Interactive Cardiovascular and Thoracic Surgery 3:390-392(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Surgical correction of postpneumonectomy syndrome by intrapleural expandable prosthesis in a child
Cemal Ozcelika,*,
Serdar Onata,
Ibrahim Askarb and
Ender Topalc
a Department of Thoracic Surgery, Dicle University School of Medicine, 21280 Diyarbakir, Turkey
b Department of Plastic and Reconstructive Surgery, Dicle University School of Medicine, 21280 Diyarbakir, Turkey
c Diyarbakir State Hospital, Department of Cardiovascular Surgery, 21280 Diyarbakir, Turkey
* Corresponding author. Tel.: +90-412-2488001; fax: +90-412-2488520
cozcelik{at}dicle.edu.tr
Received November 14, 2003;
received in revised form January 28, 2004;
accepted February 4, 2004
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Abstract
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We report a case of postpneumonectomy syndrome in a 10-year-old boy operated on for right-sided destroyed lung 1 year previously. The treatment involved the insertion of saline-filled expandable prosthesis in the postpneumonectomy cavity. A favorable outcome was observed. We think that an intrapleural inflatable prosthesis has several advantages for postpneumonectomy syndrome seen in childhood.
Key Words: Postpneumonectomy syndrome; Childhood; Intra
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1. Introduction
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Pneumonectomy is rarely carried out in children, and is only warranted if the affected lung is completely destroyed and the contralateral lung is either healthy or threatened by the chronic suppuration on the affected side. Postpneumonectomy syndrome is a rare complication of pneumonectomy. Breathing difficulties are essentially due to displacement of the mediastinum, which twists and blocks the left main bronchus. We report the case of a child in whom an expandable prosthesis was inserted into pleural space 1 year after pneumonectomy.
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2. Case report
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A 9-year-old boy was admitted with the complaints of sputum production, cough and dyspnea. Chest roentgenogram showed, multiple cyctic lesions, mediastinal shift to the right side and elevation of right hemidiaphragm (Fig. 1). Computed tomography showed right sided destroyed lung, and herniation of the left lung to the right side anteriorly. He underwent right pneumonectomy in May 1992. Postoperative chest roentgenogram showed complete opacification of right hemithorax, normal mediastinal location of the trachea.
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Fig. 1 Chest roentgenogram shows multiple cyctic lesions, mediastinal shift to the right and elevation of right hemidiaphragm.
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Approximately 1 year later, he complained of exertional dyspnea, an increased cough, and sputum production. Chest roentgenogram demonstrated gross deviation of the mediastinum to the right, with hyperexpansion of the left lung. CT showed rotation of the heart into the right posterior thorax. The left lung was herniating across the midline, virtually filling the entire chest (Fig. 2a,b). Rigid bronchoscopy did fail to enter the left main bronchus because of twisting. Arterial blood gases showed a moderate hypoxemia, and pulmonary function tests showed a severe restrictive pattern (oxygen tension [PaO2], 64 mmHg; carbon dioxide tension [PaCO2], 34 mmHg; forced vital capacity [FVC], 52% of the predicted value according to height; forced expiratory volume in 1 s/forced vital capacity [FEV1/FVC] ratio, 55). After analyzing the shape and capacity of the right hemithorax from computed tomography, a saline-filled expandable prosthesis (450 ml, rectangular type) was ordered.
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Fig. 2 (a) CT of the chest shows rotation of the heart into the right posterior thorax (mediastinal window). (b) The left lung herniates across the midline, virtually filling the entire chest (parenchymal window). (c) Postoperative computed tomographic scans shows that the mediastinal structure was recentered with relief of the left main bronchial twisting.
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In May 2003, right thoracotomy with lysis of pleural adhesions was performed; the prosthesis was inserted into the thoracic space and filled with sterile saline solution to 220 ml. 10 days later, 60 ml of saline solution was added by a 22-gauge needle through the subcutaneous injection port. Postoperative chest radiographs and computed tomographic scans showed that the mediastinal structure was recentered with relief of the left main bronchial twisting (Fig. 2c). Bronchoscopic examination showed a marked reduction in the twisting of the left main bronchus. There was a clear clinical improvement and he was healthy on follow-up.
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3. Comment
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As first described by Adams in 1972 [1], pneumonectomy in infants or children can be complicated by severe mediastinal shift. The postpneumonectomy syndrome appears usually months or years after surgery. The higher occurrence of postpneumonectomy syndrome in children, in comparison with a very low rate in adults [2], is explained by a child mediastinum being more supple and softer, with a higher capacity to shift and twist [3]. Our patient had a mediastinal shift and overexpansion of left lung before pneumonectomy due to destroyed lung. So, we think that he already had a tendency for hyperexpansion of left lung.
Surgical treatment for postpneumonectomy syndrome diminishes the severe mediastinal shift and rotation and corrects the tracheobronchial compression. In current practice, the use of expandable prosthesis is recommended in children. The use of an expandable silicone prosthesis was first described by Rasch and colleagues in a 5-month old child [4]. The value of the inflatable prosthesis is twofold. First, the mediastinum can be recentered progressively, both operatively and later, by successive inflations guided by clinical tolerance, particularly pain due to overinflation. Second, the volume of the prosthesis can be increased over a number of years to compensate for childhood growth [5,6]. As reported by Podevin et al., an expandable prosthesis allows for progressive recentering of the mediastinum and adjustment for growth [3]. We think that yearly follow-up is necessary whether children need additional saline instillation based on the symptoms and the degree of mediastinal shifting. Saline-filled expandable prosthesis are not suspected to cause complications such as ‘immune related or connective tissue disorders’ like silicone gel-filled implants [5]. Our expandable prosthesis is an improved tissue expander used to expand skin and subcutaneous tissue in the plastic surgery field, as used by Tsunezuka in 1998 [6]. The main disadvantage of saline-filled expandable prosthesis is leak [3,5,6]. Infection secondary to the insertion of expandable prosthesis has not been reported in the literature. It may be necessary to improve the intensity of the bag's wall in the future.
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Footnotes
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This paper was presented at the 17th Asia Pacific Congress on Disease of the Chest, Istanbul, Turkey, August 29–September 1, 2003.
doi:10.1016/j.icvts.2004.02.011
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References
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- Adams HD, Junod FL, Aberdeen E, Johnson J. Severe airway obstruction caused by mediastinal displacement after right pneumonectomy in a child. J Thorac Cardiovasc Surg. 1972;63:534–539[Medline]
- Jansen JP, Brutel de la Riviere A, Alting MP, Westermann CJ, Bergstein PG, Duuerkens VA. Postpneumonectomy syndrome in adulthood. Surgical correction using an expandable prosthesis. Chest. 1992;101:1167–1170[Abstract/Free Full Text]
- Podevin G, Larroquet M, Camby C, Audry G, Plattner V, Heloury Y. Postpneumonectomy syndrome in children: Advantages and long-term follow-up of expandable prosthesis. J Pediatr Surg. 2001;36:1425–1427[Medline]
- Rasch DK, Grover FL, Schnapf BM, Clarke E, Pollard TG. Right pneumonectomy syndrome in infancy treated with an expandable prosthesis. Ann Thorac Surg. 1990;50:127–129[Abstract]
- Audry G, Balquet P, Vazquez MP, Dejerine ES, Baculard A, Boulé M, Grimfeld A, Gruner M. Expandable prosthesis in right postpneumonectomy syndrome in childhood and adolescence. Ann Thorac Surg. 1993;56:323–327[Abstract]
- Tsunezuka Y, Sato H, Watanabe S, Tamura M, Tsubota M, Seki M. Improved expandable prosthesis in postpneumonectomy syndrome with deformed thorax. J Thorac Cardiovasc Surg. 1998;116:526–528[Free Full Text]
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Abstract
1. Introduction