Bilateral Recurrent Spontaneous Pneumothorax as a Late Consequence of Oesophageal Surgery: Case Report

We report a case of a patient with recurrent bilateral spontaneous pneumothorax presumably originating in a left bulla.

A 68 year old male, was admitted to the emergency department with shortness of breath and bilateral chest pain. He had had oesophageal cancer resection 2 years before, with a posterior mediastinal reconstruction using a gastric tube. Afterwards he had to be operated twice for hiatal hernia.

Bilateral chest tubes were inserted, with complete resolution in 72 hours. He was readmitted 20 days later, with a bilateral recurrence. A pneumologist was called upon. The thoracic CT scan revealed large bulla in the left upper lobe. There was no evidence of pneumomediastinum or mediastinal fluid collections. Communication between the two pleura was suspected. After discussion with the surgeon responsible for the previous interventions only the left chest was drained with bilateral lung expansion after suction. A left VATS approach revealed a partially adherent left lung, in its mediastinal face. Inflated bulla could be partially observed firmly glued to the upper mediastinum. A leak could not be demonstrated within the left thorax. Due to the firm adhesions of a presumably nonruptured bula to the phrenic nerve, a decision was made not to dissect it. A pleurectomy was performed. In the 3 days that followed, the fistula persisted and increased, in spite of lung expansion. A left thoracotomy was then performed. The full extent of the anterior mediastinal face of then left lung was dissected by opening the bulla that were partially left on the mediastinal pleura. Resection was made using tristaple endoGIA staplers ®. The posterior mediastinum was manually dissected free up to the presumed gastric tube location. At the end of surgery, no major air leaks were documented. Communication with the right pleura could not be located, not even with the aid of a 30o camera, but a large amount of fluid (1000cc) missing, was recovered after turning the patient. The postoperative period was prolonged ut to the 16th day, by a small but persistent air leak.

Although no visual proof of communication between the two pleural cavities could be found, the control of the right pneumotorax by contralateral drainage, the resolution of the case by left pleurectomy and bulla resection backup this theory. This is an unique case, not previously reported, resolved by a multidisciplinary discussion of all the specialists involved in the treatment.