SESSION TYPE: Pleural Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Primary spontaneous pneumothoraces are usually due to rupture of apical pleural blebs,small cystic spaces that lie within or immediately under the visceral pleura. Recurrent spontaneous pneumothorax (SP) may present either as a primary pneumothorax in young and otherwise healthy patients or as a secondary pneumothorax because of a complication of an underlying lung disease.
CASE PRESENTATION: 48 year old male presented to emergency department with complaint of multiple episodes of vomiting and upper abdominal pain of 2 days duration.Past medical history comprised of seizure disorder,chronic alcoholism,chronic pancreatitis,hypertension, heroin and marijuana abuse and cigarette smoking.Review of systems revealed mild chest discomfort. He denied shortness of breath,cough or trauma. On examination,patient was tall and thin built. Vitals including pulse oximetry were normal.System examination revealed absent air entry on right side of chest and tenderness in epigastrium.Chest xray revealed large right pneumothorax which was drained with a chest tube( 32 F ) in emergency department. Boerhaave's syndrome was ruled out by imaging studies.CT chest showed bilateral sub pleural blebs and bullae. Repeat CXR showed improvement in pneumothorax with mild re expansion pulmonary edema. Follow up CXR next day showed pneumothorax on left side,however the patient was asymptomatic.Chest tube was put on left side and connected to suction.Right chest tube was successfully removed after few days but the left side had persistent air leak suggesting broncho pleural fistula. VATS was done on the left hemi thorax with removal of blebs and pleurodesis.Subsequently, patient developed pneumothorax on right side again.He underwent VATS with adhenolysis, removal of apical sub pleural blebs,mechanical and talc pleurodesis. Patient was eventually discontinued off the chest tubes and discharged home. Patient was counseled for smoking cessation.
DISCUSSION: This patient had bilateral blebs and bullae likely related to his smoking history(cigarette and marijuana). In cases of primary SP, there is a tendency of bullous lesions of the lung to be bilateral, so SP on one side often recurs on the opposite side as in this patient. Male gender,tall stature,low body weight and failure to stop smoking is associated with an increased risk of recurrence. This patient underwent VATS sequentially on both sides with removal of blebs and pleurodesis.
CONCLUSIONS: Bilateral VATS approach can be done safely in selected patients with bilateral simultaneous and non simultaneous SP. It avoids the need for subsequent procedures.The procedure is usually well tolerated and has excellent long-term results.
1) Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax.Adel K Ayed.CHEST December 2002 vol. 122 no. 6 2234-2237
2) Simultaneous Bilateral Spontaneous Pneumothorax. Sayar A,Turna A, Metin M,Kucukyagci N,Solak O, Gurses A. Acta chir belg 2004,104:572-576
DISCLOSURE: The following authors have nothing to disclose: Neerja Gulati, Rakesh Vadde, Setu Patolia, Frances Schmidt, Muhammad Perwaiz, Dharani Narendra, Joseph Quist, Danilo Enriquez, Saurav Pokharel
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