Postpneumonectomy Syndrome Research Articles

Surgical Treatment for Multidrug-Resistant and Extensive Drug-Resistant Tuberculosis

Multidrug-resistant (MDR) and extensive drug-resistant (XDR) tuberculosis (TB) are still significant health problems. Surgical resection is an adjunctive intervention for patients with MDR or XDR TB. This study presents the short-term and long-term results of surgical treatment for MDR or XDR TB at a single center. Between May 1996 and March 2008, surgical resection was performed on 72 patients with MDR or XDR TB at a single institution. Among these patients, 26 patients (36%) had XDR TB. All patients received multidrug regimens preoperatively and postoperatively. The preoperative sputum smears and cultures were positive in 52 patients (72%) and 58 patients (81%), respectively. The indications for surgery included failure of medical treatment in 51 patients (71%), localized disease or persistent cavity with high probability of relapse in 17 patients (24%), and combined complications such as hemoptysis in 4 patients (5%). Thirty-eight patients (53%) had a lobectomy with or without segmentectomy or wedge resection, 23 patients (32%) had pneumonectomies, 10 patients received segmentectomies, and 1 patient had multiple wedge resections. There was one postoperative death that was attributable to a thoracic empyema. Eight (11%) postoperative complications occurred, including empyema in 5 patients, bleeding in 2 patients, and postpneumonectomy syndrome in 1 patient. A favorable outcome was achieved in 65 patients (90%) after surgical resection. The favorable outcome rates did not differ significantly between patients with MDR TB and those with XDR TB (93% versus 85%; p = 0.244). Early pulmonary resection combined with chemotherapy had high cure rates with acceptable complications and preservation of the lung parenchyma in MDR TB and XDR TB.

Unusual treatment of patent foramen ovale after pneumonectomy

To the Editors: As has often been said by Dr Harold C. Urschel Jr, pneumonectomy is “a disease” in itself. It is a major procedure with frequent perioperative complications such as empyema, fistula, cardiac problems or respiratory insufficiency. Besides frequent post-operative cardiac and respiratory complications, long-term sequelae are also seen. After pneumonectomy, anatomical adaptations occur with repositioning of intrathoracic structures. Common changes are elevation of the hemidiaphragm (especially after phrenic nerve damage), mediastinal shift, diminished intercostal space and filling of the postpneumonectomy space with fluid. Infrequently, these adaptations may lead to invalidating complications. The most frequent complication is the so-called post-pneumonectomy syndrome caused by compression of the remaining bronchus against the vertebral column or aorta. Since positioning of the organs may take years, symptoms may occur even after 5–10 yrs. In this letter, we will focus on a rare complication, shunting through a patent foramen ovale (PFO), as a long-term complication of right-sided pneumonectomy or bilobectomy. Only a few cases have been published, although this complication might be under-reported since the diagnosis of PFO is difficult, especially after pneumonectomy. This letter describes three patients who were diagnosed with shunting through a PFO following lung resection. In these patients, right ventricular compression by the elevated right hemidiaphragm was the main cause of PFO and surgical plication of the right hemidiaphragm was sufficient to close the PFO. ### Patient A A 67-yr-old male underwent a right-sided pneumonectomy 14 yrs earlier because of a bronchial carcinoid. Partial resection of the pericardium with transection of the phrenic nerve were needed for complete resection He developed progressive dyspnoea during exercise and when bending down. Echocardiography demonstrated a right-to-left interatrial shunt when increasing intra-abdominal pressure (valsalva manoeuvre) with a shunt fraction of 18%. Further analysis with right heart catheterisation at our institution showed a mean right atrial resting pressure ( P ra …

Pulmonary Vein Stenosis Following Left Pneumonectomy: A Variant Contributor to Postpneumonectomy Syndrome

Postpneumonectomy syndrome is a recognized complication following pneumonectomy, resulting from mediastinal displacement into the vacated pleural space. Mediastinal displacement causes bronchial compression and dyspnea. This report describes a 47-year-old woman who presented with shortness of breath 6 months after a left pneumonectomy. She was initially hypoxic and was found to have a patent foramen ovale. Following closure of the patent foramen ovale, she was no longer hypoxic, but she continued to have dyspnea with exertion and left lateral decubitus positioning. There was no evidence of bronchial compression, but MRI and transesophageal echocardiography suggested pulmonary vein compression due to mediastinal displacement. Transthoracic echocardiography confirmed functional pulmonary vein compression that was worse in the standing and in the left lateral positions. Her symptoms improved with mediastinal repositioning using a transesophageal echocardiography-guided approach. Positional pulmonary vein compression may be an underdiagnosed complication of pneumonectomy.

A Case of Injection of Mitomycin C for Tracheobronchial Stenosis Caused by Postpneumonectomy Syndrome

A Case of Injection of Mitomycin C for Tracheobronchial Stenosis Caused by Postpneumonectomy Syndrome

Left Postpneumonectomy Syndrome: Early Endoscopic Treatment

Postpneumonectomy syndrome is characterized by postoperative bronchial obstruction caused by mediastinal shift. The syndrome is well documented in the medical literature as a late complication of right pneumonectomy; however, it rarely occurs following resection of the left lung, and only 10 cases have been published. The pathophysiology, clinical manifestations, prognosis, and treatment are similar for both sides of the lung. We present the case of an adult patient who underwent left pneumonectomy and developed postpneumonectomy syndrome 15 months later. Stenosis of the intermediate bronchus occurred between the vertebral body and the right pulmonary artery. Endoscopic treatment with a self-expanding metal wallstent was successful, and complete remission was observed over the 6 months of follow-up.

Bronchial Obstruction after Pneumonectomy

A 42-year-old woman underwent right pneumonectomy because of extensive parenchymal destruction due to tuberculosis. Five years after resection, she reported increasing shortness of breath, wheezing, and dyspnea on exertion. A computed tomographic scan of the chest revealed counterclockwise rotation of the mediastinum, with mediastinal shift and compression of the left-lower-lobe bronchus (LLLB) between the pulmonary artery and aorta (Panel A, arrow), features consistent with the post-pneumonectomy syndrome. Mediastinal repositioning was accomplished with the use of an intrapleural-tissue expander and saline-filled prosthesis. Panel B shows a patent left-lower-lobe bronchus (asterisk) and the saline-filled prosthesis in the right side of the chest . . .

Thoracoscopic Approach for the Treatment of Postpneumonectomy Syndrome

Postpneumonectomy syndrome develops after pneumonectomy when excessive mediastinal shifting leads to compression of the contralateral main bronchus. This case report describes a total thoracoscopic approach for the treatment of postpneumonectomy syndrome.

Síndrome posneumonectomía izquierda. Tratamiento endoscópico precoz

Postpneumonectomy syndrome is characterized by postoperative bronchial obstruction caused by mediastinal shift. The syndrome is well documented in the medical literature as a late complication of right pneumonectomy; however, it rarely occurs following resection of the left lung, and only 10 cases have been published. The pathophysiology, clinical manifestations, prognosis, and treatment are similar for both sides of the lung. We present the case of an adult patient who underwent left pneumonectomy and developed postpneumonectomy syndrome 15 months later. Stenosis of the intermediate bronchus occurred between the vertebral body and the right pulmonary artery. Endoscopic treatment with a self-expanding metal stent was successful, and complete remission was observed over the 6 months of follow-up.

Postpneumonectomy syndrome: rare, sometimes severe, but treatable!

Postpneumonectomy syndrome: rare, sometimes severe, but treatable!

Triple Rule-Out CT in Patients with Suspicion of Acute Pulmonary Embolism: Findings and Accuracy 1

The aim of this study was to prospectively investigate the diagnostic value of triple rule-out computed tomography (CT) in patients suspected of having acute pulmonary embolism (PE). A total of 125 patients with suspicion of PE, of whom 14 patients had the additional clinical suspicion of acute aortic syndrome, underwent electrocardiogram-gated triple rule-out dual-source CT. The contrast media application protocol was adjusted to obtain a homogenous attenuation of the pulmonary arteries, thoracic aorta, and coronary arteries. The diagnostic performance of triple rule-out CT was assessed by using adjudicated discharge diagnoses as reference standards. A total of 161 adjudicated cardiovascular discharge diagnoses were made in the 125 patients (including all true-positive and true-negative findings): acute PE was found in 26 (21%) and was excluded by CT in 99 (79%), coronary artery disease was found in 3 (3%) and was excluded by catheter angiography in 9 (6%), left ventricular systolic dysfunction was found in 2 (2%) and was excluded by echocardiography in 8 (6%), and acute aortic syndrome was found in 5 (4%) and was excluded by CT in 9 (7%) patients. Nonvascular chest disease was found in 34 (27%) and included pneumonia (n = 17), neoplasms (n = 5), fractures/osteolysis (n = 3), pericarditis (n = 2), and post-pneumonectomy syndrome (n = 1). Triple rule-out CT was normal in 53 (42%) patients. Overall sensitivity, specificity, and positive and negative predictive value of triple rule-out CT for cardiovascular disease were 100% (95% confidence interval [CI] 90-100%), 98% (95%CI 94-100%), 95% (95%CI 82-99%), and 100% (95%CI 97-100%, respectively). Triple rule-out CT is feasible in patients with suspicion of PE, reveals a wide range of vascular and non-vascular chest disease, and offers an excellent overall diagnostic performance.

Minimally Invasive Repair of Post-Pneumonectomy Syndrome

We report on a 42-year-old female who underwent right pneumonectomy for hemoptysis from an aspergilloma cavity. Several years postoperatively she complained of increasing shortness of breath, wheezing, and dyspnea upon exertion. Chest computed tomography showed a counterclockwise rotation of the mediastinum with obstruction of the left lower lobe bronchus. Minimally invasive repair was carried out using an intrapleural tissue expander for dissection and an adjustable saline prosthesis for mediastinal centralization. Intraoperative bronchoscopy showed complete resolution of the left lower lobe bronchial obstruction, and postoperatively her symptoms resolved completely. This is the first reported case of a minimally invasive approach for the treatment of post-pneumonectomy syndrome in the United States.

Postpneumonectomy syndrome

Postpneumonectomy syndrome is a rare postoperative complication whereby mediastinal shifting toward the pneumonectomy space results in bronchial compression between the pulmonary artery, aorta, and vertebral column. This syndrome is more common after right pneumonectomy; other risk factors include young age and female sex. Imaging studies consistently reveal massive mediastinal shifting and document airway compromise. Bronchoscopy and flow-volume loops are helpful in confirming the diagnosis. Other causes of dyspnea, including cancer recurrence, should be excluded. Definitive treatment involves surgical repositioning of the mediastinum in the midline, as well as insertion of a saline-filled silicone prosthesis into the pneumonectomy space in order to prevent recurrence.

Right pneumonectomy syndrome presenting as a cardiac arrest in a two-year-old

Pneumonectomy syndrome is a rare complication after pneumonectomy with variable onset and presentation. It is characterized by extrinsic airway compression secondary to mediastinal shift. As far as we are aware, we are reporting the first pediatric case of pneumonectomy syndrome presenting as a cardio-pulmonary arrest. A two-year-old boy presented with a cardiac arrest 8 months after his pneumonectomy. He failed extubation twice. A flexible bronchoscopy was then performed which revealed external compression of the left mainstem bronchus. He underwent surgical correction with a prosthetic, thoracic implant. The patient's trachea was subsequently extubated to room air on postoperative day 1. He remains clinically stable at 6 month follow-up. Postpneumonectomy syndrome is a rare but serious complication after pneumonectomy. If the airway compression occurs in conjunction with compromised vena caval return, cardio-pulmonary arrest can occur. Therefore, timely diagnosis and early intervention is required.

Postpneumonectomy Syndrome: Results of mediastinal repositioning vs. stent placement

Background: Postpneumonectomy syndrome (PPS) is a late complication of pneumonectomy characterized by mediastinal shift and bronchial compression. It is most common following right pneumonectomy but is also seen left pneumonectomy. It can be treated with mediastinal repositioning and tissue expander placement in the postpneumonectomy space, but there is some interest in less invasive modalities. Endobronchial stent placement may be an option. We looked at our experience treating PPS with these two modalities. Methods: All patients with PPS treated with mediastinal repositioning/tissue expander placement or bronchial stenting at our institution from 1991 to 2005 were reviewed. Results: Mean age at the time of pneumonectomy was 45 years. Mean follow-up was 33 months. Six patients underwent tissue expander placement. They had relief of symptoms with the following complications: wound infection, atrial fibrillation, expander leak and esophageal dysmotility. Two patients underwent silastic stent placement with immediate resolution of symptoms, however they suffered from frequent mucous plugging, stent migration, and granulation tissue formation requiring repeat bronchoscopic treatment and stent replacement. Conclusions: Mediastinal repositioning with tissue expander placement provides durable relief of symptoms. Endobronchial stenting is a less invasive treatment option for PPS, however patients require close follow-up due to a high complication rate. Need for frequent bronchoscopy often emergently present serious limitations in this small group.

The postpneumonectomy syndrome: clinical presentation and treatment☆

Postpneumonectomy syndrome (PPS) is a rare complication after pneumonectomy. It consists of an excessive mediastinal shift resulting in compression and stretching of the tracheobronchial tree and the esophagus. The aim of this study was to give a comprehensive overview of diagnosis, variety of symptoms and evaluation of surgical treatment of PPS. We retrospectively reviewed the charts of all our patients with PPS since 1994 with respect to symptomatology, treatment and outcome. Our results were compared with case reports and case series in the literature. Six women with a median age of 56.5 years (range 49-65) developed PPS after pneumonectomy for the treatment of lung cancer. Four presented with a right PPS and two with a left PPS, respectively. Symptoms consisted of shortness of breath in all patients and dysphagia as well as heartburn in two patients. Correction of PPS required re-exploration of the pneumonectomy space, reposition of the mediastinum followed by the insertion of single silicone prosthesis in five patients or fixation of the mediastinum with a xenopericardial graft in one patient. We could observe an improvement of the FEV(1)/FVC ratio in all our patients and the clinical improvement of shortness of breath was better than we expected by changes of lung function. Four patients returned to their regular activities with a follow-up of four years. We found 73 cases of PPS in the literature, on the right side in 50 patients (68%) and on the left side in 23 patients (32%). Fifty-nine patients (81%) were treated surgically. Symptoms can be suspicious for cardiogenic origin and vary from heartburn to recurrent syncopes. PPS is rare and not predictable. It can occur after right or left pneumonectomy. Symptoms are manifold and result from a shift, leading to compression and stretching of the two conduits located within the mediastinum, the tracheobronchial tree and the esophagus and consists of shortness of breath, stridor and heartburn. Diagnosis must be made by exclusion. Implantation of prosthesis is the most commonly used and effective treatment.

Postpneumonectomy syndrome: Surgical management and long-term results

Postpneumonectomy syndrome is a rare syndrome of dynamic airway obstruction caused by extreme rotation and shift of the mediastinum after pneumonectomy, resulting in symptomatic central airway compression. We have treated this syndrome by mediastinal repositioning and placement of saline-filled prostheses into the pneumonectomy space. There is a paucity of outcome data for patients treated surgically, with only a single series of 11 patients previously reported. We analyzed our recent experience with treatment of this syndrome and report on the short and long-term outcomes and quality of life assessment of the largest series ever reported of patients treated by mediastinal repositioning. Records were reviewed of all patients who underwent mediastinal repositioning for postpneumonectomy syndrome between January of 1992 and June of 2006. Long-term health-related quality of life was assessed by administration of the Saint George's Respiratory Questionnaire. There were 18 patients (15 women and 3 men) with a median age of 44 years (range 14-67 years). Thirteen patients had undergone right pneumonectomy, and 5 patients had undergone left pneumonectomy. None of the patients in whom postpneumonectomy syndrome developed after left pneumonectomy had a right-sided aortic arch. Five patients had undergone pneumonectomy in childhood (age < 13 years). The median interval between pneumonectomy and mediastinal repositioning was 7.5 years (range 1.1-54.8 years). The median follow-up was 32 months (range 4-143 months). The operative mortality was 5.6% (1/18). Complications occurred in 5 patients (27.8%): pneumonia in 3 patients and acute respiratory distress syndrome in 2 patients. The median hospitalization was 6 days (range 3-155 days). Some 77% (10/13) of patients reported significant improvement in their breathing and overall state of health after surgery; 15.4% of patients (2/13) were somewhat better, and 7.7% of patients (1/13) had no improvement. No patients' condition was worse after surgery. All patients who reported improvement in their symptoms after surgery remained symptomatically improved at the time of the quality of life assessment. Some 92.3% (12/13) were not at all or only slightly limited in their social activities because of breathing problems, and 84.6% (11/13) were not at all or only slightly limited in their ability to work as a result of their physical health. Repositioning of the mediastinum with placement of prostheses for postpneumonectomy syndrome can be performed with low mortality and morbidity. Surgical repositioning provides immediate and lasting symptomatic relief to patients in whom postpneumonectomy syndrome develops.

Surgical correction of postpneumonectomy-like syndrome in a patient with a tuberculosis-destroyed lung

Postpneumonectomy syndrome is a rare condition that is characterized by dyspnea resulting from an extreme mediastinal shift and bronchial compression of the residual lung after right or left pneumonectomy. 1-3 Severe fibrosis of the lung such as is seen in a lung destroyed by tuberculosis (TB) can cause similar clinical features in the absence of pneumonectomy. 4 We report here a couple of unique cases of postpneumonectomy syndrome without pneumonectomy in which treatment via pneumonectomy and mediastinal repositioning with tissue expanders was successful.

Tuberculous tracheobronchial stricture causing post-pneumonectomy-like syndrome corrected by insertion of a bespoke Dumon stent

Post-pneumonectomy syndrome is a well-recognised but uncommon late complication of pneumonectomy. Usually occurring after right-sided surgery, the mediastinal contents are rotated and displaced into the right hemithorax, producing airways or oesophageal compression. We report a case in which the radiological features and symptoms of post-pneumonectomy syndrome appeared to be precipitated by the development of a complex tuberculous tracheobronchial stenosis that resolved after the insertion of a bespoke Dumon stent.

Use of tissue expanders in adult postpneumonectomy syndrome

Mediastinal shift and rotation after pneumonectomy can lead to severe symptomatic airway compression. Historically, a variety of treatments, such as muscle-flap transposition, pericardial fixation, and plombage, have been used. In this study we retrospectively evaluated the effectiveness of intrathoracic tissue expansion in postpneumonectomy syndrome. Since 1990, our center has used tissue expanders as plombage in patients with postpneumonectomy syndrome. Between 1990 and 2005, a total of 20 patients were treated. The outcome was evaluated by using preoperative, perioperative, and postoperative bronchoscopy and imaging studies. Patient satisfaction was determined with a validated questionnaire. In 19 of the 20 patients, up to 3 tissue expanders were placed and filled within the pleural cavity. Access to the pleural cavity could not be obtained in 1 patient because of adhesions. Perioperative and postoperative bronchoscopic scans demonstrated decompression of the left main bronchus in 16 (84%) of 19 patients. On discharge, all patients reported improvement of their respiratory symptoms. Six (32%) patients required reoperation because of herniation (n = 2), luxation (n = 1), inadequate positioning (n = 2), and leakage of the tissue expander (n = 4). In 4 patients additional filling was performed in the outpatient clinic, with immediate improvement of respiratory distress. Use of tissue expanders in adults with postpneumonectomy syndrome is an effective means of decompressing the remaining bronchus, thereby leading to a significant improvement in respiratory symptoms. Although 32% of patients required reoperation for complications, each complication was readily correctable.

Postpneumonectomy Syndrome: A Spectrum of Clinical Presentations

Postpneumonectomy syndrome has classically been described as a late complication after pneumonectomy where gradually increasing shortness of breath develops secondary to mediastinal shift. We present our experience and a review of the literature demonstrating a variety of clinical scenarios that, when necessary, were successfully managed with mediastinal repositioning.