Contralateral pneumothorax after pneumonectomy for carcinoma.

Fortunately, contralateral pneumothorax occurs rarely after pneumonectomy. This complication was detected during the immediate postoperative period in four of 340 patients having pneumonectomy for carcinoma at the Ochsner Clinic from January 1942 through June 1958. To our knowledge delayed pneumothorax has not occurred in any of the remaining patients. This lends support to the impression that in these cases the pneumothorax is not truly spontaneous but is precipitated by some operative or postoperative condition, which may be apparent or may defy clarification even after reoperation or at necropsy. The obvious compromise of pulmonary reserve incident to pneumonectomy renders such patients unusually vulnerable to pulmonary complications. For this reason, almost any complication of pneumonectomy may be a major one. The attending physician is constantly aware of the more common complications, such as pulmonary edema, excessive bronchial secretion, atelectasis, pneumonitis, congestive atelectasis, and tension hemopneumothorax of the operative side, whereas this rarer condition may be completely unsuspected. Pneumothorax has been reported as a complication of surgical procedures involving the neck,”2 chest,” subdiaphragmatic regiont3 and abdomen.’4 It has also complicated induced pneumothorax,’5’2#{176} and pneumoperitoneum.’6 Such an abnormal accumulation of air gains access to the pleural space by one or both of two ways: 1) through a defect in the respiratory tract or 2) through a defect in some structure in proximity to or in fascial plane continuity with the mediastinum and pleural spaces. There seem to be several possible sources and mechanisms of pneumomediastinum and pneumothorax after pneu.monectomy: 1) Development of tension hemopneumothorax on the operated side by rapid accumulation of fluid in the pleural space. This may, at least theoretically, result in “driving” the air into the thoracic wall and mediastinum at sites of pleural disruption. 2) Tension pneumothorax may result from flutter valve type leakage of the sutured bronchial stump. 3) Leakage of the trachea, contralateral bronchus, or pulmonary parenchyma incident to operative injury. 4) Leakage of the contralateral pulmonary parenchyma, either from visceral pleural disruption or from disruption of alveoli within the pulmonary substance with extravasation of air to the surface of the lung, root of the lung, mediastinum, and pleural space. 5) Aspiration of outside air into the anatomic planes of the thoracic wall and mediastinum, either through a defect in the skin or perforation of the esophagus. Because of the rarity of this complication, the four cases encountered at the Ochsner Clinic will be described in detail.