Case Report
Pneumothorax as a Complication of Arthroscopic Shoulder Surgery
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array:23 [ "pii" => "S030028962300162X" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.05.004" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "3318" "copyright" => "SEPAR" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2023;59:520-1" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0300289623001588" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.05.003" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "3317" "copyright" => "SEPAR" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Arch Bronconeumol. 2023;59:522-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical Image</span>" "titulo" => "Beyond B-Lines: POCUS and the Diagnosis of Pulmonary Arteriovenous Malformations!" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "522" "paginaFinal" => "523" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2920 "Ancho" => 1667 "Tamanyo" => 342950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lung CT revealed a dilated vascular structure in the right middle lobe close to the pleura (A and B, white arrow), compatible with PAVM. Pulmonary echography showed a right parasternal hypoechoic image with an intraluminal hyperechoic area, compatible with thrombosis (C, white arrow). Doppler mode revealed a ‘mosaic-pattern’ indicative of mixing of arterial and venous blood consistent with PAVMs (D). Here, the anterograde and retrograde flow form a “ying-yang sign” (asterisk). Pulsed doppler image demonstrated arterial and venous flows (E).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María Martina Echarri, Santiago Ezequiel Noya, Luis Patricio Maskin" "autores" => array:3 [ 0 => array:2 [ "nombre" => "María Martina" "apellidos" => "Echarri" ] 1 => array:2 [ "nombre" => "Santiago Ezequiel" "apellidos" => "Noya" ] 2 => array:2 [ "nombre" => "Luis Patricio" "apellidos" => "Maskin" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001588?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000008/v3_202311210631/S0300289623001588/v3_202311210631/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289623001576" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.04.009" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "3316" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2023;59:518-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "From the Pleura to the Skin: A Case of Metastatic Melanoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "518" "paginaFinal" => "519" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 990 "Ancho" => 2925 "Tamanyo" => 611276 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(1.1) Chest computed tomography images. (A and B) Mediastinal window. (C) Parenchymatous window. Massive right pleural effusion (white arrows) associated with focal pleural thickening (red arrows), mediastinal structures shifted to the left (yellow arrow), and right paratracheal mediastinal lymph nodes (blue arrow) are observed. (1.2) Results of the study of pleural fluid obtained by thoracentesis. (1.3) Panoramic image of pleural tumor infiltration (H–E 20×). (B) Detail of medium-sized plasmacytoid cell types and lateralized basophil nuclei, occasional nucleoles, and scant or moderate cytoplasms arranged in threads, strings or diffusely (H–E 40×). (C) Absence of epithelial marker expression (CK AE1-3 10×). (D) Intense diffuse cytoplasmic expression to melanocytic markers (HMB-45 10×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Amina Bekki, Nuria Mancheño-Franch, Andrés Briones-Gómez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Amina" "apellidos" => "Bekki" ] 1 => array:2 [ "nombre" => "Nuria" "apellidos" => "Mancheño-Franch" ] 2 => array:2 [ "nombre" => "Andrés" "apellidos" => "Briones-Gómez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001576?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000008/v3_202311210631/S0300289623001576/v3_202311210631/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Pneumothorax as a Complication of Arthroscopic Shoulder Surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "520" "paginaFinal" => "521" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Laura Sacristán, Montserrat Blanco, Manuel Castro" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Laura" "apellidos" => "Sacristán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Montserrat" "apellidos" => "Blanco" "email" => array:1 [ 0 => "montseblancoramos@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Manuel" "apellidos" => "Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Thoracic Surgery Service, Hospital Álvaro Cunqueiro, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Traumatology Service, Hospital Álvaro Cunqueiro, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1374 "Ancho" => 1740 "Tamanyo" => 377407 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Parietal pleural lesion corresponding to the trocar entry point. (b) Simulation of the patient's position in the operating theatre and possible direction of the trocar for penetrating the thorax. Insert: working control of the arthroscope with the sharp trocar used. (c) Wound in the lung parenchyma located immediately below the chest wall injury (arrow). (d) Healing of the arthroscopy incisions. The arrow points to the trocar incision causing the pneumothorax. (e) Chest X-ray in AP showing complete right pneumothorax accompanied by subcutaneous emphysema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumothorax after shoulder arthroscopy is an infrequent complication that has hardly ever been published in the literature and for which there is no clear cause.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1–3</span></a> Possible causes are postulated to be surgery-related, anaesthesia-related and respiratory comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1–3</span></a> The most commonly advocated hypotheses are inadvertent accidental injuries to the pleura or lung during regional anaesthetic block, continuous positive pressure from the arthroscopic pump, the patient's position during surgery or excessive intra-articular debridement.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1–3</span></a> Nonetheless, the exact cause has not been proven in any case.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 66-year-old male smoker with no other medical or surgical history of interest who underwent arthroscopic surgery of the right shoulder through the usual portals for a ruptured supraspinatus muscle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d). Six hours after completion of surgery, the patient presented dyspnoea with an O<span class="elsevierStyleInf">2</span> saturation of 85%. The patient underwent a chest X-ray which showed massive right pneumothorax and subcutaneous emphysema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>e). We proceeded to place an endothoracic drainage tube as a matter of urgency, but in the absence of complete lung re-expansion and persistent air leak, we decided to perform surgery by videothoracoscopy. Here we identified the origin of the leak as a deep rounded laceration in the posterolateral aspect of the right upper pulmonary lobe. This was of iatrogenic origin secondary to the insertion of the posterior arthroscopy trocar, and with an opening notch in the parietal pleura above it (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a, c, and d). We repaired the laceration with a wedge resection using a surgical stapler.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There are very few documented cases such as this one of pneumothorax associated with surgical instrumentation in the literature. We can affirm that the difference between this case and the others is that when performing videothoracoscopy we could see the iatrogenic pulmonary lesion, which occurred while introducing the working trocar through the posterior portal. We believe that there may have been several reasons for this complication. Firstly, although we generally use a blunt trocar to introduce the arthroscope sleeve through the posterior portal, in this case we used a sharper trocar, which was similar to the one used in knee arthroscopy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b, inset). Secondly, the position of the patient and the experience and confidence of the surgeon, in this case an accomplished surgeon, may also have played a role. The patient was placed in the lateral decubitus position but with excessive posterior body tilt with the arm in traction, with antepulsion and some adduction. Pleural penetration with the trocar could take place at the end of the procedure, when after tendon suture, we accessed the glenohumeral space again to visualise the correct tendon reinsertion from this area. At this point, as the shoulder was swollen by the insufflated water, the coracoid was not correctly referenced. Combined with the patient's poor position and the surgeon's faith, it is possible that this could have led to iatrogenesis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore, we insist on the correct positioning of the patient, awareness of this possible complication and extreme caution during surgery. In addition, it is important to recognise this complication in the postoperative period and to manage it appropriately at an early stage.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ Contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">All authors have contributed intellectually to the case, meet the conditions of authorship and have approved the final version of the case.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">There has been no funding or sponsorship for the publication of this article.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ Contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1374 "Ancho" => 1740 "Tamanyo" => 377407 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Parietal pleural lesion corresponding to the trocar entry point. (b) Simulation of the patient's position in the operating theatre and possible direction of the trocar for penetrating the thorax. Insert: working control of the arthroscope with the sharp trocar used. (c) Wound in the lung parenchyma located immediately below the chest wall injury (arrow). (d) Healing of the arthroscopy incisions. The arrow points to the trocar incision causing the pneumothorax. (e) Chest X-ray in AP showing complete right pneumothorax accompanied by subcutaneous emphysema.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous pneumothorax with extensive subcutaneous emphysema: a rare complication of shoulder arthroscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Asghar" 1 => "M. Azam" 2 => "R. Gjeka" 3 => "A. Adams" 4 => "A. Barakzai" 5 => "A. Maeza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.2278764" "Revista" => array:4 [ "tituloSerie" => "Chest" "fecha" => "2015" "volumen" => "148" "paginaInicial" => "34A" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumothorax after shoulder arthroscopy: a rare but life-threatening complication" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Bamps" 1 => "D. Renson" 2 => "S. Nijs" 3 => "Sermon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.13107/jocr.2250-0685.542" "Revista" => array:5 [ "tituloSerie" => "J Orthop Case Rep" "fecha" => "2016" "volumen" => "6" "paginaInicial" => "3" "paginaFinal" => "5" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumothorax following shoulder arthroscopy under combined regional and general anaesthesia – a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O. Leander-Olsson" 1 => "A. Borglund-Hemph" 2 => "J.G. Jakobsson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijscr.2016.05.012" "Revista" => array:5 [ "tituloSerie" => "Int J Surg Case Rep" "fecha" => "2016" "volumen" => "24" "paginaInicial" => "73" "paginaFinal" => "76" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005900000008/v3_202311210631/S030028962300162X/v3_202311210631/en/main.assets" "Apartado" => array:4 [ "identificador" => "93562" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005900000008/v3_202311210631/S030028962300162X/v3_202311210631/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S030028962300162X?idApp=UINPBA00003Z" ]
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