Thoracoscopic surgery using local and epidural anesthesia for intractable pneumothorax after BMT

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Although BMT offers potentially curative therapy for hematological malignancies, pulmonary complications occur in 40–60% of these patients and are a major cause of morbidity and mortality.1 Such problems include pneumonitis, GVHD and chronic obstructive pulmonary disease. Bronchiolitis obliterans (BO) is recognized as an important problem after BMT and is known to be a manifestation of GVHD.2 Air-leak syndromes such as pneumomediastinum, s.c. emphysema and pneumothorax have been documented in patients with BO. Patients suffering from pneumothoraces associated with BO sometimes have a fatal outcome because of the difficulty in controlling air leaks. Such persistent air leakage can be managed by nonsurgical or surgical procedures. Nonsurgical procedures include tube thoracostomy or chemical pleurodesis with agents such as tetracycline, talc or silver nitrate. Successful treatment with autologous blood pleurodesis has also been reported in a patient with a pneumothorax due to BO after BMT.3 Surgical procedures include ablation, ligation and excision of bullae or emphysematous lesions, and usually require single lung ventilation under general anesthesia. However, this can result in adverse effects in patients with severe pulmonary disease.

We report a case of intractable pneumothorax due to BO after BMT, successfully treated by a thoracoscopic surgical approach under local and epidural anesthesia.

A 40-year-old female with a history of acute myelomonocytic leukemia presented with severe dyspnea in 2006. She had undergone allogeneic BMT from an unrelated and HLA-identical donor in 2001. The preparative regimen consisted of CY and TBI, and immunosuppression was carried out with CYA. She developed grade I skin GVHD in the early post transplant period. After an episode of influenza in 2003, her dyspnea worsened and pulmonary functions deteriorated, suggestive of BO due to chronic GVHD. Pulmonary function test showed reduced vital capacity (1.88 l, 64% of predicted value) and a forced expiratory volume in 1 s (0.54 L, 29% of predicted value). Home oxygen therapy was started with 1.5 L/min in 2004. A chest X-ray and computed tomography on admission showed a large hydropneumothorax on the right side and a small pneumothorax on the left side (Figure 1). Arterial blood gas analysis revealed hypercapnea (PaCO2: 77 Torr; PaO2: 55 Torr) with poor oxygenation. She required immediate chest tube drainage on the right side. A chemical pleurodesis was attempted three times with minocycline to control a persistent air leak, but this failed. Subsequently, pleurography was performed and revealed a site of air leakage. To avoid the adverse effects of general anesthesia, we planned a surgical approach under local and epidural anesthesia to treat the persistent air leak. The anesthetic and surgical procedures were as described elsewhere.4, 5 A thoracic epidural catheter was placed before surgery and 0.25% ropivacaine was injected and added as needed to maintain analgesia. The patient was made to lie down in the decubitus position and maintained spontaneous breathing during surgery. Oxygen was administered through a face mask. The patient was able to communicate with the anesthesiologists and surgeons throughout surgery. After additional local anesthesia with 1% lidocaine, a thoracoscope was inserted through the optimal intercostal space determined by pleurography. The air-leak site was identified by instilling saline into the thoracic cavity and immersing the lung in water. It was covered with a polyglycolic acid sheet (Neoveil; Gunze, Osaka, Japan) using aerosolized fibrin glue (Bolheal; Chemo-Sero Therapeutic Institute, Kumamoto, Japan) (Figure 2). The postoperative course was uneventful and the patient was discharged soon after. As lung transplantation is a therapeutic option for patients who develop BO after BMT,6 she registered on the waiting list for lung transplantation.

Figure 1
figure1

(a) Chest roentgenogram showed a right hydropneumothorax. (b) Computed tomographic scan revealed bilateral pneumothorax.

Figure 2
figure2

(a) Bubbles were observed from the air-leak site (arrow head). (b) The air-leak site was covered with a piece of polyglycolic acid sheet (black arrow) using aerosolized fibrin glue.

Persistent air leakage remains a problem in patients with severe pulmonary disease, especially BO after BMT. A nonsurgical procedure such as chemical or blood pleurodesis is preferred for the treatment of air leak. However, it is not always successful. In such cases, a less invasive surgical approach should be considered as an alternative. Recently, surgery using epidural anesthesia has been introduced and applied in general thoracic surgery.7 This approach prevents the adverse effects of general anesthesia and endotracheal intubation and provides benefits such as less invasiveness and a shorter hospital stay. A thoracoscopic operation using local and epidural anesthesia has been applied and gave excellent results in high-risk patients with severe pulmonary diseases, even after lung transplantation.4, 5 Locating the air-leak site using a thoracoscope is more accurate and effective than is pleurodesis through thoracostomy tube, if the patient is able to tolerate the local and epidural anesthesia. As the polyglycolic acid sheet is absorbable, resistant to infection and easy to manipulate, it has been widely used as a buttress along the staple lines in patients who underwent pulmonary resection and has offered good results with regard to control of air leaks;8 covering an air-leak site with a piece of polyglycolic acid sheet using a fibrin glue is a simple strategy for persistent air leaks.

In conclusion, thoracoscopic surgery for the treatment of air leakage under local and epidural anesthesia is a safe and useful approach for patients at risk from general anesthesia who have severe pulmonary dysfunction.

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Correspondence to H Shigematsu.

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Shigematsu, H., Andou, A., Matsuo, K. et al. Thoracoscopic surgery using local and epidural anesthesia for intractable pneumothorax after BMT. Bone Marrow Transplant 46, 472–473 (2011) doi:10.1038/bmt.2010.142

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