Post-pneumonectomy syndrome in adults: a qualitative systematic review of treatment evidence, pathophysiology, and diagnosis

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Background: Post-pneumonectomy syndrome (PPS) is a rare, potentially life-threatening late complication of pneumonectomy, defined by progressive dynamic airway obstruction arising from extreme mediastinal shift and rotation into the vacant hemithorax. Published evidence is limited to case reports, small series, and one prior systematic review; no formal practice guidelines exist. This review synthesizes the available evidence on the pathophysiology, diagnosis, and treatment of adult PPS. Methods: Co-primary outcomes were symptomatic relief and radiological correction; secondary outcomes included treatment durability, procedural complications, recurrence, and mortality. Risk of bias was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklists, the Newcastle-Ottawa Scale, and the ROBIS tool. A structured patient-overlap analysis was performed across overlapping institutional series. Results: After deduplication, 42 studies (27 case reports, nine case series, five retrospective cohorts, and one prior systematic review) reporting 117 adult patients met inclusion criteria; 76% carried a high risk of bias. Right pneumonectomy accounted for approximately 72% of cases. Women outnumbered men by roughly three to one, and median age at diagnosis was 44 years (range, 16-70 years). Dyspnea was virtually universal (98% of cases). Surgical mediastinal repositioning with prosthetic implantation achieved symptomatic relief in approximately 88% of surgical candidates, with operative mortality of 0-5.6%. Endobronchial stenting achieved short-term relief in approximately 75% of stented patients but was complicated in approximately 50%. Conclusions: Drawing on very low-certainty evidence, surgical mediastinal repositioning with saline-filled prosthetic implantation appears to be the most effective management strategy for adult PPS. Endobronchial stenting should be restricted to patients who are not candidates for thoracotomy. Establishment of prospective registries and consensus on standardized diagnostic criteria are the most pressing research priorities. The evidence base remains substantially limited by the predominance of case reports, inconsistent outcome definitions, short follow-up, and the absence of comparative data.

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