The Pneumonectomized Hemithorax

Bronchopleural Fistula

 

• First 24 hours, postpneumonectomy side contains only air
  • Slight shift of the mediastinum toward the pneumonectomized side
  • Slight elevation of ipsilateral hemidiaphragm
     
• Postpneumonectomy space fills with serosanguineous fluid at rate of 2 rib spaces/day
  • By end of 2 weeks, 80-90% of space obliterated
  • By 4 months, complete obliteration
    
    
• Mediastinum gradually shifts more toward side of pneumonectomy
  • Maximum shift at 6-8 months
    
    
• Failure of this ipsilateral shift almost always indicates an abnormality in the postpneumonectomy space, including:
  • BP fistula
  • Empyema
  • Hemorrhage
  • Chylothorax
• Pneumonectomized side fills more rapidly on the left than the right and more rapidly when the pneumonectomy is extrapleural (i.e. includes the parietal pleura)
• Most sensitive indicator of late complications is the return to midline of a previously shifted mediastinum
  • Causes
    • Recurrent neoplasm
    • BP fistula
    • Hemorrhage
    • Chylothorax
    • Empyema
• Rare complications
  • Herniation of the heart through a pericardial defect after radical pneumonectomy with a partial pericardiectomy
  • Post-pneumonectomy syndrome
    • More on right side
    • More in children and adolescents
    • Produces marked rightward and posterior displacement of the mediastinum
    • This, in turn, produces clockwise rotation of the heart and great vessels
      • Trachea and left main bronchus are compressed between the aorta and pulmonary artery
        • Leads to dyspnea and recurrent left-sided pneumonia
    • Displacement of the overinflated left lung into the anterior right hemithorax

 

·       Broncho-pleural fistula

o       Incidence 2%

o       Mortality 30-70%

o       Causes:

§         Necrosis of bronchial stump

§         Dehiscence of suture line

o       More common on the right

o       Increased risk in association with

§         Residual carcinoma

§         Preoperative radiation

§         Diabetes

o       Clinical

§         Sudden onset of dyspnea

§         Expectoration of bloody fluid

o       Imaging findings

§         Return to midline of a previously shifted mediastinum

§         A drop in the fluid level by more than 2 cm is abnormal

 

 

Top image demonstrates an air-fluid level normal for the 5th post-operative day;
the lower image taken two weeks later shows a drop in the
height of the fluid level highly suggestive of a bronchopleural fistula

 

§         Thin-section CT may demonstrate the BP fistula

 

Fraser and Pare