift, and compression of the left main bronchus and pulmonary vein. The mediastinum was repositioned by insertion of saline-filled prostheses into the pneumonectomy space with symptomatic and radiologic improvement. Clinicians caring for patients after pneumonectomy should be aware of this rare but treatable complication. Clinical Lung Cancer, Vol. 11, No. 6, 423-425, 2010; DOI: 10.3816/CLC.2010.n.054 Keywords: Right thoracotomy, Saline-filled prostheses, Venous compression
Case Report
Discussion
A previously fit and well 59-year-old woman with a 13 pack-year smoking history underwent a right pneumonectomy for primary lung adenocarcinoma involving all 3 lobes. Resection margins, visceral pleura, and lymph nodes were free of tumor. Her preoperative forced expiratory volume in 1 second (FEV1) was 2.33 L (93% predicted). At routine clinical review 6 weeks after surgery, she reported a 2-week history of increasing breathlessness on minimal exertion. Plain chest radiography demonstrated marked mediastinal shift to the right (Figure 1A). A computed tomography pulmonary angiogram excluded pulmonary embolism, and confirmed rightward shift of the mediastinum, with mild kinking of the left lower lobe bronchus against the aorta but severe narrowing of the pulmonary vein (Figure 1B and 1C). Flexible bronchoscopy was performed which did not reveal significant compression of the airway. Postpneumonectomy syndrome because of venous compression was diagnosed, and she underwent a repeat right thoracotomy with insertion of saline-filled silicone prostheses into the pneumonectomy space to reposition the mediastinum centrally (Figure 2A). The required volume of the saline-filled implants was estimated at the time of surgery by instilling a measured amount of saline into the hemithorax. Recovery was uneventful and at follow-up (1 month later) she had excellent symptomatic and radiologic improvement (Figure 2B and 2C).
Usually after pneumonectomy, air in the postpneumonectomy space is reabsorbed and fluid accumulation occurs over days to weeks, with total obliteration of the space taking weeks to months. Postpneumonectomy syndrome (PPS) is a rare complication following pneumonectomy with an incidence of up to 2%.1 Postpneumonectomy syndrome is characterized by marked shift of the mediastinum toward the side of the pneumonectomy with compression of the main bronchus over the descending aorta causing breathlessness. More rarely, other mediastinal structures such as the esophagus can become compromised.2 Postpneumonectomy syndrome is more common in children and after right pneumonectomy. Patients usually present several months after pneumonectomy with insidious onset of breathlessness, with or without stridor. Postpneumonectomy syndrome occurring many years after surgery has been described, and some patients are asymptomatic. The differential diagnosis of breathlessness after pneumonectomy includes pulmonary embolism, heart failure, pulmonary hypertension, and disease in the remaining lung. Echocardiography or cardiac magnetic resonance imaging, not performed in our case, may show evidence of compression of cardiac and vascular structures. Left untreated, PPS can result in progressive obstruction of the main bronchus with ongoing symptoms, recurrent lower respiratory tract infection, and tracheobronchomalacia. There are no widely accepted maneuvers to prevent the development of PPS. Our practice is to insert a chest drain into the pneumonectomy space which is clamped immediately before tracheal extubation. Chest radiography is performed postoperatively to evaluate the position of the mediastinum, and the drain is unclamped to release air if necessary. The treatment of choice for PPS is insertion of prostheses into the pneumonectomy space3 usually via an open procedure, although thoracoscopic insertion has been reported.4 Over time, the mediastinum may become ‘fixed’, necessitating division of adhesions and scars to release and mo-
1Unit
of Critical Care, Royal Brompton Hospital, London, UK Heart and Lung Institute, Imperial College London, UK 3Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK 2National
Submitted: Feb 13, 2010; Revised: Apr 2, 2010; Accepted: Apr 28, 2010 Address for correspondence: Mr. Eric Lim, Consultant Thoracic Surgeon, Academic Division of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP Fax: 44-20-7351-8560; e-mail: [email protected]
This article might include the discussion of investigational and/or unlabeled uses of drugs and/or devices that might not be approved by the FDA. Electronic forwarding or copying is a violation of US and international copyright laws. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by CIG Media Group, LP, ISSN #1525-7304, provided the appropriate fee is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 USA. www.copyright.com 978-750-8400.
Clinical Lung Cancer November 2010
|
423
Postpneumonectomy Syndrome and Breathlessness Figure 1 Chest Radiograph and Computed Tomography Scan of a Patient With Postpneumonectomy Syndrome
Figure 2 Chest Radiograph and Computed Tomography Scan After Insertion of Saline-Filled Silicone Prostheses Into the Postpneumonectomy Space
A A
B
B
C C
(A) Rightward displacement of trachea and left heart border. (B) Mediastinal shift with rightward displacement of carina (arrow) and ascending aorta. (C) Narrowed left inferior pulmonary vein (arrow) because of the rightward displacement of the heart. Abbreviations: AA = ascending aorta; DA = descending aorta
424
|
Clinical Lung Cancer November 2010
(A) Restored position of trachea and left heart border. (B) Restored position of carina (arrow) and ascending aorta. (C) Normal caliber of pulmonary vein (arrow). Abbreviations: AA = ascending aorta; DA = descending aorta; P = prostheses
Anthony J Bastin et al bilize the mediastinum before implantation of saline-filled implants. Other less commonly used options include tracheobronchial stenting5 and surgical fixation of the mediastinum to the sternum. Operative morbidity and mortality are low, and longer-term outcomes are generally good.6 Our patient developed symptoms relatively early after surgery. Computed tomography imaging demonstrated features of PPS with evidence of marked venous compression. Pulmonary vein compression after pneumonectomy has been rarely described in the literature7 and may have contributed additionally to breathlessness.
Conclusion Recognition of PPS followed by appropriate surgical reintervention with implantation of prostheses leads to good short and longer-term outcomes in the majority of patients. Clinicians caring for patients after pneumonectomy should be aware of this rare but treatable complication.
Disclosures Eric Lim has served as a paid consultant or been on the Advisory Board of Strategen.
References 1. Soll C, Hahnloser D, Frauenfelder T, et al. The postpneumonectomy syndrome: clinical presentation and treatment. Eur J Cardiothorac Surg 2009; 35:319-24. 2. Yüksel M, Yildizeli B, Evman S, et al. Postpneumonectomy oesophageal compression: an unusual complication. Eur J Cardiothorac Surg 2005; 28:180-1. 3. Macaré van Maurik AF, Stubenitsky BM, van Swieten HA, et al. Use of tissue expanders in postpneumonectomy syndrome. J Thorac Cardiovasc Surg 2007; 134:608-12. 4. Reed MF, Lewis JD. Thoracoscopic mediastinal repositioning for postpneumonectomy syndrome. J Thorac Cardiovasc Surg 2007; 133:264-5. 5. Nakamura Y, Ohata M, Kawabe K, et al. Left pneumonectomy syndrome successfully treated with endobronchial stent. Intern Med 1998; 37:880-3. 6. Shen KR, Wain JC, Wright CD, et al. Postpneumonectomy syndrome: surgical management and long term results. J Thorac Cardiovasc Surg 2008; 135:1210-9. 7. Smulders SA, Marcus JT, Holverda S, et al. Images in cardiovascular medicine. Compression of the pulmonary vein after right pneumonectomy. Circulation 2006; 113:e743-4.
Clinical Lung Cancer November 2010
|
425