Kim, Hojoong

Kim, Hong Kwan

Kim, Jhingook

Lee, Seunghoon

Lee, Yongjik

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Brief CommunicationsSurgical correction of postpneumonectomy-like syndrome in a patient
with a tuberculosis-destroyed lung
Yongjik Lee, MD,a Hong Kwan Kim, MD,b Seunghoon Lee, MD,b Hojoong Kim, MD,b and Jhingook Kim, MD,b Seoul, KoreaP
ostpneumonectomy syndrome is a rare condition that is
characterized by dyspnea resulting from an extreme medi-
astinal shift and bronchial compression of the residual lung
after right or left pneumonectomy.1-3 Severe fibrosis of the
lung such as is seen in a lung destroyed by tuberculosis (TB) can
cause similar clinical features in the absence of pneumonectomy.4
We report here a couple of unique cases of postpneumonectomy
syndrome without pneumonectomy in which treatment via pneumo-
nectomy and mediastinal repositioning with tissue expanders was
successful.
Clinical Summaries
PATIENT 1. A 47-year-old woman had had severe progressive
dyspnea for 6 months. She had had pulmonary TB 20 years earlier,
which was completely cured by administration of anti-TB drugs. On
physical examination, breath sounds were decreased in the left lung
field. A simple chest radiograph and computed tomogram (Figure 1,
A) revealed that the left lung was almost completely destroyed and
the right main bronchus was compressed by the right main pulmo-
nary artery and the vertebral body.
The operation was performed via a left posterolateral thoracot-
omy. The severe pleural adhesion was dissected, and then left pneu-
monectomy was performed followed by insertion of two types of
tissue expanders into the pleural cavity. One expander was ellipsoid
(350 mL) and the other was crescent shaped (250 mL). After inser-
tion of the tissue expanders, normal saline that included antibiotics
From the Department of Thoracic and Cardiovascular Surgery, Asan Med-
ical Center, University of Ulsan College of Medicine,a and the Department
of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sung-
kyunkwan University School of Medicine,b Seoul, Korea.
Received for publication Sept 13, 2007; revisions received Nov 19, 2007;
accepted for publication Dec 27, 2007.
Address for reprints: Jhingook Kim, MD, Department of Thoracic and Car-
diovascular Surgery, Samsung Medical Center, 50 Ilwon-Dong, Kangnam-
Ku, Seoul, 135-710, Korea (E-mail: jkim@smc.samsung.co.kr).
J Thorac Cardiovasc Surg 2008;136:780-1
0022-5223/$34.00
Copyright  2008 by The American Association for Thoracic Surgery
doi:10.1016/j.jtcvs.2007.12.035780 The Journal of Thoracic and Cardiovascular Surgery c Sepwas injected into the tissue expanders, and the thoracotomy wound
was closed.
Postoperatively, she recovered without any problem. A plain
chest radiograph showed that the mediastinum had returned to a nor-
mal position (Figure 1, B). In addition, the expiratory wheezing and
dyspnea disappeared.
The patient was discharged from the hospital on the 13th postop-
erative day. At present, 4 years after the operation, she is being ob-
served at the outpatient department and is without dyspnea.
PATIENT 2. A 50-year-old woman had had severe progressive
exertional dyspnea for the previous 6 months. She had had pulmo-
nary TB 30 years earlier, which was completely cured by anti-TB
medication. Six months before her current admission, the right
lung totally collapsed and she had paroxysmal severe exertional
dyspnea, which led her to visit our hospital’s emergency room.
On physical examination, there was no audible breath sound in
the right side of the chest. Chest computed tomography revealed a to-
tally collapsed right lung, extreme deviation of the mediastinal
structure, and a narrowed left main bronchus, which was com-
pressed between the left main pulmonary artery and the descending
aorta (Figure 2, A). We performed a right pneumonectomy via a pos-
terolateral thoracotomy. There was no pleural adhesion. Two types
of tissue expanders were inserted, with 320 mL of normal saline be-
ing infused into the ellipsoid one and 450 mL into the crescent-
shaped one.
Postoperatively, the mediastinum returned to the normal position
(Figure 2, B). The patient was discharged on the seventh postoper-
ative day. Five months after the operation, she remains free of expi-
ratory stridor and dyspnea on exertion.
Discussion
Postpneumonectomy syndrome is a rare complication that is charac-
terized by tracheal stenosis and severe dyspnea; these symptoms are
caused by mediastinal shifting after pneumonectomy. In the cases
we presented, the right or left main bronchus was compressed be-
tween the main pulmonary artery and vertebra/aorta not by surgical
pneumonectomy, but by auto-pneumonectomy that was due to TB.
These 2 cases show that surgical pneumonectomy is not a prerequi-
site for postpneumonectomy syndrome because this malady occurs
as a result of stenosis of the bronchus after vigorous movement and
rotation of the mediastinum.tember 2008
Brief CommunicationsFigure 1. A, Preoperative chest com-
puted tomogram shows narrowing of
the right main bronchus compressed
between the right main pulmonary ar-
tery and thoracic vertebral body. B,
Postoperative chest radiograph shows
the mediastinum in its normal position.Figure 2. A, Preoperative chest computed tomo-
gram shows narrowing of the left main bronchus
compressed between the left main pulmonary ar-
tery and descending aorta. B, Postoperative chest
radiograph shows the mediastinum in its normal
position.The diagnostic approach for our cases was the same as that for
postpneumonectomy syndrome. On a plain chest radiograph, the
mediastinum and bronchi are shifted posterolaterally and the oppo-
site lung is herniated toward the lesion. Computed tomography of
the chest can reveal that the heart and the great vessels are rotated
toward the lesion and the bronchi are compressed by the vertebra
and the great vessels.
Many methods have been tried to treat this syndrome. The most
favorable method is insertion of tissue expanders in the hemithorax
to shift the mediastinum to the midline and alleviate the obstruction
of the trachea. Pneumonectomy must precede repositioning of the
mediastinum by insertion of one or more tissue expanders in the
case of a TB-destroyed lung without surgical pneumonectomy.
In conclusion, postpneumonectomy syndrome must be consid-
ered in the differential diagnosis when patients exhibiting dyspnea
have a TB-destroyed lung or a reduced lung volume that is caused
by severe pulmonary fibrosis. Once this syndrome is diagnosed, me-The Journal of Thodiastinal repositioning by insertion of one or more tissue expanders
can be expected to lead to successful treatment.
References
1. Grillo HC, Shepard JAO,Mathisen DJ, KanarekDJ. Postpneumonectomy
syndrome: diagnosis, management, and result. Ann Thorac Surg. 1992;
54:638-51.
2. Shamji FM, Deslauriers J, Daniel JM, Matzinger FR, Mehran RJ,
Todd TRJ. Postpneumonectomy syndrome with an ipsilateral aor-
tic arch after left pneumonectomy. Ann Thorac Surg. 1996;62:
1627-31.
3. Valji AM, Maziak DE, Shamji FM, Matzinger F. Postpneumonectomy
syndrome: recognition and management. Chest. 1998;114:1766-9.
4. Veronesi G, Spaggiari L, Solli PG, Leo F, Villa G, Pastorino U. Postpneu-
monectomy-like syndrome after chemoradiation therapy for lymphoma.
Ann Oncol. 2002;13:1945-7.racic and Cardiovascular Surgery c Volume 136, Number 3 781


Surgical correction of postpneumonectomy-like syndrome in a patient with a tuberculosis-destroyed lung 

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Surgical correction of postpneumonectomy-like syndrome in a patient with a tuberculosis-destroyed lung

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