EP1.17-14 Less Is More: An Unusual Case of Benign Emptying of the Post - Pneumonectomy Space

Abstract

To describe an unusual case of benign emptying of the post-pneumonectomy space. A 68-years-old man presented to our clinic with a large swelling located on the previous thoracotomy increasing at Valsalva maneuvers. One month before he underwent right pneumonectomy for lung adenocarcinoma. He was discharged on the seventh post-operative day uneventfully. Patient denied any history of chest trauma, fever, neither productive cough nor vomica. Chest X-Ray showed a drop of the air-fluid level within the post-pneumonectomy space. Suspecting of a broncho-pleural fistula (BPF), patient underwent a flexible fiberoptic bronchoscopy which showed a regular bronchial stump. A chest CT-scan revealed an empty right hemithorax associated with an air collection in the subcutaneous tissues. No pleural puncture was performed, in order to avoid any contaminations of the pleural cavity. A BPF was ruled out; a watchful waiting approach without surgical intervention or antimicrobial therapy was decided. A roentgenogram 10 weeks later showed the almost refill of the pleural cavity and at physical examination the swelling was dramatically decreased. At chest CT-scan 3 months later the post-pneumonectomy space was completely filled by fluid associated with an overexpansion of the residual lung. After one year the patient is healthy and disease-free. Patient’s presentation meets the clinical and laboratory criteria of Benign Emptying of the Postpneumonectomy Space (BEPS) (afebrile, normal WBC, no fluid expectoration, negative bronchoscopy, negative pleural culture if performed). Among the hypotheses about the pathogenesis of BEPS we advocated the valve-like mechanisms of “occult bronchopleural fistula”, which was large enough to let enter only air into the postpneumonectomy space although arresting the passage of pleural effusion to the airways. A spontaneous healing of the micro-fistula was maybe the underlying mechanisms of the refilling of the thoracic cavity. BEPS seldom occurred after pneumonectomy although it should be considered during differential diagnosis of a sudden drop of the pleural fluid especially in asymptomatic patients, in order to avoid unnecessary invasive procedures. Benign emptying of the postpneumonectomy space should be considered when facing with a sudden drop of the pleural fluid in asymptomatic patients in order to avoid unnecessary invasive procedures.