Computed tomography diagnostics of mediastinal hernias after pneumonectomy

The formation of mediastinal hernias after pneumonectomy may be associated with the development of complications from the remaining lung. The lack of information about the patterns of their development, morphometric characteristics, and dynamics in the postoperative period indicates the urgency of the problem.

The OBJECTIVE was to reveal the topographic and anatomical patterns of the formation of mediastinal hernias after pneumonectomy, to give anatomometric characteristics at various times after the operation.

METHODS AND MATERIALS. Computed tomography of the chest of 53 patients (50 men and 3 women) aged 39 to 75 years before and after pneumonectomy (26 on the left, 27 on the right) were examined. Computed tomography was performed on the 10–12th day, 6 and 12 months after surgery. The transverse size of anterior and posterior mediastinal hernias after left- and right-sided pneumonectomies, their dynamics, and density of lung tissue in the hernial protrusion area were studied. 3D was performed – modeling of the remaining lung. RESULTS. Hernial protrusions were visualized in patients with atelectasis of the lung part before surgery. 10 days after left pneumonectomy, anterior and posterior mediastinal hernias were visualized in 80.8 % of patients. One year after left surgery, anterior hernias were observed in 91.7 % of patients, they increased in size and the average size was (57.3±5.2) mm at the ThV–VI level. Posterior mediastinal hernias 12 months after left pneumonectomy were found in 80.5 % of patients, the average size was (34.9±5.2) mm at the ThVIII level. After right pneumonectomy in the early postoperative period, anterior mediastinal hernias occurred in 70.3 % of patients, a year later-in 88.2 %, the average size was (41.0±7.6) mm at the ThV level. The average transverse sizes of anterior mediastinal hernias 12 months after left and right pneumonectomies did not differ significantly (P=0.950). Posterior mediastinal hernias after right surgery were found in 20.0 % of patients, the largest size was determined at the ThIX level, with an average of (12.7±5.8) mm. After pneumonectomy, bullous changes occured in the lung tissue of mediastinal hernias.

CONCLUSION. Anterior mediastinal hernias are equally common after left and right pneumonectomy, while the size of the hernias did not differ significantly. Posterior mediastinal hernias after left pneumonectomy occurs in 88.2 % of patients, after right pneumonectomy – in 20 % of cases.

1. Amosov N. M. Pneumonectomy and lung resection for tuberculosis. Moscow, 1957:196. (In Russ.).

2. Kievskii F. R. To the doctrine of lung resection. Warsaw, 1905:220.

3. Orel S. G. About the clinic of the long-term period after pneumonectomy // Grekov’s Bulletin of Surgery. 1957;(9):48–54. (In Russ.).

4. Slepuha I. М. Clinical and retgenological characteristics of persons who underwent pulmonectomy in childhood and adolescence 15–25 years after surgery // Grekov’s Bulletin of Surgery. 1977;(11):48–53. (In Russ.).

5. Pougachev A. G., Krasovskii U. S, Adamiya S. N. O pul’monektomii u detej // Grekov’s Bulletin of Surgery. 1973;(5):63. (In Russ.).

6. Wechsler R., Goodman L. Mediastinal position after pneumonectomy // AJR. 1985;(145):1173–1176.

7. Goodman L. Postoperative Chest Radiograph // AJR. 1980;134(4):803–813.

8. Encyclopedic Dictionary of Medical Terms: In 3 Vol. Moscow, Soviet Encyclopedia, 1982. (In Russ.).

9. Evfim’evskij V. P., Korsunskij V. N. K voprosu o funkcional’noj sposobnosti chasti legkogo nahodyashchegosya v mediastinal’noj gryzhe // Grudnaya khirurgiya. 1970;(3):67–70. (In Russ.).

10. Evfimievskii V. P. Effect of mediastinal hernia lung on the function of the external breath of patients after pneumonectoy // Chest Surgery. 1975; (4):60–65. (In Russ.).

11. Biondetti P., Fiore D., Sartori F., Colognato A., Ravasini R., Romani S. Evaluation of the Post-Pneumonectomy Space by Computed Tomography // Journal of Computer Assisted Tomography. 1982;6(2):238–242. Doi: 10.1097/00004728-198204000-00002.

12. Padovani B. et. al. Postoperative chest: normal imaging feature // J. Radiol. 2009;90(7–8 Pt 2):991–1000. Doi: 10.1016/s0221-0363(09)73237-8.

13. Benian A. S., Iudin A. E., Airapetova M. P. Rare observation of bilateral pneumothorax at patient with bullous emphysema of the contralateral lung and mediastinal hernia after pneumonectomy: case report // Diagnostic radiology and radiotherapy. 2019;10(4):93–97. (In Russ.). Doi: 10.22328/2079-5343-2019-10-4-93-97.

14. Maniwa T., Saito Y., Saito T., Kaneda H., Imamura H. Evaluation of chest computed tomography in patients after pneumonectomy to predict contralateral pneumothorax // General Thoracic and Cardiovascular Surgery. 2009;57(1):28–32. Doi: 10.1007/s11748-008-0322-z.

15. Deutsch M., Martetschlaeger F., Muenzel D., D’Haese J., Krane M., Bau ernschmitt R., Lange R., Bumm R. Combined Spontaneous Contralateral Pneumothorax and Post-Pneumonectomy Mediastinal Shift-Associated Dextrocardia // The Thoracic and Cardiovascular Surgeon. 2011;59(01):60–62. Doi: 10.1055/s-0030-1250202.

16. Takahashi T., Murakawa T., Fukami T., Nakajima J. Pneumothorax after left pneumonectomy: accentuated negative pressure at azygoesophageal recess by a mediastinal shift and rotation // European Journal of Cardio-Thoracic Surgery. 2010;37(5):1222–1222. Doi: 10.1016/j.ejcts.2009.11.039.

17. Bagirov M., Krasnikova E., Ergeshova A., Lovacheva O., Karpina N., Penagi R. Anterior mediastinal plastics during pneumonectomy as prevention and treatment of a mediastinal hernia in fibrous cavernous pulmonary tuberculosis patients // Tuberculosis and lung diseases. 2017;95(11):36– 40. (In Russ.). Doi: 10.21292/2075-1230-2017-95-11-36-40.

18. Krasnikova E., Aliev V., Tarasov R., Karpov S., Sadovnikova S., Bagirov М. The use of a polymer mesh implant for mediastinal pulmonary hernia // Doctor. 2019;(5):73–76. (In Russ.). Doi: 10.29296/25877305-2019-05-15.

19. Ergeshova A. E., Krasnikova E. V., Penagi R. N. А., Salikhov B. U., Chitorelidze G. V., Tarasov R. V., Bagirov М. B. The prevention of postpneumonectomy mediastinal lung herniation by intraoperative anterior mediastinale plasty in patient with destructive pulmonary TB and the evalution of its effect on respiratory function // Bulletin of the Central Research Institute of Tuberculosis. 2020;(2):60–66. (In Russ.).