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The One-Lung Conundrum
Cardiothoracic Surgery SESSION TITLE: Fellow Case Report Slide: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Wednesday, October 26, 2016 at 11:00 AM - 12:15 PM
The One-Lung Conundrum Evan Butlin MD* Charles Daley MD; and John Mitchell MD Naval Medical Center San Diego, San Diego, CA INTRODUCTION: Postpneumonectomy syndrome is a rarely described complication of surgical pneumonectomy patients. We present a case of postpneumonectomy syndrome following a suboptimal surgical outcome.
CARDIOTHORACIC SURGERY
CASE PRESENTATION: A 25 year old female with a longstanding history of recurrent pulmonary infections since infancy presented to National Jewish Health following a pneumonectomy. Multiple pulmonary infections and a prolonged NICU stay culminated in a childhood diagnosis of focal bronchiectasis. Past medical history included IgG subclass 4 deficiency and anorexia, now resolved. She is a lifetime non-smoker and used Albuterol as needed. Six months prior to current presentation, she underwent a planned right lower lobectomy near her home institution. Intraoperatively, the right middle lobe demonstrated disease burden and was also removed. Due to an intraoperative pulmonary vascular injury, a completion right pneumonectomy was required. 3 months post-pneumonectomy, she noted progressive onset of dyspnea and a barking cough prompting present to National Jewish Health. Chest CT scan demonstrated rightward mediastinal shifting with almost complete obliteration of the left mainstem bronchus consistent with postpneumonectomy syndrome. The patient underwent redo thoracotomy with the insertion of saline implant to correct her mediastinal shift. Following re-positioning, she notes improvement in her stridor and follow up imaging demonstrates improvement in her mediastinal shift. DISCUSSION: Postpneumonectomy syndrome is a rarely describe complication of a pneumonectomy. Extrinsic compression occurs of the distal trachea and mainstem bronchus caused by a shifting of the mediastinum and hyperinflation of the remaining lung. Symptoms include progressive dyspnea, cough and stridor. Untreated, postpneumonectomy syndrome may lead to severe dyspnea, dysphagia, and asphyxiation. Current surgical procedures are aimed at prosthetic replacement of the thoracic volume often with saline implants or tissue expanders. Outcomes of surgical revision are poorly studied with approximately 60% of patients showing improved dyspnea. CONCLUSIONS: We present a case of postpneumonectomy syndrome, characterized by left mainstem bronchial compression and mediastinal shift. Surgical correction with mediastinal repositioning alleviated the bronchial compression, resulting in symptom improvement. Reference #1: Shen, et al. “Postpneumonectomy syndrome” J Thorc Cardiovasc Surg. 2008 Reference #2: Jung, et al. “Management of post-pneumonectomy syndrome using tissue expanders” Thoracic Ca. 2016 DISCLOSURE: The following authors have nothing to disclose: Evan Butlin, Charles Daley, John Mitchell No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.049
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
42A
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150#4S CHEST OCTOBER 2016
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The One-Lung Conundrum Evan Butlin MD* Charles Daley MD; and John Mitchell MD Naval Medical Center San Diego, San Diego, CA INTRODUCTION: Postpneumonectomy syndrome is a rarely described complication of surgical pneumonectomy patients. We present a case of postpneumonectomy syndrome following a suboptimal surgical outcome.
CARDIOTHORACIC SURGERY
CASE PRESENTATION: A 25 year old female with a longstanding history of recurrent pulmonary infections since infancy presented to National Jewish Health following a pneumonectomy. Multiple pulmonary infections and a prolonged NICU stay culminated in a childhood diagnosis of focal bronchiectasis. Past medical history included IgG subclass 4 deficiency and anorexia, now resolved. She is a lifetime non-smoker and used Albuterol as needed. Six months prior to current presentation, she underwent a planned right lower lobectomy near her home institution. Intraoperatively, the right middle lobe demonstrated disease burden and was also removed. Due to an intraoperative pulmonary vascular injury, a completion right pneumonectomy was required. 3 months post-pneumonectomy, she noted progressive onset of dyspnea and a barking cough prompting present to National Jewish Health. Chest CT scan demonstrated rightward mediastinal shifting with almost complete obliteration of the left mainstem bronchus consistent with postpneumonectomy syndrome. The patient underwent redo thoracotomy with the insertion of saline implant to correct her mediastinal shift. Following re-positioning, she notes improvement in her stridor and follow up imaging demonstrates improvement in her mediastinal shift. DISCUSSION: Postpneumonectomy syndrome is a rarely describe complication of a pneumonectomy. Extrinsic compression occurs of the distal trachea and mainstem bronchus caused by a shifting of the mediastinum and hyperinflation of the remaining lung. Symptoms include progressive dyspnea, cough and stridor. Untreated, postpneumonectomy syndrome may lead to severe dyspnea, dysphagia, and asphyxiation. Current surgical procedures are aimed at prosthetic replacement of the thoracic volume often with saline implants or tissue expanders. Outcomes of surgical revision are poorly studied with approximately 60% of patients showing improved dyspnea. CONCLUSIONS: We present a case of postpneumonectomy syndrome, characterized by left mainstem bronchial compression and mediastinal shift. Surgical correction with mediastinal repositioning alleviated the bronchial compression, resulting in symptom improvement. Reference #1: Shen, et al. “Postpneumonectomy syndrome” J Thorc Cardiovasc Surg. 2008 Reference #2: Jung, et al. “Management of post-pneumonectomy syndrome using tissue expanders” Thoracic Ca. 2016 DISCLOSURE: The following authors have nothing to disclose: Evan Butlin, Charles Daley, John Mitchell No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.049
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
42A
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150#4S CHEST OCTOBER 2016
]