persistent pneumothorax with persistent air leak post VATS pleurodesis
| Discussion in 'All Categories' started by Dr Manoj Sangoi (M.D. paed. ) - Apr 21st, 2013 5:20 am. | |
Dr Manoj Sangoi (M.D. paed. )
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I am a 53 yrs old practicing pediatrician, non smoker, non alpha 1 anti trypsin deficient. I had my first episode of primary spontaneous pneumothorax on the left side at the age of around 20 yrs (in 1980). In spite of multiple ICDs (totaling 3), the pneumothorax would either persist or recur soon. This went on for approx 3 months. Just when a thoracotomy was being contemplated, it appeared to resolve and the surgery was postponed. Few years down the line, I again started feeling some heaviness in the left lower chest, off and on, with prolonged symptom free periods in between. Every time when symptomatic, an x ray would show a very small localized air pocket in the lower left side. The adhesions formed by the repeat ICDs would probably hold the lung from collapsing and the general opinion would be that it doesn't merit any intervention. While the left side was silent for quiet sometime, in 2007, my right lung collapsed and would behave similarly as the left had behaved in 1980. Repeat ICDs with trials of medical pleurodesis with tetracycline and bleomycin were attempted, but in vein. (Plain XRC and CT Scan 2008 attached) A VATS Rt bulla stapling with pleurectomy was successfully done in March 2008, with remarkable recovery, with ICD removed after 8 days post surgery. After an asymptomatic period of more than 3 yrs (during which I even took many flights), I started getting mild symptoms again on the left side (since July 2011), this time mainly only a feeling of bubbling in the lower back every-time while bending down, with occasional mild heaviness in the left lower chest. Plain x ray again showed a very limited left lower localized sliver of air. The symptoms persisted continuously for almost 20 months (till today) while leading a very normal active life. A CT Scan done in June 2012 (attached) showed small fissural air pocket with ? some bullae, but a well expanded lung. Intervention was considered but thought unwise in view of the minimal symptoms and very small pneumothorax. The symptoms seemed to increase from feb 2013, with mild cough appearing and heaviness in lt hemithorax with lt shoulder pain becoming more prominent, with very mild exertional dyspnoea. Plain Xray done in March 2013 (attached) showed a much larger collapse of the lower lobe. Surgical intervention was planned and pre op CT was worse (2 Apr 2013 attached). On 3rd of April a VATs adhesiolysis with partial pleurectomy was done, without attempting to search actively for the original leak site, hoping that the pleurodesis would take care of the leak. It was a difficult surgery with very strong stray adhesions holding the lung at places, and the upper lobe badly compressed and adherent posteromedially. Handling of the lung caused fresh leaks. Current situation 17 days after surgery the ICD is still in place draining air, and the lung has refused to expand completely, ( though better than before) inspite of lung exercises and negative suction appliied for 2-3 days 7 days after surgery. All my 3 sibs have had one episode of PSP with one of them requiring unilaeral stapling of bulla and partial pleurectomy. What should be the further course of action? How early one should do redo surgery? How important is it to find the original leak site? How easy to identify the leak? On table? Pre op? Different surgical options |
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re: persistent pneumothorax with persistent air leak post VATS pleurodesis
by Dr J S Chowhan -
Apr 23rd, 2013
8:50 am
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Dr J S Chowhan
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Dear Dr Manoj Sangoi We have discussed your case with Dr. Arun Prasad (FRCS)Senior Thoracoscopic Surgeon. According to him you should wait for three month for spontaneous healing and expansion of lung to occur but if the situation does not come under control you may need thoracotomy. With regard Dr J S Chowhan |