Benign Emptying of the Postpneumonectomy Space

Massachusetts General Hospital, Boston, Massachusetts, United States
The Annals of thoracic surgery (Impact Factor: 3.85). 09/2011; 92(3):1076-81; discussion 1081-2. DOI: 10.1016/j.athoracsur.2011.04.082
Source: PubMed


A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment.
After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics.
Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%.
To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level.

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    ABSTRACT: Causes of benign emptying of the postpneumonectomy space include small bronchopleural fistulas with spontaneous healing and escape of fluid into the chest wall or diaphragm. We present an additional cause: severe dehydration. As postpneumonectomy empyema usually involves drainage of the pleural space, it is important to be aware of this uncommon cause so as to avoid unnecessary instrumentation and contamination of the postpneumonectomy space. (Ann Thorac Surg 2013;95:1088-9) (C) 2013 by The Society of Thoracic Surgeons
    The Annals of thoracic surgery 03/2013; 95(3):1088-9. DOI:10.1016/j.athoracsur.2012.07.069 · 3.85 Impact Factor
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    ABSTRACT: One of the most morbid postoperative complications after a lobectomy or a pneumonectomy is a bronchopleural fistula (BPF). The diagnosis and identification of BPF may be challenging, often requiring repeat imaging and invasive tests, including bronchoscopy, thoracoscopic exploration, or even open exploration. The purpose of this article is to review the types and presentations of BPF and to describe the role of noninvasive imaging for diagnosis and surgical treatment planning. We focused on multidetector computed tomography and advanced postprocessing applications such as multiplanar reconstructions, virtual bronchoscopy, and volume rendering images, including minimum-intensity and maximum-intensity projections. Both multidetector computed tomography and nuclear scintigraphy are reliable noninvasive imaging modalities that can be used expeditiously in an outpatient setting and may prove to be a more cost-effective strategy to identify the fistula as well as conduct postoperative surveillance. These modalities can be used for accurate and efficient testing for earlier diagnosis and treatment planning, thereby significantly improving patient outcome. Additional advanced postprocessing techniques using already acquired imaging data can provide complementary information that is both visually accessible and anatomically meaningful for the surgeon. Better understanding of the potential uses and benefits of these techniques will eventually improve the diagnostic accuracy, optimize preoperative planning, and facilitate follow-up for patients with BPF with improved patient outcomes.
    The Journal of thoracic and cardiovascular surgery 12/2013; 148(1). DOI:10.1016/j.jtcvs.2013.11.009 · 4.17 Impact Factor
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    ABSTRACT: Background. Benign emptying of the postpneumonectomy space (BEPS) is considered to be a rare complication following pneumonectomy. BEPS is defined as an asymptomatic status even with a decrease in the fluid level in the postpneumonectomy thoracic space on chest X-ray, which cannot be explained by a bronchopleural fistula (BPF) or postpneumonectomy empyema. Case. An abnormal shadow was pointed out in a female in her 60's on a plain chest roentgenogram. Computerized axial tomography (CAT) revealed a nodule measuring 16 mm in maximum dimension in the left upper lobe, as well as swollen hilar nodes suspected to be metastatic. Because the hilar nodes, which were suspected to be metastatic, invaded the pulmonary artery, left upper lobectomy was technically impossible for complete resection. Therefore, a left pneumonectomy was performed, which revealed pathological adenocarcinoma of the lung with pStage IIA. A month later, adjuvant chemotherapy was administered. Following the first cycle of the chemotherapy, a decrease in the fluid level in the left thoracic cavity was noted on chest X-ray. There was no apparent fistula on bronchoscopy, nor an elevated inflammatory response. Thus, we diagnosed this status as having BEPS, and no additional treatment was administered. The patient remains alive, without any evidence of disease for 1.5 years since the surgery. Conclusion. BEPS is a relatively rare complication after pneumonectomy. Although ruling out a BPF and empyema is important, this rare complication should be taken into consideration following pneumonectomy.
    Haigan 01/2014; 54(3):141-145. DOI:10.2482/haigan.54.141
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