M

1
MM presentation

• Sanjay Munireddy
• Sinai Hospital
• Feb 6, 2007

2
HP

• Mr. PA - 48 yo male with h/o high grade sarcoma
  of Rt. Leg with metastases to lungs (April,
  2005), s/p Rt. AKA, s/p VATS wedge resection of
  lung lesions (May, 2006)
• Presented with dyspnea to NWH on Jan 5th 2007
  had spontaneous PTX on left side CT inserted and
  sent home with Heimlich valve 2 days later
• Presented few days later (Jan 13th) to Sinai with
  dyspnea and pain - began on that morning

3
HP

• PMH Sarcoma of rt. leg with metastases to both
  lungs Chemotherapy CyberKnife therapy
• PSH Rt. AKA (April, 2005), VATS and wedge
  resection of lung lesions (May, 2006)
• PE T 36.9, HR 118, BP 121/74, RR 20, SpO2 99
  
  
  
  dyspneic
  decreased
  breath sounds on both sides
• CXR - Lt. pneumothorax with the CT

4
Hospital Course

• 2nd CT was placed on the lt. side with resolution
  of PTX
• 1st CT was removed
• Pt. continued to have a moderate sized air leak
• Talc pleurodesis was done per the chest tube,
  however, air leak persisted

5
OPERATIVE PROCEDURE

• Date Jan 26th, 2007
• Indication persistent air leak
• Procedure VATS and partial pleurectomy
• Findings Lung was densely adherent to the chest
  wall a pleural implant was seen and was
  excised lateral pleura was removed

6
POST-OP COURSE

• Overnight and pod 1, pt. was tachycardic in
  130-140 range.
• Workup for tachycardia hypovolemia, pain,
  infection, pneumothorax, bleeding, PE
• Dry vac placed _at_ -- 40 cm H2O suction
• CXR pleural effusion vs pleural thickening
• CT Thorax Loculated large lt. pleural collection

7
POST-OP COURSE

• Pt. continued to be tachycardic
• Hct dropped from 33 (pod 1) to 27 (pod 3)
• Pt was taken back to the OR on 01/29/07
• Underwent thoracotomy and was found to have about
  3 liters of clotted blood which was evacuated and
  decorticated. No obvious source of bleeding
  found.

8
POST-OP COURSE

• Tachycardia resolved.
• Lung re-expanded.
• CT removed.
• Pt. to be discharged home today.

9
COMPLICATION

• Hemorrhage after pleurectomy
• How to avoid it?
• Correct coags
• Good hemostasis intra-op
• Post operatively, recognize early
• Otherwise, may develop into fibrothorax
• Empyema if it becomes secondarily infected

10
PLEURECTOMY

• Most common indications are recurrent PTX and
  pleural effusion
• Removal of parietal pleura either by thoracotomy
  or by VATS
• Common complications hemorrhage, bronchopleural
  fistula, pneumonia, empyema
• Causes apposition of visceral pleura against the
  raw surface

11
Persistent Air Leak

• Most common complication after pulmonary
  resection.
• 2 types of air leak
  
• alveolar-pleural fistula
  
• broncho-pleural fistula
• Alveolar-pleural fistula is the commonest air
  leak
• Incidence varies from 10-301
• Risk factors old age, COPD, steroid use, DM,
  presence of pleural adhesions, upper lobectomy
• Prevention
• 1 Cerfolio, Current Opinion in Pulm. Med 11(4),
  July 2005, 319-323

12
Persistent Air Leak

• Classification of air leak (RDC)
• qualitative (timing during resp. cycle)
• quantitative (size of the leak)
• Management
• Time and patience
• Water seal safe and superior to suction for
  stopping air leaks (except for large ones or with
  a large PTX)1
• Heimlich valve
• Pleurodesis
• Pleurectomy
• Autologous blood patch pleurodesis??

13
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