INTRODUCTION: Pneumonectomy has been called a “disease unto itself,” and is associated with significant morbidity and mortality. Many complications occur early, but long-term sequelae are also possible. Proper surgical technique remains an important factor in outcomes after pneumonectomy.
CASE PRESENTATION: 68-year-old man underwent a left pneumonectomy 7 years previously, at another institution, for a T2 N0 M0 squamous cell carcinoma. Two years after resection, a chest x-ray demonstrated an air-fluid level in a previously opacified hemithorax. During the past year, he developed a productive cough with a scant amount of blood. Initial treatment with antibiotics prior to referral was unsuccessful in improving his symptoms. He was referred to our institution where a work-up for presumed bronchopleural fistula (BPF) was initiated. Computed tomography scan demonstrated an air-fluid level in the left pleural space and suggested an elongated bronchial stump. Bronchoscopy showed a 4 cm left mainstem bronchial stump without evidence of a frank BPF or tumor recurrence.We performed a left thoracotomy. Air bubbles emanating from the mediastinum on positive pressure ventilation confirmed the diagnosis of BPF and assisted in guiding dissection of the left bronchial stump in the scarred mediastinum. Reresection of the left bronchus was carried back to a level flush with the carina. The new left bronchial stump was covered by a pedicled ipsilateral serratus anterior muscle flap. The chest was initially packed open due to the chronic pleural space infection. It was ultimately closed 2 weeks later using the modified Clagett technique.
DISCUSSIONS: The clinical scenario of cough and air-fluid level in the post-pneumonectomy space heralds the presence of a BPF. Despite the lack of overt bronchoscopic findings, the clinical suspicion was sufficiently high to proceed to thoracotomy for definitive surgical repair. Long bronchial stump syndrome occurs when redundant main-stem bronchus remains after pneumonectomy. Often, this occurs when the pneumonectomy is performed as a series of lobectomies, instead of at the hilum. The stump acts as a reservoir for secretions and a nidus for infection leading to complications including BPF and empyema.
CONCLUSION: Complications following pneumonectomy may occur years later. Meticulous surgical technique along with appropriate postoperative care can reduce the rate of morbidity. Long-bronchial stump syndrome can be prevented by transecting the bronchus flush with the carina.
DISCLOSURE: Jess Thompson, None.