Postoperative Pneumothorax: Diagnosis Gastrothorax

6 May
2011

The postoperative differential diagnoses for lung radiolucencies include pneumatoceles, bronchopleu­ral fistulas, pneumothorax, and elevation of hemidia- phragms with superimposition of abdominal contents. Lung torsion can occur but usually presents as opaci­fication due to infarction and atelectasis.

Pneumatoceles are thin-walled cystic structures that develop secondarily to pneumonia. Though they are unusual in adults, they have been reported and can produce cardiopulmonary dysfunction by collapse of adjacent lung or pneumothorax.

Bronchopleural fistulas are feared complications following resection for carcinoma, with an incidence between 2.5 to 9 percent. The occurrence is believed related to the method of stump closure, vascular supply, postoperative radiation, recurrence of carci­noma or infection along the suture line. Presentation is most commonly after the fourth postoperative week, though it can occur earlier. Mortality is high, ranging from 17 to 50 percent. The incidence is slightly greater in smokers.

FIGURE 2

Postoperative pneumothorax can occur after baro­trauma from mechanical ventilation, spontaneously due to ruptured blebs, as a consequence of invasive catheter insertion, or due to breakdown of the bron­chial stump. Symptomatically, they can be clinically silent or cause acute cardiac and pulmonary decom­pensation.
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Paralysis of the hemidiaphragin can occur posttho- racic surgery. In this case, elevation of the gastric fundus under the left diaphragm produced the ap­pearance of a loculated pneumothorax (Fig 2). A barium swallow was the definitive study to demon­strate displacement of the gastric fundus above the right hemidiaphragm. A chest tube would not have been therapeutic and may have been disastrous.

FIGURE 3

Our patient had a repeat bronchoscopy because of persistent atelectasis. After remov al of several mucus plugs, he continued to convalesce without difficulty, though his chest x-ray film remains unchanged. With the loss of lung volume from lower lobectomy, dia­phragmatic elevation will persist indefinitely. He has recovered and remains asymptomatic 24 months post­operatively.

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