- Email: [email protected]
Intraoperative Pneumothorax Presenting as Abdominal Distention
336
CASE REPORT YANG ET AL PNEUMOTHORAX WITH ABDOMINAL DISTENTION
Ann Thorac Surg 2016;101:336–8
Fig 1. (A) Echocardiography demonstrating the lung hydatid cyst and atrial septal defect (arrow). (B) Chest tomography demonstrating the location and contour of the lung hydatid cyst. (LA ¼ left atrium; RA ¼ right atrium.)
FEATURE ARTICLES
Fig 2. (A) Opened lung hydatid cyst as viewed intraoperatively with the edge of the incision grasped by forceps (its content has been evacuated). (B) Histologic evaluation of the cyst content demonstrates a protoscolex and cyst wall of Echinococcosis granulosus (hematoxylin and eosin, original magnification 200).
and cardiopulmonary bypass. Special care is needed when removing the cyst content to avoid any potential leak and spreading of viable Echinococcus. We believe that removal of the lung hydatid cyst and repair of the ASD can be achieved with one-stage surgery with a satisfactory outcome.
References 1. McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003;362:1295–304. 2. Geva T, Martins JD, Wald RM. Atrial septal defects. Lancet 2014;383:1921–32. 3. Turk F, Yuncu G, Karabulut N, et al. A single-center largevolume experience in the surgical management of hydatid disease of the lung with and without extrapulmonary involvement. World J Surg 2013;37:2306–12. 4. Garipov MK, Rasulov RR. [Simultaneous mitral commissurotomy and surgical treatment of echinococcosis of the left lung]. Klin Khir 1990:64. 5. Atalay A, Salih OK, Gezer S, et al. Simultaneous heart and bilateral lung hydatid cyst operated in a single session. Heart Lung Circ 2013;22:682–4. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Intraoperative Pneumothorax Presenting as Abdominal Distention Stephen Su Yang, MD, Kenneth Kardash, MD, and Christian Sirois, MD Departments of Anesthesia and Thoracic Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
A 74-year-old man with a history of lung cancer presented for right upper lobectomy. After induction of anesthesia, it was noted that the abdomen became progressively more distended. Soon afterward, there was a significant decrease in tidal volume. Ultrasonography of the lung showed no sign of pneumothorax at the anterior second intercostal space. However, the roentgenograms showed a massive right-sided pneumothorax and extensive pneumoperitoneum. Both the pneumothorax 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.073
Ann Thorac Surg 2016;101:336–8
CASE REPORT YANG ET AL PNEUMOTHORAX WITH ABDOMINAL DISTENTION
337
and the pneumoperitoneum were decompressed in the operating room, and the elective lobectomy proceeded as previously planned. The patient was extubated at the end of the operation, and there were no sequelae postoperatively. (Ann Thorac Surg 2016;101:336–8) Ó 2016 by The Society of Thoracic Surgeons
P
neumothorax is a potentially life-threatening condition [1]. Its diagnosis must be made in a timely fashion. Nearly every lung disease can cause a secondary spontaneous pneumothorax. This is particularly true for patients with chronic obstructive pulmonary disease (COPD) [2]. In our case, the initial clinical presentation was atypical, and the unusual distribution of air invalidated some traditional aspects of diagnosis and treatment. Fig 1. Chest roentgenogram showing pneumothorax.
obtained and showed a large amount of free air in the diaphragmatic pleural cavity and the abdominal cavity (Figs 1 and 2). During this time, there was no sign of hemodynamic instability or desaturation. However, the end-tidal CO2 increased to a maximum of 53 mm Hg. The patient was placed in the left lateral decubitus position. A right thoracotomy was performed. This immediately decompressed the pneumothorax. A 24
FEATURE ARTICLES
A 74-year-old man with a history of lung cancer presented for a right upper lobectomy. He had a history of moderate COPD, with a forced expiratory volume in 1 second (FEV1) of 67% of its predicted value, and hypertension, dyslipidemia, and benign prostatic hyperplasia. Positron emission tomography (PET) revealed a 4.7 4.6 cm mass in the right upper lobe. He had a 16-gauge intravenous catheter and an arterial catheter inserted. A thoracic epidural catheter was placed at T4–5 before induction without any adverse event. General anesthesia was induced with propofol, sufentanil, and rocuronium. Bag-and-mask ventilation was performed with ease, and a 39F left-sided double-lumen endotracheal tube was inserted easily on the first attempt. The position of the double-lumen tube was confirmed with fiberoptic bronchoscopy. Ten minutes after intubation, it was noted the abdomen was becoming progressively distended. The ventilator was set on pressure-control mode. Soon afterward, the tidal volume decreased considerably. At a peak pressure of 35 cm of water, the tidal volume had dropped from 600 mL to 164 mL. We initially attributed the abdominal distention to ventilation of the stomach, either during mask ventilation at induction or from an ongoing leak into the esophagus, despite confirmed endotracheal placement of the doublelumen tube. Failure to decompress the stomach upon insertion of an orogastric tube was initially thought to be caused by possible kinking or blockage of the tube. This led to replacement of the orogastric tube and confirmation of its position by video laryngoscopy. This had no effect on the abdominal distention. Bedside ultrasonography was performed by the attending anesthesiologist. Both lungs showed a positive “sliding lung” [3] and “B lines” [4] at the anterior second intercostal space, ruling out pneumothorax at this site. Roentgenograms of the chest and abdomen were Accepted for publication Jan 16, 2015. Address correspondence to Dr Kardash, Department of Anesthesia, Jewish General Hospital, Pavilion A, Rm A-335, 3755 Cote-Ste-Catherine Rd, Montreal, Quebec, H3T 1E2; email: [email protected].
Fig 2. Abdominal roentgenogram showing pneumothorax and pneumoperitoneum.
ˇ
338
CASE REPORT RUIZ-MOYA ET AL CHIMERIC ALT FLAP FOR THORACIC ESOPHAGOPLASTY
Fig 3. Gross specimen of the right lower lobe showing defect in pleura.
French chest tube was also inserted temporarily through the diaphragm to decompress the pneumoperitoneum. The compliance of the lungs improved, and the lobectomy proceeded as previously planned. Intraoperatively, no gross abnormality was noticed at the site of the mass excision. However, a defect in the pleura was seen grossly at the base of the right lower lobe (Fig 3). The patient recovered uneventfully.
FEATURE ARTICLES
Comment We report this case to raise awareness of a possible atypical presentation of pneumothorax. Several clinical features of the case were striking: (1) the presenting sign was abdominal distention; (2) ultrasonography of the anterior chest wall was falsely negative, which delayed diagnosis; and (3) hemodynamic instability was absent because of the decompression of air into the peritoneum. This falsely reassuring factor would likely have changed had the pneumothorax continued to go untreated. Our patient did not experience any hemodynamic compromise or desaturation. Although a large amount of pneumothorax was present, the fact that it tracked caudally negated potential hemodynamic effects. However, the increase in intraabdominal pressure had a major influence on ventilation. At 16 mm Hg of intraabdominal pressure, there is a decrease in 50% of pulmonary compliance [5]. Pneumoperitoneum associated with pneumothorax is unusual. In these cases, air dissects from ruptured alveoli along adjacent pulmonary vessels and into the mediastinum. As pressure increases, air would then move into the retroperitoneal space along the thoracic great vessels and the esophagus [6]. Even more unusual in this case was that air tracked only in a caudal direction, creating tension below the lung and compressing it against the apical pleural Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;101:338–42
space, obliterating any sign of pneumothorax in this area. The liver consequently had the appearance of “floating in air” (Fig 2). The reason for this preferential accumulation toward the peritoneum in our case remains unknown. One of the most instructive lessons of this case was the falsely reassuring ultrasonography findings. We visualized both B lines and a sliding lung bilaterally at the second intercostal space, the highest point in the chest in a supine patient and conventionally the first place air would localize. The standard emergent treatment for suspected tension pneumothorax in a patient in the supine position is decompression at the midclavicular line in the second intercostal interspace. This is another reason we performed sonography in this area. Recently, the risk-tobenefit ratio of this approach has been questioned [7]. Performing this procedure could have led to further lung injury in our case because there was no distention of the pleural space at this level. In retrospect, it seems that the source of the pneumothorax we describe was a bleb near the site of the tumor, which ruptured during positive pressure ventilation, even though airway pressure was never above 35 cm of water.
References 1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii18–31. 2. Chen CH, Liao WC, Liu YH, et al. Secondary spontaneous pneumothorax: which associated conditions benefit from pigtail catheter treatment? Am J Emerg Med 2012;30:45–50. 3. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest J 1995;108:1345–8. 4. Volpicelli G. Sonographic diagnosis of pneumothorax. Intens Care Med 2011;37:224–32. 5. Obeid F, Saba A, Fath J, et al. Increases in intra-abdominal pressure affect pulmonary compliance. Arch Surg 1995;130:544–8. 6. Glauser FL, Bartlett RH. Pneumoperitoneum in association with pneumothorax. Chest J 1974;66:536–40. 7. Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury 2001;32:749–52.
Chimeric Anterolateral Thigh Flap for Total Thoracic Esophageal Reconstruction Alejandro Ruiz-Moya, MD, Juan J. Segura-Sampedro, MD, Domingo Sicilia-Castro, MD, PhD, Francisco Carvajo-P erez, MD, PhD, Tom as G omez-Cía, MD, PhD, Antonio V azquez-Medina, MD, PhD, and ~ ez-Delgado, MD, PhD Francisco Ib an Departments of Plastic and Reconstructive Surgery, and General Surgery, Virgen del Rocío University Hospital, Seville, Spain
Gastric pull-up is generally the first choice for a total thoracic esophageal reconstruction. Malfunction of this 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.121
CASE REPORT YANG ET AL PNEUMOTHORAX WITH ABDOMINAL DISTENTION
Ann Thorac Surg 2016;101:336–8
Fig 1. (A) Echocardiography demonstrating the lung hydatid cyst and atrial septal defect (arrow). (B) Chest tomography demonstrating the location and contour of the lung hydatid cyst. (LA ¼ left atrium; RA ¼ right atrium.)
FEATURE ARTICLES
Fig 2. (A) Opened lung hydatid cyst as viewed intraoperatively with the edge of the incision grasped by forceps (its content has been evacuated). (B) Histologic evaluation of the cyst content demonstrates a protoscolex and cyst wall of Echinococcosis granulosus (hematoxylin and eosin, original magnification 200).
and cardiopulmonary bypass. Special care is needed when removing the cyst content to avoid any potential leak and spreading of viable Echinococcus. We believe that removal of the lung hydatid cyst and repair of the ASD can be achieved with one-stage surgery with a satisfactory outcome.
References 1. McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003;362:1295–304. 2. Geva T, Martins JD, Wald RM. Atrial septal defects. Lancet 2014;383:1921–32. 3. Turk F, Yuncu G, Karabulut N, et al. A single-center largevolume experience in the surgical management of hydatid disease of the lung with and without extrapulmonary involvement. World J Surg 2013;37:2306–12. 4. Garipov MK, Rasulov RR. [Simultaneous mitral commissurotomy and surgical treatment of echinococcosis of the left lung]. Klin Khir 1990:64. 5. Atalay A, Salih OK, Gezer S, et al. Simultaneous heart and bilateral lung hydatid cyst operated in a single session. Heart Lung Circ 2013;22:682–4. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Intraoperative Pneumothorax Presenting as Abdominal Distention Stephen Su Yang, MD, Kenneth Kardash, MD, and Christian Sirois, MD Departments of Anesthesia and Thoracic Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
A 74-year-old man with a history of lung cancer presented for right upper lobectomy. After induction of anesthesia, it was noted that the abdomen became progressively more distended. Soon afterward, there was a significant decrease in tidal volume. Ultrasonography of the lung showed no sign of pneumothorax at the anterior second intercostal space. However, the roentgenograms showed a massive right-sided pneumothorax and extensive pneumoperitoneum. Both the pneumothorax 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.073
Ann Thorac Surg 2016;101:336–8
CASE REPORT YANG ET AL PNEUMOTHORAX WITH ABDOMINAL DISTENTION
337
and the pneumoperitoneum were decompressed in the operating room, and the elective lobectomy proceeded as previously planned. The patient was extubated at the end of the operation, and there were no sequelae postoperatively. (Ann Thorac Surg 2016;101:336–8) Ó 2016 by The Society of Thoracic Surgeons
P
neumothorax is a potentially life-threatening condition [1]. Its diagnosis must be made in a timely fashion. Nearly every lung disease can cause a secondary spontaneous pneumothorax. This is particularly true for patients with chronic obstructive pulmonary disease (COPD) [2]. In our case, the initial clinical presentation was atypical, and the unusual distribution of air invalidated some traditional aspects of diagnosis and treatment. Fig 1. Chest roentgenogram showing pneumothorax.
obtained and showed a large amount of free air in the diaphragmatic pleural cavity and the abdominal cavity (Figs 1 and 2). During this time, there was no sign of hemodynamic instability or desaturation. However, the end-tidal CO2 increased to a maximum of 53 mm Hg. The patient was placed in the left lateral decubitus position. A right thoracotomy was performed. This immediately decompressed the pneumothorax. A 24
FEATURE ARTICLES
A 74-year-old man with a history of lung cancer presented for a right upper lobectomy. He had a history of moderate COPD, with a forced expiratory volume in 1 second (FEV1) of 67% of its predicted value, and hypertension, dyslipidemia, and benign prostatic hyperplasia. Positron emission tomography (PET) revealed a 4.7 4.6 cm mass in the right upper lobe. He had a 16-gauge intravenous catheter and an arterial catheter inserted. A thoracic epidural catheter was placed at T4–5 before induction without any adverse event. General anesthesia was induced with propofol, sufentanil, and rocuronium. Bag-and-mask ventilation was performed with ease, and a 39F left-sided double-lumen endotracheal tube was inserted easily on the first attempt. The position of the double-lumen tube was confirmed with fiberoptic bronchoscopy. Ten minutes after intubation, it was noted the abdomen was becoming progressively distended. The ventilator was set on pressure-control mode. Soon afterward, the tidal volume decreased considerably. At a peak pressure of 35 cm of water, the tidal volume had dropped from 600 mL to 164 mL. We initially attributed the abdominal distention to ventilation of the stomach, either during mask ventilation at induction or from an ongoing leak into the esophagus, despite confirmed endotracheal placement of the doublelumen tube. Failure to decompress the stomach upon insertion of an orogastric tube was initially thought to be caused by possible kinking or blockage of the tube. This led to replacement of the orogastric tube and confirmation of its position by video laryngoscopy. This had no effect on the abdominal distention. Bedside ultrasonography was performed by the attending anesthesiologist. Both lungs showed a positive “sliding lung” [3] and “B lines” [4] at the anterior second intercostal space, ruling out pneumothorax at this site. Roentgenograms of the chest and abdomen were Accepted for publication Jan 16, 2015. Address correspondence to Dr Kardash, Department of Anesthesia, Jewish General Hospital, Pavilion A, Rm A-335, 3755 Cote-Ste-Catherine Rd, Montreal, Quebec, H3T 1E2; email: [email protected].
Fig 2. Abdominal roentgenogram showing pneumothorax and pneumoperitoneum.
ˇ
338
CASE REPORT RUIZ-MOYA ET AL CHIMERIC ALT FLAP FOR THORACIC ESOPHAGOPLASTY
Fig 3. Gross specimen of the right lower lobe showing defect in pleura.
French chest tube was also inserted temporarily through the diaphragm to decompress the pneumoperitoneum. The compliance of the lungs improved, and the lobectomy proceeded as previously planned. Intraoperatively, no gross abnormality was noticed at the site of the mass excision. However, a defect in the pleura was seen grossly at the base of the right lower lobe (Fig 3). The patient recovered uneventfully.
FEATURE ARTICLES
Comment We report this case to raise awareness of a possible atypical presentation of pneumothorax. Several clinical features of the case were striking: (1) the presenting sign was abdominal distention; (2) ultrasonography of the anterior chest wall was falsely negative, which delayed diagnosis; and (3) hemodynamic instability was absent because of the decompression of air into the peritoneum. This falsely reassuring factor would likely have changed had the pneumothorax continued to go untreated. Our patient did not experience any hemodynamic compromise or desaturation. Although a large amount of pneumothorax was present, the fact that it tracked caudally negated potential hemodynamic effects. However, the increase in intraabdominal pressure had a major influence on ventilation. At 16 mm Hg of intraabdominal pressure, there is a decrease in 50% of pulmonary compliance [5]. Pneumoperitoneum associated with pneumothorax is unusual. In these cases, air dissects from ruptured alveoli along adjacent pulmonary vessels and into the mediastinum. As pressure increases, air would then move into the retroperitoneal space along the thoracic great vessels and the esophagus [6]. Even more unusual in this case was that air tracked only in a caudal direction, creating tension below the lung and compressing it against the apical pleural Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;101:338–42
space, obliterating any sign of pneumothorax in this area. The liver consequently had the appearance of “floating in air” (Fig 2). The reason for this preferential accumulation toward the peritoneum in our case remains unknown. One of the most instructive lessons of this case was the falsely reassuring ultrasonography findings. We visualized both B lines and a sliding lung bilaterally at the second intercostal space, the highest point in the chest in a supine patient and conventionally the first place air would localize. The standard emergent treatment for suspected tension pneumothorax in a patient in the supine position is decompression at the midclavicular line in the second intercostal interspace. This is another reason we performed sonography in this area. Recently, the risk-tobenefit ratio of this approach has been questioned [7]. Performing this procedure could have led to further lung injury in our case because there was no distention of the pleural space at this level. In retrospect, it seems that the source of the pneumothorax we describe was a bleb near the site of the tumor, which ruptured during positive pressure ventilation, even though airway pressure was never above 35 cm of water.
References 1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii18–31. 2. Chen CH, Liao WC, Liu YH, et al. Secondary spontaneous pneumothorax: which associated conditions benefit from pigtail catheter treatment? Am J Emerg Med 2012;30:45–50. 3. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest J 1995;108:1345–8. 4. Volpicelli G. Sonographic diagnosis of pneumothorax. Intens Care Med 2011;37:224–32. 5. Obeid F, Saba A, Fath J, et al. Increases in intra-abdominal pressure affect pulmonary compliance. Arch Surg 1995;130:544–8. 6. Glauser FL, Bartlett RH. Pneumoperitoneum in association with pneumothorax. Chest J 1974;66:536–40. 7. Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury 2001;32:749–52.
Chimeric Anterolateral Thigh Flap for Total Thoracic Esophageal Reconstruction Alejandro Ruiz-Moya, MD, Juan J. Segura-Sampedro, MD, Domingo Sicilia-Castro, MD, PhD, Francisco Carvajo-P erez, MD, PhD, Tom as G omez-Cía, MD, PhD, Antonio V azquez-Medina, MD, PhD, and ~ ez-Delgado, MD, PhD Francisco Ib an Departments of Plastic and Reconstructive Surgery, and General Surgery, Virgen del Rocío University Hospital, Seville, Spain
Gastric pull-up is generally the first choice for a total thoracic esophageal reconstruction. Malfunction of this 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.121