*From the Division of Pulmonary and Critical Care Medicine, New York Presbyterian-Weill Cornell Medical Center, New York, NY.
Correspondence to: Abraham Sanders, MD, FCCP, 520 E 70th St, Starr 505, New York, NY 10021; e-mail: firstname.lastname@example.org
The occurrence of pneumothorax after an invasive transthoracic procedure is a well-known complication. Less well-recognized is the occurrence of bilateral pneumothoraces after a unilateral intervention with a potential for life-threatening consequences in patients who have undergone median sternotomies. We present a patient who had undergone a thymoma resection in the remote past and developed bilateral pneumothoraces after undergoing transthoracic needle biopsy of a right lung nodule.
and shifting pneumothorax3
are recognized complications of transthoracic procedures in patients who have undergone heart or heart-lung transplant surgery. The prevalence of pleuro-pleural communication after patients undergo a median sternotomy for other thoracic surgeries is unknown. In our review, we found only three reports2,4–5
of bilateral pneumothoraces following a single intervention in patients who were not prior heart or heart-lung transplant recipients. We present the case of a patient in whom a pleuro-pleural communication was established during resection of a thymoma by median sternotomy, who developed bilateral pneumothoraces after undergoing transthoracic needle biopsy of a right lung nodule.
A 55-year-old man with a medical history of bronchial asthma, myasthenia gravis, and thymoma resection by median sternotomy 8 months previously underwent a fine-needle aspiration biopsy of a right lung nodule. The aspiration was performed with a 22-gauge, 5.5-inch Wescott needle under CT guidance with the patient in the supine position. The follow-up chest radiograph was reported as a small right apical pneumothorax (Fig 1
). The patient was asymptomatic. Room air oxygen saturation was 95 to 97%. Breath sounds were slightly diminished on the right side. A chest radiograph obtained 3 h later showed no further expansion of the pneumothorax. The patient was discharged from the hospital with instructions to repeat a chest radiograph the next day, which showed bilateral pneumothoraces (Fig 2
). An 11F intrapleural catheter was inserted into the second right interspace, midclavicular line, and 3 L air was aspirated. A follow-up chest radiograph showed the complete reexpansion of both lungs (Fig 3
). There was no further accumulation of air, and the catheter was removed after 48 h. A careful review of the first radiograph showed that there had been bilateral pneumothoraces initially (Fig 1)
In humans, the right and the left pleural spaces are completely separated without evidence of preformed anatomic communications.2
A median sternotomy and mediastinal surgery place both pleural cavities at risk for entry. The subsequent fusion of bilateral pleural rents may form a pleuro-pleural communication, resulting in a single pleural cavity. Schorlemmer et al4
have referred to this condition to as “iatrogenic buffalo chest” because the North American buffalo is one of the few mammals that has communicating pleural spaces. The North American Indian hunters used this anatomy to their advantage, as a single chest wound in the buffalo resulted in rapid death from a sudden tension pneumothorax.4
Persistent pleural connections after heart and heart-lung transplantation have been observed in 33 to 40% of the patients, manifesting as bilateral pneumothoraces in one series1
and shifting pneumothoraces in another.3
The anterior pleural reflections are severed during the course of heart-lung transplant surgery, leading to permanent interpleural communications in these patients.6
Other major thoracic surgeries requiring extensive dissection in the vicinity of the anterior junctional line may cause the disruption of bilateral pleural surfaces and a residual communicating pleural space. Most pleural rents probably heal, thus closing the channel, because, given the enormous numbers of such surgeries that are performed, this complication is rarely seen. In most reports, interpleural connection has been demonstrated by the development of an intercurrent pleural effusion or pneumothorax anywhere between 2 weeks to 2 years after transplant surgery.1,3
In our review, we encountered only three reports of iatrogenic buffalo chest in patients who had undergone nontransplant thoracic surgery. The first report was of a child who had undergone multiple cardiac surgeries for congenital heart disease in whom large bilateral effusions were evacuated simultaneously after unilateral thoracentesis.2
Another patient had undergone coronary artery bypass graft surgery and had developed bilateral pneumothoraces after attempts to catheterize a subclavian vein.4–
The third patient had undergone transthoracic esophageal resection and had developed pneumomediastinum, pneumoperitoneum, and bilateral pneumothoraces after undergoing a percutaneous needle biopsy of a lung nodule.5
The occurrence of iatrogenic bilateral pneumothoraces as a consequence of thymoma resection has never been reported before.
Theoretically, any patient who has undergone a median sternotomy, cardiac surgery, or anterior mediastinal surgery is at risk for having a persistent pleuro-pleural channel. The vast magnitude of patients undergoing median sternotomies who also receive some form of invasive thoracic intervention that places them at risk for pneumothorax underscores the fact that although the occurrence of a persistent pleuro-pleural channel is rare, the implications of having a single pleural space may be life-threatening. The potential for bilateral pneumothoraces should be considered for all patients who have undergone a median sternotomy and should be specifically looked for in follow-up radiologic studies, regardless of the side of thoracic intervention. If it is identified intraoperatively, one or both pleural rents should be repaired to prevent the formation of a persistent postoperative communication. Unilateral drainage usually suffices in most patients; however, close radiologic follow-up is essential to ensure adequate lung expansion.7
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