Post pneumonectomy syndrome: a narrative review of current management strategies

Post pneumonectomy syndrome (PPS) is a rare but potentially life-threatening complication following pneumonectomy. Progressive mediastinal shift into the post-resection space results in distortion and compression of mediastinal structures, including the tracheobronchial tree, esophagus, and vasculature. Patients often present with dyspnea and recurrent pulmonary infections, with imaging with computed tomography (CT) scan classically showing compression of the distal trachea or remaining bronchus. Diagnosis is confirmed with bronchoscopy demonstrating dynamic airway obstruction with extrinsic compression and airway displacement. While surgical mediastinal repositioning remains the standard of care, multiple operative and minimally invasive strategies exist, and long-term outcomes are poorly reported with relatively high complication and reoperation rates. This review evaluates the current management strategies, compares surgical and endoscopic approaches, and highlights emerging techniques in PPS treatment.

A narrative review was performed of existing literature on PPS diagnosis and management options, including stenting and surgical interventions. A PubMed search was performed of the key terms: "post pneumonectomy syndrome", "post-pneumonectomy syndrome", "postpneumonectomy syndrome", "management of post-pneumonectomy syndrome", "implant-based treatment of post pneumonectomy syndrome", "endobronchial stenting for postpneumonectomy syndrome", and "classic post pneumonectomy syndrome presentation". Novel approaches, reviews that reported long-term results, and those with comparative analysis of current treatment options were prioritized in the literature evaluation.

For those patients who are surgical candidates, the most common treatment involves mediastinal repositioning with fixed-volume or tissue expander prostheses. For patients who are not surgical candidates, airway stenting is required to palliate symptoms. Overall, mediastinal repositioning with prosthetic implantation is the current standard of care and provides reasonable short-term and long-term resolution of PPS, though a personalized approach to surgical management remains paramount.

Though rare, PPS is a potentially life-threatening complication of pneumonectomy. Identification and diagnosis may be difficult due to the dynamic nature of mediastinal shifting and wide range of symptomatology. Surgical intervention remains the best definitive management to correct mediastinal shifting, though endobronchial stenting may be indicated in some cases. Surgical management should be reviewed on a case-by-case basis with a multi-disciplinary evaluation, usually in conjunction with plastic surgery.