Recurrent Pneumothorax in a Post-pneumonectomy Patient: Surgical Management Under Extracorporeal Membrane Oxygenation Support

Pneumothorax after a pneumonectomy is a rare but potentially fatal condition due to markedly reduced pulmonary reserve. Preventing recurrence is crucial in this population. When surgery is required, intraoperative ventilation is particularly challenging. Options include conventional strategies such as high-frequency jet ventilation or endobronchial blockade, or extracorporeal membrane oxygenation (ECMO) when apnea tolerance is limited. We report the case of a 79-year-old male with a history of a left pneumonectomy for lung cancer, chronic obstructive pulmonary disease, and pulmonary emphysema who presented with sudden-onset, right-sided chest pain. Chest radiography revealed a right-sided pneumothorax, which was managed with chest tube drainage. A chest CT demonstrated a large bulla in the middle lobe. The pneumothorax recurred a few days later, requiring the reinsertion of an 18-Fr chest drain. The patient was evaluated by the thoracic surgery team but was deemed high risk, and chemical pleurodesis with talc slurry was performed through the chest drain to prevent recurrence. Two days after discharge, the pneumothorax recurred. Following recurrent episodes despite drainage and talc pleurodesis, the case was discussed in a multidisciplinary team involving pulmonology, thoracic surgery, and intensive care. Given his age, frailty, comorbidities, and severely reduced pulmonary reserve, conventional ventilation strategies were considered unsafe, and ECMO was selected to permit definitive surgical treatment. He underwent venovenous femoro-jugular ECMO cannulation, followed by uniportal video-assisted thoracic surgery with wedge resection of the middle-lobe bulla and combined chemical pleurodesis with talc and mechanical pleurodesis by pleural abrasion, without complications. He was extubated on the day of surgery and decannulated the following day. Postoperative Doppler ultrasonography revealed deep venous thrombosis of both cannulated vessels, and anticoagulation with low-molecular-weight heparin was initiated. The patient was discharged on postoperative day 12, with a switch to the direct oral anticoagulant edoxaban. No recurrence was observed at the five-month follow-up. Recurrent pneumothorax in a post-pneumonectomy patient represents a high-risk scenario in which conventional ventilation may not safely permit surgery. ECMO-assisted surgery offers a viable option for definitive management in patients with prohibitive pulmonary function.