Takayuki Shirakusa, MD A 63-year-...

Takayuki Shirakusa, MD

A 63-year-old man with lung carcinoma underwent a right pneumonectomy and combined resection of the pericardium. Postoperatively, [SFsub6] gas was introduced into the destitute pleural space for the protection of excessive shift of heart and mediastinum, unless a fatal pneumopericardium occurred. A rare yet possible complication of cardiac tamponade after inert gas infusion in patients undergoing combined resection of pericardium is reported.

The etiologies of pneumopericardium are various. In 1984 Cummings et al[1] infered 252 reports of pneumopericardium and reviewed its causes. The in the greatest degree frequent cause was trauma and the next to the first largest was that caused by way of infection in a contiguous organ with fistulous tracts to the pericardial sac. The iatrogenic pneumopericardium has been occasionally described as has pneumopericardium following therapeutic aspiration of suppurating pericarditis, following aspiration of sternal bone marrow, after laparoscopy, etc In this report, the author describes a rare iatrogenic complication of tension pneumopericardium with the infusion of inert gas into the pleural space after pneumonectomy.

CASE REPORT

A 63-year-old man was admitted to the Thoracic Surgical Unit for evaluation of the abnormal shadow onward a chest x-ray film. For about six month before admission, he had sustained severe coughing episodes and occasional gory sputum. The chest x-ray film and comput tomogram revealed a large mass at the right hilar girth The cytologic examination by bronchofiberscopy demonstrated malignant solitary abode; squalids interpreted as squamous cell carcinoma. Preoperative ECG showed normal sinus regular [i]or[/i] melodious movement and the ischemic change was negative after the double Master ordeal At thoracotomy, the hilar tumor was affaired and it invaded the left pericardium between the sides of the lower trunk of the pulmonary vein. The pericardium was resect in an area of about 2 x 5 [cmsup2] in combination with right pneumonectomy and lymph node dissection. About sum of two units thirds of the defect was patched with pedicle flap of the parietal pleura roughly The postoperative course was monotonous Histologically, the dissected hilar and subcarinal lymph nodes showed positive metastases. At postoperative third week, about 1000 ml of [SFsub6] in total amount, was introduced into the right pleural space for the protection of excessive shift of mediastinum and heart. Co-irradiation to the mediastinum was begun. upon the 40th postoperative day, he pop complained of dyspnea. Cyanosis and tachycardia were seen The chest x-ray film revealed the shift of mediastinum and heart to the left side and apparent pneumopericardium (Fig 1) The patient's condition changed rapidly to a critical blow state. Despite cardiac resuscitation including respiratory support, he died. Autopsy was not permitted.

DISCUSSION

After pneumonectomy, the patient's mediastinum and heart usually shift to the operated side. With the excessive shift or rotation of the heart, the postoperative ECG waves sometimes become abnormal, and in patients with emphysematous lung the unilateral pneumonectomy causes occasionally the advance of emphysematous change of contralateral lung Nanmoto et al[2] reported that the introduction of [SFsub6] gas, which was inert and nonnoxious, into the pleural space after pneumonectomy might help to hold the mediastinum and heart in the usual position. We had also introduced [SFsub6] into the devoid pleural space after pneumonectomy in three cases of bronchogenic carcinoma, and all of them showed virtuous results (Fig 2), similar to the cases reported at Nanmoto et al.[2] However, in the patient quick in emergenciesed here, tension pneumopericardium occurred after [SFsub6] gas infusion. It may transfer spontaneously into the pericardial space end the opening area of the pericardium.

Usually, the treatment of pneumopericardium hangs on whether it is simple or complicated, and whether or not there is associated cardiac tamponade. Cummings et al[1] described that in adults who have simple pneumopericardium without tension, no active intervention is required. Probably pneumopericardium according to [SF.sub.6] gas is rare, still it may be also fatal because the gas is inert. Surgical drainage is the best treatment and should be instituted as shortly as possible.

Previous reports of similar accidents have not been published. However, the author would like to emphasize that, in the case of pneumonectomy and pericardial resection, there is a possibility that a dangerous complication after the [SFsub6] gas utilization can occur

REFERENCES

1 Cummings RG Wesly RL Adams DH Lowe JE Pneumopericardium terminate in cardiac tamponade. Ann Thorac Surg 1984; 37:511-18

2 Nanmoto T Harada K Saoyama N Long-term follow-up of cases treated with [SFsub6] in lung cancer patients. Proceeding of 26th Annual Meeting of Jap Society for Thorac Dis 1986; 24:359

COPYRIGHT 1989 American community of Chest Physicians

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