Archived case 175 · February 13-February 20, 2015
You are presented with a series of post-operative chest radiographs on a 62 yr old man following a right pneumonectomy
Describe the radiographic findings. Is this the expected post-operative course? If not, what is your leading diagnosis?
Serial post-operative chest exams of a 62-year-old man following a right pneumonectomy. Post-operative day-21 (Fig. 1) chest x-ray shows 80% opacification of the pneumonectomy space and expected ipsilateral mediastinal shift. Post-operative day-25 (Fig. 2) and post-operative day-29 (Fig. 3) chest radiographs show a marked drop in the air-fluid level and bubbles of air layering below it. The mediastinum is now midline. Chest radiograph on post-operative day-33 (Fig. 4) shows a further drop in the air-fluid level. Surgical re-exploration revealed a bronchopleural fistula and bronchial stump dehiscence. Answer Diagnosis: Bronchopleural fistula and bronchial stump dehiscence
Bronchopleural fistula and bronchial stump dehiscence
Differential Diagnosis:
None
Discussion
Bronchopleural fistula is a potentially life-threatening complication with an incidence of 0-9% and associated mortality of 16-23%. Bronchopleural fistula occurs more commonly following right pneumonectomy. Predisposing factors include: active pre-operative lung or pleural infection, trauma, pre-operative radiation therapy, faulty closure of bronchial stump, and post-operative mechanical ventilation.
Imaging Features:
· Failure of post-pneumonectomy space to fill with fluid
· Persistent or progressive ipsilateral pneumothorax
· ≥2.0 cm drop in the air-fluid level (decrease < 1.5 cm can be ignored unless associated with contralateral mediastinal shift).
· Persistent or progressive pneumomediastinum or subcutaneous air; sudden onset of pneumothorax or reappearance or air in a previously opaque pneumonectomy space.
· New foci of consolidation in contralateral lung (i.e., transbronchial contamination)
Selected Readings
1. Chae EJ, Seo JB, Kim SY, et al. Radiographic and CT Findings of Thoracic Complications after Pneumonectomy. RadioGraphics 2006; 26: 1449-1467.
2. Kim EA, Lee KS, Shim YM, et al. Radiographic and CT findings in Complications Following Pulmonary Resection. RadioGraphics 2002; 22:67–86.
3. Parker MS, Rosado-de-Christenson ML, Abbott GF. Post-Thoractomy Complications. In: Chest Imaging Case Atlas 2nd edition, 2012 Thieme, New York, pp. 898-903.
4. Tsukada G, Stark P. Postpneumonectomy Complications. AJR Am J Roentgenol 1997; 169:1363–1370.
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.