Successful Use of Mediastinal Repositioning Employing PTFE Sheet for Right-Sided Post-Pneumonectomy Syndrome

Abstract

IntroductionPost-pneumonectomy syndrome (PPS), a rare, late complication of pneumonectomy, is characterized by shift and rotation of the mediastinum to the pneumonectomy side, which leads to stretching and compression of the remaining bronchus. In the past, diverse treatments were employed. We herein present the useful technique of mediastinal repositioning using a PTFE (polytetrafluoroethylene) sheet for right-sided PPS. Case ReportThe patient was a 53-year-old female who underwent a right pneumonectomy through a thoracotomy for locally advanced squamous cell lung cancer at 51 years of age. The post-operative classification was pT2N2M0 (stage IIIA). Post-operative recovery was uneventful. However, mild dyspnea and stridor developed approximately 1 year after surgery, and her symptoms progressed. A chest roentgenogram demonstrated a right-sided mediastinal shift with signs of emphysema of the left lung (Fig. 1a) compared with the X-ray taken 1 year previously. A computed tomography (CT) scan showed the right-sided mediastinal shift (Fig. 2a). A stretched left main bronchus was markedly compressed between the descending aorta and left pulmonary artery. Under local anesthesia, a 20-mm incision in the seventh intercostal space at the right middle axillary line was made and a chest tube with a balloon Post-pneumonectomy syndrome (PPS) is a rare late complication of pneumonectomy, and diverse treatments have been employed. We herein present a useful technique for right-sided PPS. The patient was a 53-year-old female who underwent a right pneumonectomy for locally advanced squamous cell lung cancer (pT2N2M0). Mild dyspnea and stridor developed and progressed 1 year after surgery. A chest roentgenogram and computed tomography (CT) scan showed a right-sided mediastinal shift. Under local anesthesia, a chest tube with a balloon was inserted into the right thoracic cavity, and the balloon was inflated with air. Dyspnea and stridor improved and disappeared as the balloon expanded. Then, mediastinal fixation was performed under general anesthesia. Mediastinal fixation involved a PTFE (polytetrafluoroethylene) sheet which was sewn on the sternum and costal cartilage anteriorly, on the vertebra posteriorly, and covered the azygos vein level superiorly and two thirds of the pericardium inferiorly using nonabsorbable sutures. A post-operative chest roentgenogram and CT scan showed improvement of the right-sided mediastinal shift. The post-operative course was uneventful, and dyspnea and stridor were improved and became stable. In conclusion, the presented method is a useful procedure for right-sided PPS.

Post-pneumonectomy syndrome: a systematic review of the current evidence and treatment options

“…of patients) Revision (Y/N) (no. of patients) OCEBM score Chujo et al [ 15 ] 1 Mediastinal fixation with PTFE sheet 2 y Good 6 mo Died—cancer recurrence N 4 Soll et al [ 42 ] 1 Mediastinal fixation with a xenopericardial graft (1) Median: 30 mo Range: 10 mo–8 y Good 4 y Graft infection Y: removal of pericardial patch 4 Wasserman et al [ 31 ] 1 Thoracotomy and release of adhesions (no prosthesis) 1 y Poor 6 mo Good Y: repositioning with prostheses (990mls) sutured to chest wall 4 Grillo et al [ 37 ] 4 Aortic division and bypass to relieve bronchial compression (1) Reposition (no prosthesis) (3) Range: 5 mo–17 y Died—pneumonia, bronchomalacia (1) Reposition without prosthesis failed (3) Range: 1 mo–6 y Died—respiratory failure (1) Good (2) Y: re-operations required (3) 4 Jansen et al [ 21 ] 1 Chemical blockage of phrenic nerve 6 mo Poor 20 mo Good following re-positioning with tissue expander Y 4 Karasaki et al [ 32 ] 1 <...…”

“…Other reported corrective procedures of PPS included mediastinal graft fixation (n = 2), repositioning the mediastinum (without prostheses) (n = 4), chemical blockage of the phrenic nerve (n = 1), intra-pleural injection of sulphur hexafluoride (SF 6 ) (n = 1) and resection of a portion of the adjacent thoracic vertebra (n = 1) (Table 6 ). The use of bioprosthetic patches and synthetic meshes to maintain the mediastinal position have shown varying results and insufficient follow-up [ 15 , 42 ]. Uyama et al described the echocardiography-guided injection of SF 6 into the pleural space in a high-risk surgical candidate with satisfactory symptomatic improvement [ 16 ].…”

“…The use of a xenopericardial graft described by Soll et al required removal 5 months later due to infection [ 42 ]. Chujo et al used a PTFE mesh to re-position the mediastinum through a right mini-thoracotomy with uncertain long-term effects as the patient died of cancer recurrence 6 months later [ 15 ].…”