a three - month - old male presented with cough , sputum , and intermittent cyanosis that had lasted for one week .
a postoperative esophagogram showed a bronchoesophageal fistula , and a secondary operation involving fistulectomy and right lower and middle bilobectomy was performed .
nevertheless , he required right pneumonectomy due to recurrent pneumonia in the remaining right upper lobe . on readmission
five months after the pneumonectomy , a chest computed tomography ( ct ) scan revealed post - pneumonectomy changes , with mediastinal shift to the right and collapse of the posterior wall of the trachea compressed by the aortic arch ( fig .
aortopexy was performed , followed by insertion of a tissue expander into the right pleural cavity .
after the insertion of the tissue expander , 45 ml of normal saline was instilled , and the thoracotomy wound was closed .
the patient was discharged 29 days after the operation . at a one - year follow - up , he had no symptoms
. a 22-month - old female with esophageal atresia ( type c ) underwent fistula resection and an esophageal anastomosis .
a fistulectomy between the right intermediate bronchus and the distal esophagus was performed , as well as right pneumonectomy for persistent collapse of the right lung .
twenty - two months after the pneumonectomy , she experienced unspecific respiratory symptoms of cough and sputum for five days .
a chest ct scan demonstrated mediastinal shift to the right and a narrowed left main bronchus , which was compressed between the left main pulmonary artery and the descending thoracic aorta ( fig .
we performed mediastinal repositioning by inserting a tissue expander with 120 ml of saline . during the first two postoperative days she required ventilator therapy , and venovenous extracorporeal membrane oxygenation
the patient was discharged on the 77th postoperative day , following successful weaning from extracorporeal membrane oxygenation . at a one - year follow - up ,
the patient showed no symptoms and a chest x - ray showed no specific findings .
a three - month - old male presented with cough , sputum , and intermittent cyanosis that had lasted for one week .
a postoperative esophagogram showed a bronchoesophageal fistula , and a secondary operation involving fistulectomy and right lower and middle bilobectomy was performed .
nevertheless , he required right pneumonectomy due to recurrent pneumonia in the remaining right upper lobe . on readmission
five months after the pneumonectomy , a chest computed tomography ( ct ) scan revealed post - pneumonectomy changes , with mediastinal shift to the right and collapse of the posterior wall of the trachea compressed by the aortic arch ( fig .
aortopexy was performed , followed by insertion of a tissue expander into the right pleural cavity .
after the insertion of the tissue expander , 45 ml of normal saline was instilled , and the thoracotomy wound was closed .
the patient was discharged 29 days after the operation . at a one - year follow - up , he had no symptoms .
a 22-month - old female with esophageal atresia ( type c ) underwent fistula resection and an esophageal anastomosis .
a fistulectomy between the right intermediate bronchus and the distal esophagus was performed , as well as right pneumonectomy for persistent collapse of the right lung .
twenty - two months after the pneumonectomy , she experienced unspecific respiratory symptoms of cough and sputum for five days .
a chest ct scan demonstrated mediastinal shift to the right and a narrowed left main bronchus , which was compressed between the left main pulmonary artery and the descending thoracic aorta ( fig .
we performed mediastinal repositioning by inserting a tissue expander with 120 ml of saline . during the first two postoperative days she required ventilator therapy , and venovenous extracorporeal membrane oxygenation
the patient was discharged on the 77th postoperative day , following successful weaning from extracorporeal membrane oxygenation . at a one - year follow - up
, the patient showed no symptoms and a chest x - ray showed no specific findings .
postpneumectomy syndrome ( pps ) is a rare disorder involving the extrinsic compression of the trachea or bronchus due to shifting of the mediastinum and over - inflation of the remaining lung parenchyma .
it results in a counterclockwise rotation of the heart and great vessels , along with herniation of the remaining lung into the contralateral hemithorax .
pps is more common in children , occurring in up to 15% of patients who undergo right pneumonectomy ( or , rarely , left pneumonectomy in patients with a right aortic arch ) .
the frequency with which this syndrome occurs in infants and young children is thought to be related to the increased elasticity and pliability of their lungs and mediastinum , compared with those of adults .
they have more pliable and mobile mediastinal tissue than older patients , with a greater tendency to shift that can easily lead to anatomic distortion .
pps is characterized by progressive dyspnea , cough , and recurrent pneumonia at least six months after pneumonectomy .
because of the rarity and unspecific symptoms of the disease , most patients already have bronchomalacia by the time of diagnosis .
various procedures have been proposed , including phrenectomy or crushing of the phrenic nerve , tracheal or bronchial transection with anastomosis , suspension of the aorta to the sternum , and endoscopic bronchial stent insertion [ 14 ] .
more recently , surgical repositioning of the mediastinum with a non - absorbable material has been widely accepted as a standard treatment .
many studies have reported that the insertion of an intrathoracic prosthesis can improve clinical symptoms and relieve functional obstructions .
shen et al .   reported that placement of a saline - filled tissue expander led to successful mediastinal repositioning . at a median follow - up of 32 months
, 10 of 13 patients ( 77% ) reported a significant improvement in their symptoms , with a relatively low operative mortality rate of 27.8% .
the early insertion of a tissue expander when pneumonectomy is performed may prevent the possible detrimental consequences that result from the delayed diagnosis and treatment of pps .
furthermore , some reports have described an inability to place a tissue expander due to postoperative adhesion when the pps is developed after pneumonectomy .
choi et al .   have suggested that prophylactic implantation of a tissue expander may prevent the potentially very serious complication of pps . in our two cases , tissue expanders improved the ventilation of the remaining lung by alleviating the obstruction of the trachea or bronchus and shifting the mediastinum to the midline .
although our follow - up duration was short , we observed decreased respiratory compromise and no complications involving leakage or rupture related to the tissue expander . in our opinion , pps can be completely and successfully treated using a tissue expander , which can restore the position of the mediastinum .
 postpneumonectomy syndrome ( pps ) is a rare late complication of pneumonectomy . 
 it occurs more often in children than in adults , and is characterized by respiratory failure resulting from bronchial compression caused by severe mediastinal shift . 
 various methods have been used to treat pps , including aortopexy and the insertion of plastic balls , silastic implants , and saline - filled breast prostheses . 
 we describe two cases of pps corrected with tissue expanders after right pneumonectomy in patients with esophageal atresia . 
CASE REPORTS
1) Case 1
2) Case 2
DISCUSSION