Minimally Invasive Repair of Post-Pneumonectomy Syndrome

Case Report

The patient was a 42-year-old Hispanic female who underwent a right pneumonectomy six years ago for hemoptysis from an aspergilloma cavity. Three years postoperatively, the patient began to experience shortness of breath, wheezing, dyspnea upon exertion, and dysphagia. She was treated for “adult-onset asthma” without any improvement. Her symptoms continued to worsen and cardiac evaluation showed normal overall heart function. She was then referred for surgical evaluation. Chest X‐ray suggested rotation of the mediastinum into the right pleural cavity ([Fig. 1]) and CT scan confirmed a marked counterclockwise rotation of the heart, trachea, left main stem bronchus, and esophagus into the post-pneumonectomy space with near-complete obstruction of the left lower lobe bronchus between the pulmonary artery and the descending thoracic aorta ([Fig. 2 a]), confirming the diagnosis of post-pneumonectomy syndrome (PPS). Preoperative pulmonary function tests showed an obstructive defect with a forced expiratory volume in 1 second (FEV₁) of 1.52 liters (43 % predicted).

Fig. 1 Preoperative chest X‐ray suggested rotation of the mediastinum into the right pleural cavity.

Fig. 2 a to d Pre- (a) and postoperative (b) computed tomography of the chest, and intraoperative bronchoscopy before (c) and after (d) insertion of the saline implant.

Intraoperative bronchoscopy revealed enlargement of the left main stem bronchus and marked stenosis of the left lower lobe bronchus in the anteroposterior plane without other endoluminal pathology ([Fig. 2 c]). A six centimeter incision was made in the midaxillary line within the previous thoracotomy incision and a segment of the seventh rib was resected. Minimal dissection was carried out within the pleural space to free the pericardium from the lateral chest wall. A tissue expander was inserted and slowly filled with saline to produce mediastinal movement toward the midline. The central venous pressure (CVP) was monitored during the inflation and was terminated when the CVP rose by 10 mmHg. Intraoperative chest X‐ray confirmed centralization of the mediastinum. The tissue expander was removed and replaced by a saline prosthesis (Mentor Siltex Spectrum Style 2400, 475 cc, Mentor Corporation, Santa Barbara, CA, USA) with a subcutaneous port for postoperative volume adjustment as needed. Repeat bronchoscopy revealed patency of all branches of the left bronchial tree ([Fig. 2 d]). Postoperatively, she experienced immediate relief of her symptoms and was discharged home on the third postoperative day without complications. Her postoperative forced expiratory volume in 1 second (FEV₁) increased to 2.25 liters (61 % predicted). Six months after the operation, she remains asymptomatic and in excellent condition.

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