We present a challenging case of a patient with postpneumonectomy syndrome in the setting of previous BPF following pneumonectomy for aspergilloma, which was successfully corrected with adhesiolysis and placement of implants. Reflecting on our experience with this case, there are two main problems, unique to the presentation of postpneumonectomy syndrome following BPF.
First, we had concern of a subclinical infection as a result of previous empyema. Even though the previous pneumonectomy pleural space had essentially obliterated, we found a small serous collection and fibrinous rind at time of operative exploration. Our approach was to check intraoperative gram stain to rule out residual colonization prior to introducing a foreign body. In the absence of organisms detected by intraoperative gram stain, we were assured to place the implants. The use of saline implants had been previously described for modified-thoracoplasty following aspergillosis-related lung resection [
7]. Prophylactic antibiotics were continued for 24 h postoperatively, and negative cultures were confirmed. In the event of positive intra-operative gram stain, it would have been ill advised to introduce a foreign body at that time. The second concern was the ability to correct the mediastinal shift in a patient with previous bronchopleural fistula. A literature review of patients with postpneumonectomy syndrome showed a high success rate with use of saline implants. Of 55 patients treated with saline implants, 41 (75%) achieved symptom free outcomes over a median follow-up time of 2 years [
5]. However, to our knowledge, correction of postpneumonectomy syndrome after BPF has not been previously described. As a result of the BPF, this patient had an excessive amount adhesions and scar tissue, as well bulky viable muscle flaps in the upper pleural space, which had closed the BPF. Previous case reports of postpneumonectomy syndrome describe the need for complete adhesiolysis of the mediastinum. To ensure optimal medialization of the mediastinum, it is typically recommended to divide scar tissue around the right bronchus and pneumonectomy stump [
3]. For this patient, only the mid and inferior mediastinum was mobilized from the chest wall due to concern for disturbing the integrity of the existing muscle flap coverage over the healed BPF. The limited dissection allowed a relatively low volume of saline prosthesis to be implanted. Our patient received 350 mL of implants, whereas previous literature has calculated the median volume of saline between 805 and 945 mL [
3,
5]. However, despite the partial mobilization of the mediastinum and limited volume of saline, the implants caused enough mediastinal correction to completely alleviate the patient’s symptoms.
In summary, postpneumonectomy syndrome may present in patients following bronchopleural fistula, and may be successfully treated with adhesiolysis and placement of saline implants. In this context, precautions should be taken to rule out subclinical infection or persistent empyema to ensure saline implant longevity and prevent postoperative complications. Sufficient medialization may be accomplished without extensive pneumonectomy stump dissection to achieve symptom resolution.