Disclosures: Heidi Chen, MD: No financial relationships or conflicts of interest

Case Description: This is a patient diagnosed with primary lung acinar and lepidic adenocarcinoma who underwent a right lower lobectomy followed by resection of right ribs 8-10 with the creation of Eloesser flap (EF) for chronic loculated empyema. He presented 7 months later with right-sided abdominal wall bulging on right-sided trunk rotation and 1 month history of clicking sensation over right thorax with deep inspiration and twisting. On exam, he had an open skin flap over the right posterior chest that was actively draining, asymmetric rise of the right chest, missing posterolateral right ribs 8-10, reduced sensation over anterior T8-T11 dermatomes, and right abdominal wall bulging when bearing down. Abdominal hernia was ruled out and on monitoring, he was also found to have hemidiaphragm weakness.

Setting: Outpatient office

Patient: 73-year-old male with synchronous primary lung acinar and lepidic adenocarcinoma Assessment/

Results: Symptoms determined to be caused by intercostal denervation (ID), slipping rib syndrome (SRS), and phrenic nerve injury following EF. He continues to play tennis painlessly and will begin pulmonary physical therapy for aerobic therapy. Symptoms have largely improved.

Discussion: EF is indicated for post-resection or bronchopleural fistula associated empyema; an open communication between pleural space and atmosphere is created with resection of subjacent posterolateral ribs and folding skin into pleural space. Reported complications include sepsis and prolonged wound care. In the literature, thoracic surgery with rib resection can cause flank bulging due to ID and hemidiaphragm weakness due to phrenic nerve injury. SRS occurs when hypermobile cartilage of ribs 8-10 slide beneath superior rib cartilages causing a clicking sensation. Diagnosis is clinical via hooking maneuver or dynamic ultrasound of the ribs. The nature of the EF predisposes patients to SRS, ID, and phrenic nerve injury.

Conclusion: Providers should be aware of EF complications including ID, SRS, and phrenic nerve injury for effective management of this uncommon procedure.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/click-click-bulge-complications-following-eloesser-flap-a-case-report/