FAILED CONSERVATIVE MANAGEMENT FOR SPONTANEOUS LUNG HERNIA: WILL SURGERY IMPROVE PATIENT OUTCOMES?

Abstract

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous lung herniation (SLH) is a rare entity seen in male smokers with underlying COPD. This most commonly occurs at the 8th and 9th intercostal spaces. SLH can be managed conservatively, surgically with primary repair, or repair utilizing mesh, sternal wires, or sternal plates. The literature is comprised of case reports and small case series. No surgical approach has been established to be superior. However the management of any particular symptomatic patient should be individualized. CASE PRESENTATION: A 72 year old male, former smoker, with past medical history (PMH) significant for COPD with no prior history of thoracic surgery or chest wall trauma, presented to emergency department multiple times over a period of three months with worsening left lower chest wall pain radiating to the back and worsening chronic dyspnea on exertion. He had recurrent admissions for COPD exacerbations over the same time span of 3 months. He received steroids and breathing treatments. He was ultimately found to have a left spontaneous lung hernia as seen on CXR and CT scan. He was initially treated conservatively. However, his symptoms persisted and was referred to thoracic surgery. He underwent thoracotomy with primary repair utilizing sternal wires at a tertiary care center. He developed a DVT and prolonged air leak postoperatively requiring chest tube management. Patient presented 2 months later with a complaint of persistent recurrent chest wall pain and discomfort. Upon physical examination, the recurrent hernia was noted. CT scan of chest confirmed recurrent the left lung herniation and fracture of the sternal wires. The patient elected no further surgical management. DISCUSSION: The true incidence of this rare condition is difficult as many go unnoticed. These patients do not seek medical attention because of minimal symptoms. This may explain the scarce literature and most cases being related to traumatic conditions where imaging is completed as part of the trauma protocol. COPD patients are predisposed because of long-term steroid use, chronic hyperinflation and cough. Clinical presentation varies significantly among cases. Thorough physical examination and imaging studies are warranted for a correct diagnosis. Asymptomatic patients and patients with less severe discomfort could be managed non-operatively to avoid complications. With failure of conservative management, prompt surgical repair should be performed by those with particular expertise. CONCLUSIONS: Our patient’s primary repair failed causing complications with no improvement in quality of life. We hypothesize that surgical repair with mesh may have been superior to primary closure with sternal wires because of hernia recurrence. Reference #1: Cox Michele LT, Thota Darshan, Trevino R: Spontaneous Lung Herniation Through the Chest Wall. Military Medicine. 2018:183(3-4):e233-e234. Reference #2: Wani AS, Kalamkar P, Alhassan S, Farrell MJ: Spontaneous intercostal lung herniation complicated by rib fractures: a therapeutic dilemma. Oxf Med Case reports. 2015; 2015:378-81. Reference #3: Tack D. Wattiez A et. al. Spontaneous lung hernia after a single cough. Eur. Radiol. 2000 (10) 500-502. DISCLOSURES: No relevant relationships by Stacey Brown-Brocklehurst, source=Web Response No relevant relationships by James Comerci, source=Web Response No relevant relationships by Sathyanarayana Machani, source=Web Response No relevant relationships by Victor Maevsky, source=Web Response No relevant relationships by Trishala Menon, source=Web Response No relevant relationships by Bradley Schmitt, source=Web Response