# Subcutaneous and mediastinal emphysema after lobectomy: Two case reports with different courses

## TL;DR

Two cases of subcutaneous and mediastinal emphysema after lobectomy are presented, with one developing a rare contralateral pneumothorax.

## Contribution

This is the first reported case of contralateral pneumothorax secondary to postoperative subcutaneous emphysema.

## Key findings

- Conservative management was sufficient for subcutaneous emphysema without pneumothorax.
- A contralateral pneumothorax occurred due to minor air leakage, requiring chest tube drainage.
- The pressure threshold for contralateral pneumothorax may be lower than for the surgical side.

## Abstract

Subcutaneous and mediastinal emphysema after lobectomy is uncommon and is typically caused by minor air leakage from the residual lung; however, the development of a contralateral pneumothorax is particularly rare, and if missed, it can be fatal.

Two cases of subcutaneous and mediastinal emphysema occurring after a lobectomy in a 77-year-old man and a 78-year-old man are reported here. The former received conservative treatment, while the latter he developed a pneumothorax on the side contralateral to the surgical site after readmission. Chest tube drainage was then performed.

The occurrence of subcutaneous and mediastinal emphysema after lobectomy is not uncommon. Conservative management is often sufficient if no pneumothorax is present, as in Case 1. However, in Case 2, pneumothorax occurred on the contralateral side due to a minor air leakage, which is an unusual complication. Generally, a pneumothorax of the residual lung on the surgical side occurs earlier than a pneumothorax on the contralateral lung. The earlier onset on the contralateral side in Case 2 suggests that the pressure threshold for rupturing the contralateral mediastinal pleura and/or alveoli may have been lower than that for collapsing the residual lung on the operative side. We recommend that pulmonologists should also monitor the contralateral side and that follow-up radiographic examinations should be performed a few hours later.

Pulmonologists should monitor the side contralateral to the surgical site, even if the emphysema is caused by a postoperative minor air leakage.

•Two postoperative subcutaneous emphysema cases after lobectomy; one uniquely developed a contralateral pneumothorax.•Case 1 was managed conservatively, while Case 2 required urgent chest drainage four hours after presentation.•This is the first reported case of contralateral pneumothorax secondary to postoperative subcutaneous emphysema.•Highlights the importance of monitoring the contralateral hemithorax, even in the absence of ipsilateral pneumothorax.

Two postoperative subcutaneous emphysema cases after lobectomy; one uniquely developed a contralateral pneumothorax.

Case 1 was managed conservatively, while Case 2 required urgent chest drainage four hours after presentation.

This is the first reported case of contralateral pneumothorax secondary to postoperative subcutaneous emphysema.

Highlights the importance of monitoring the contralateral hemithorax, even in the absence of ipsilateral pneumothorax.