Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass
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《血管的通路杂志》
Department of Cardiothoracic Surgery, Allegheny General Hospital, 320 East North Avenue, South Tower, 14th Floor, Pittsburgh, PA 15212, USA
Abstract
Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. Management can be quite challenging, as surgical intervention other than tube thoracostomy poses significant risks. We report a case of spontaneous pneumothorax that did not resolve with conventional management, necessitating thoracoscopic bleb resection with the use of cardiopulmonary bypass.
Key Words: Minimally invasive surgery; Pleura; Lung-other
1. Introduction
Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. Management can be quite challenging, as surgical intervention, other than tube thoracostomy, can be quite complicated and poses significant risks. We report a case of spontaneous pneumothorax that did not resolve with conventional management, necessitating thoracoscopic bleb resection with the use of cardiopulmonary bypass.
A 63-year-old African American male underwent a right pneumonectomy in January of 2003 for a hilar stage II (T2N1) adenocarcinoma of the lung. He received adjuvant chemoradiation therapy and recovered well. Seven months postoperatively, he presented to the emergency department with new-onset dyspnea and was diagnosed with a left pneumothorax (PTX) (Fig. 1). A thoracostomy tube was inserted but failed to completely resolve the pneumothorax and he remained with a persistent air leak. A second chest tube was inserted, following a chest CT scan that showed residual PTX and significant apical bullous disease. Both tubes were maintained on –20 cm water suction, as attempts to decrease the suction resulted in significant worsening of symptoms.
An operative intervention was considered. Due to the presence of significant emphysematous changes, it was felt that a simple surgical approach (thoracotomy with intermittent apnea) might not be adequate, as prolonged periods of apnea would be required to deflate the lung. Additionally, a minimally invasive approach would be desirable, so as to minimize postoperative pain and facilitate recovery. We therefore opted for a thoracoscopic approach (VATS) with the use of cardiopulmonary bypass.
The patient was placed under general endotracheal anesthesia with a single lumen endotracheal tube. The left common femoral artery and vein were exposed through a groin incision and cannulated in the standard fashion. The patient was placed in the lateral decubitus position and standard 3-port thoracoscopy was performed. Femorofemoral cardiopulmonary bypass was then instituted and ventilation was arrested. A wedge excision of an upper lobe bleb was performed with the use of endoscopic linear staplers. Mechanical pleural abrasion completed the procedure. Meticulous hemostasis was obtained. Three chest tubes were used through the operative ports.
The patient was then awakened and extubated in the operating room. His chest tubes were placed on water seal within the first 4 days and were subsequently removed without development of new PTX. His postoperative course was characterized by development of pneumonia, requiring reintubation on the 5th postoperative day; he underwent a tracheostomy on the 18th postoperative day. He was eventually weaned from the ventilator and discharged from the hospital.
2. Discussion
Contralateral pneumothorax after pneumonectomy is a rare but potentially fatal complication [1]. Few isolated case reports exist in the literature [2,3] with most events occurring in the early postoperative period, so experience with management of this condition is limited. Traditional thinking would dictate that definitive treatment should be attempted, since recurrence may have grave consequences for the patient. However, surgery for pleurodesis and/or bleb resection in a patient with pneumonectomy is quite complicated and dangerous. In the reported cases, the most common management option was insertion of a thoracostomy tube, followed by surgery in two cases, secondary to persistent air leak.
The indications and techniques of surgical management of spontaneous pneumothorax continue to evolve. Thoracoscopic procedures, with wedge resections and/or pleurodesis, are now most frequently used for surgical treatment of this entity [4]. In addition, several authors have reported on the operative techniques for lung resections following pneumonectomy [5–10]. Most of these operations were performed for lung cancer. Different approaches were used in this challenging group of patients, including standard posterolateral thoracotomy, median sternotomy and VATS; these were combined with intermittent apnea [5], selective lobar isolation [6], high-frequency jet ventilation [10] and extracorporeal oxygenation [7,9]. Patients with spontaneous pneumothorax may not be suitable candidates for some of these approaches. Intermittent apnea, for instance, may not work well with severely emphysematous lungs, such as in our patient. This is particularly important when thoracoscopic approaches are contemplated. Indeed, in one of the reported cases, conversion to thoracotomy was necessary, as inadequate lung deflation during the brief periods of apnea limited visualization.
In our patient, the limited respiratory reserve, the persistent air leak and the inability to tolerate water seal and potentially a Heimlich valve, necessitated surgical intervention, even though the previous pneumonectomy significantly increased the operative risk. Due to the presence of substantial bullous disease, we anticipated that the traditional approach (use of intermittent apnea) would not allow for adequate lung deflation and completion of the procedure. We elected, therefore, to proceed with the use of cardiopulmonary bypass. The operation was completed successfully; no bleeding or access complication occurred. The postoperative course was marked by the development of pneumonia and respiratory failure, reflecting one of the major risks of further pulmonary resection—with any approach–in pneumonectomy patients.
In summary, contralateral spontaneous pneumothorax after pneumonectomy is, fortunately, a rare condition. No specific management guidelines exist, as reported experience is very limited. Conservative management with tube thoracostomy is a sensible initial approach, but persistent air leak may necessitate surgical intervention. Thoracoscopic surgery with bleb resection and/or pleurodesis can be performed with the use of cardiopulmonary bypass. Careful patient selection and consideration of all available approaches are essential prior to operating in this challenging group of patients.
Appendix A. ICVTS on-line discussion
Author: Mohamed F. Ismail (Mansoura University, Egypt)
eComment: I read with interest the article and I am astonished by your effort with this poor patient. However, I do have some comments.
The article title, "Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass" is a point of discussion.
I do not agree with the fact that "contralateral" should be added in the title. If pneumothrax occurs after a pneumonectomy it is absolutely clear that it could only be contralateral [1]. In fact these words were taken from the authors but i want to reach for a unique definition of that case. I also would like to discuss some other points about the indications of inserting another tube and why you didn't proceed to surgical intervention directly after delayed expansion of the lung.
My last comment is about the large number of three postoperative tubes.
References
1 Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late post pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
Author: Sameh Sersar (Mansoura University, Egypt)
eComment: The authors supported my opinion published in ICVTS [1] as a comment on the paper cited in their article by A. Caesario 2003 [2]. My opinion was that the title (Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case) is not indicative enough: it would be more indicative if contralateral was added before spontaneous pneumothorax making "Contralateral persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case". Cesario A. et al. replied that they do not agree with the fact that "contralateral" should be added in the title. If pneumothorax occurs after a pneumonectomy it is absolutely clear that it could only be contralateral. The title of Birdas et al. [3] is "Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass" as I suggested. I still would like to know why three tubes were inserted and how they were able to manage the coagulation in such a bloody operation under cardiopulmonary bypass and VATS.
References
1 Sersar IS. Comment on Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
2 Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late postpneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
Birdas TJ, Beckart DH, Keenan RJ. Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass. Interact Cardiovasc and Thorac Surg. In press. 3
Author: Biruta Witte (Katholisches Klinikum, Germany)
eComment: I'd like to ask the authors whether it is possible to clearly outline the indications for extracorporal circulation. Our institutional experience with post pneumonectomy thoracic surgery is very limited, but a VATS debridement for empyema and an open segmentectomy for a second bronchial carcinoma have been carried out with "single lung ventilation". That was not too comfortable for the surgeon and the anesthesiologist, but safe for the patients.
References
Kopec SE, Irwin RS, Umali-Torres CB, Balikian JP, Conlan AA. The postpneumonectomy state. Chest 1998;114:1158–84.
Hubbard JG, Nkere UU, Bhatngar NK. Spontaneous contralateral pneumothorax, following pneumonectomy. Postgrad Med J 1997;73:107–8.
Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003;2:477–479.
Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590–602.
Donington JS, Miller DL, Rowland CC, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy. Ann Thorac Surg 2002;74:154–8.
Lewis RJ and Caccavale RJ. Pulmonary resection after pneumonectomy. Ann Thorac Surg 1997;64:583–4.
Oey IF, Peek GJ, Firmin RK, Waller DA. Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation. Eur J Cardiothorac Surg 2001;20:874–6.
Spaggiari L, Grunenwald D, Girard P, Baldeyrou P, Filaire M, Dennewald G, Saint-Maurice O, Tric L. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602.
Spaggiari L, Rusca M, Carbognani P, Contini S, Barboso G, Bobbio P. Segmentectomy on a single lung by femorofemoral cardiopulmonary bypass. Ann Thorac Surg 1997;64:1519–20.
Terzi A, Furlan G, Gorla A, Falezza G, Attino M, Calabro F. Lung resection on single residual lung after pneumonectomy for bronchogenic carcinoma. Thorac Cardiovasc Surg 1997;45:273–6.(Thomas J. Birdas, Daniel )
Abstract
Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. Management can be quite challenging, as surgical intervention other than tube thoracostomy poses significant risks. We report a case of spontaneous pneumothorax that did not resolve with conventional management, necessitating thoracoscopic bleb resection with the use of cardiopulmonary bypass.
Key Words: Minimally invasive surgery; Pleura; Lung-other
1. Introduction
Spontaneous contralateral pneumothorax after pneumonectomy is a rare condition. Management can be quite challenging, as surgical intervention, other than tube thoracostomy, can be quite complicated and poses significant risks. We report a case of spontaneous pneumothorax that did not resolve with conventional management, necessitating thoracoscopic bleb resection with the use of cardiopulmonary bypass.
A 63-year-old African American male underwent a right pneumonectomy in January of 2003 for a hilar stage II (T2N1) adenocarcinoma of the lung. He received adjuvant chemoradiation therapy and recovered well. Seven months postoperatively, he presented to the emergency department with new-onset dyspnea and was diagnosed with a left pneumothorax (PTX) (Fig. 1). A thoracostomy tube was inserted but failed to completely resolve the pneumothorax and he remained with a persistent air leak. A second chest tube was inserted, following a chest CT scan that showed residual PTX and significant apical bullous disease. Both tubes were maintained on –20 cm water suction, as attempts to decrease the suction resulted in significant worsening of symptoms.
An operative intervention was considered. Due to the presence of significant emphysematous changes, it was felt that a simple surgical approach (thoracotomy with intermittent apnea) might not be adequate, as prolonged periods of apnea would be required to deflate the lung. Additionally, a minimally invasive approach would be desirable, so as to minimize postoperative pain and facilitate recovery. We therefore opted for a thoracoscopic approach (VATS) with the use of cardiopulmonary bypass.
The patient was placed under general endotracheal anesthesia with a single lumen endotracheal tube. The left common femoral artery and vein were exposed through a groin incision and cannulated in the standard fashion. The patient was placed in the lateral decubitus position and standard 3-port thoracoscopy was performed. Femorofemoral cardiopulmonary bypass was then instituted and ventilation was arrested. A wedge excision of an upper lobe bleb was performed with the use of endoscopic linear staplers. Mechanical pleural abrasion completed the procedure. Meticulous hemostasis was obtained. Three chest tubes were used through the operative ports.
The patient was then awakened and extubated in the operating room. His chest tubes were placed on water seal within the first 4 days and were subsequently removed without development of new PTX. His postoperative course was characterized by development of pneumonia, requiring reintubation on the 5th postoperative day; he underwent a tracheostomy on the 18th postoperative day. He was eventually weaned from the ventilator and discharged from the hospital.
2. Discussion
Contralateral pneumothorax after pneumonectomy is a rare but potentially fatal complication [1]. Few isolated case reports exist in the literature [2,3] with most events occurring in the early postoperative period, so experience with management of this condition is limited. Traditional thinking would dictate that definitive treatment should be attempted, since recurrence may have grave consequences for the patient. However, surgery for pleurodesis and/or bleb resection in a patient with pneumonectomy is quite complicated and dangerous. In the reported cases, the most common management option was insertion of a thoracostomy tube, followed by surgery in two cases, secondary to persistent air leak.
The indications and techniques of surgical management of spontaneous pneumothorax continue to evolve. Thoracoscopic procedures, with wedge resections and/or pleurodesis, are now most frequently used for surgical treatment of this entity [4]. In addition, several authors have reported on the operative techniques for lung resections following pneumonectomy [5–10]. Most of these operations were performed for lung cancer. Different approaches were used in this challenging group of patients, including standard posterolateral thoracotomy, median sternotomy and VATS; these were combined with intermittent apnea [5], selective lobar isolation [6], high-frequency jet ventilation [10] and extracorporeal oxygenation [7,9]. Patients with spontaneous pneumothorax may not be suitable candidates for some of these approaches. Intermittent apnea, for instance, may not work well with severely emphysematous lungs, such as in our patient. This is particularly important when thoracoscopic approaches are contemplated. Indeed, in one of the reported cases, conversion to thoracotomy was necessary, as inadequate lung deflation during the brief periods of apnea limited visualization.
In our patient, the limited respiratory reserve, the persistent air leak and the inability to tolerate water seal and potentially a Heimlich valve, necessitated surgical intervention, even though the previous pneumonectomy significantly increased the operative risk. Due to the presence of substantial bullous disease, we anticipated that the traditional approach (use of intermittent apnea) would not allow for adequate lung deflation and completion of the procedure. We elected, therefore, to proceed with the use of cardiopulmonary bypass. The operation was completed successfully; no bleeding or access complication occurred. The postoperative course was marked by the development of pneumonia and respiratory failure, reflecting one of the major risks of further pulmonary resection—with any approach–in pneumonectomy patients.
In summary, contralateral spontaneous pneumothorax after pneumonectomy is, fortunately, a rare condition. No specific management guidelines exist, as reported experience is very limited. Conservative management with tube thoracostomy is a sensible initial approach, but persistent air leak may necessitate surgical intervention. Thoracoscopic surgery with bleb resection and/or pleurodesis can be performed with the use of cardiopulmonary bypass. Careful patient selection and consideration of all available approaches are essential prior to operating in this challenging group of patients.
Appendix A. ICVTS on-line discussion
Author: Mohamed F. Ismail (Mansoura University, Egypt)
eComment: I read with interest the article and I am astonished by your effort with this poor patient. However, I do have some comments.
The article title, "Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass" is a point of discussion.
I do not agree with the fact that "contralateral" should be added in the title. If pneumothrax occurs after a pneumonectomy it is absolutely clear that it could only be contralateral [1]. In fact these words were taken from the authors but i want to reach for a unique definition of that case. I also would like to discuss some other points about the indications of inserting another tube and why you didn't proceed to surgical intervention directly after delayed expansion of the lung.
My last comment is about the large number of three postoperative tubes.
References
1 Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late post pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
Author: Sameh Sersar (Mansoura University, Egypt)
eComment: The authors supported my opinion published in ICVTS [1] as a comment on the paper cited in their article by A. Caesario 2003 [2]. My opinion was that the title (Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case) is not indicative enough: it would be more indicative if contralateral was added before spontaneous pneumothorax making "Contralateral persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case". Cesario A. et al. replied that they do not agree with the fact that "contralateral" should be added in the title. If pneumothorax occurs after a pneumonectomy it is absolutely clear that it could only be contralateral. The title of Birdas et al. [3] is "Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass" as I suggested. I still would like to know why three tubes were inserted and how they were able to manage the coagulation in such a bloody operation under cardiopulmonary bypass and VATS.
References
1 Sersar IS. Comment on Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
2 Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late postpneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003 2 pp. 477–9
Birdas TJ, Beckart DH, Keenan RJ. Contralateral spontaneous pneumothorax after pneumonectomy: thoracoscopic management with cardiopulmonary bypass. Interact Cardiovasc and Thorac Surg. In press. 3
Author: Biruta Witte (Katholisches Klinikum, Germany)
eComment: I'd like to ask the authors whether it is possible to clearly outline the indications for extracorporal circulation. Our institutional experience with post pneumonectomy thoracic surgery is very limited, but a VATS debridement for empyema and an open segmentectomy for a second bronchial carcinoma have been carried out with "single lung ventilation". That was not too comfortable for the surgeon and the anesthesiologist, but safe for the patients.
References
Kopec SE, Irwin RS, Umali-Torres CB, Balikian JP, Conlan AA. The postpneumonectomy state. Chest 1998;114:1158–84.
Hubbard JG, Nkere UU, Bhatngar NK. Spontaneous contralateral pneumothorax, following pneumonectomy. Postgrad Med J 1997;73:107–8.
Cesario A, Kawamukai K, Margaritora S, Granone P. Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case. Interact Cardiovasc Thorac Surg 2003;2:477–479.
Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590–602.
Donington JS, Miller DL, Rowland CC, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy. Ann Thorac Surg 2002;74:154–8.
Lewis RJ and Caccavale RJ. Pulmonary resection after pneumonectomy. Ann Thorac Surg 1997;64:583–4.
Oey IF, Peek GJ, Firmin RK, Waller DA. Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation. Eur J Cardiothorac Surg 2001;20:874–6.
Spaggiari L, Grunenwald D, Girard P, Baldeyrou P, Filaire M, Dennewald G, Saint-Maurice O, Tric L. Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 1996;62:1598–602.
Spaggiari L, Rusca M, Carbognani P, Contini S, Barboso G, Bobbio P. Segmentectomy on a single lung by femorofemoral cardiopulmonary bypass. Ann Thorac Surg 1997;64:1519–20.
Terzi A, Furlan G, Gorla A, Falezza G, Attino M, Calabro F. Lung resection on single residual lung after pneumonectomy for bronchogenic carcinoma. Thorac Cardiovasc Surg 1997;45:273–6.(Thomas J. Birdas, Daniel )