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Ann Thorac Surg 2000;69:394-397
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Cukuroua, Adana, Turkey
Address reprint requests to Dr Topcuoglu, Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Cukuroua, 01330 Balcali, Adana, Turkey
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. Bronchopleural fistula developed in 16 of the 172 patients who had pneumonectomy between 1982 and 1996. In one case closure with fibrin sealant by bronchoscopy was tried. In the remaining cases fistula was closed by the transsternal transpericardial approach.
Results. The interval between pneumonectomy and fistula occurrence was 10 days or less in 5 patients and 10 days to 1 month in 11 patients. In all patients the empyema space was treated by continued drainage through the thoracostomy tube. Fibrin sealant was tried unsuccessfully for closure of moderate-sized bronchopleural fistula in one case. In three cases of right bronchopleural fistula, carinal resection and anastomosis of the trachea to the left main stem bronchus were performed. In the remaining cases bronchopleural fistula was closed using a hand suture technique. One patient died within 30 days after operation (6.25%) because of renal insufficiency. There was no recurrence of bronchopleural fistula.
Conclusions. Transsternal transpericardial approach seems to be a safe and effective method with an easier technique in cases of bronchopleural fistula complicated with empyema. It has the added advantage of less recurrent fistula formation and enables resection in cases without sufficient bronchial stump.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Nonsurgical and surgical methods have been used to close the postpneumonectomy fistula with empyema. Nonsurgical techniques include application of fibrin glue or tube thoracostomy and antibiotic pleural irrigation but are only useful in small fistulas [3, 4]. To close a wide-open bronchial stump a direct approach is mandatory. In this study we retrospectively reviewed our incidence and results of BPFs after pneumonectomy and transsternal transpericardial approach for the repair of BPF.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Postpneumonectomy BPF developed in 16 (15 men and 1 woman) of the 172 patients. Fourteen of these patients had tumors and the remaining 2 patients had benign disease. These 16 patients are the subjects of this retrospective study. Sudden onset of cough, serosanguineous sputum, and sign of respiratory failure were used for the diagnosis of BPF. In all patients bronchial dehiscence was confirmed by bronchoscopy. Tube thoracostomy and pleural irrigation with antibiotics were employed in 4 of the 16 patients for a duration of 2 months. Application of fibrin glue was tried unsuccessfully in 1 patient. The remaining 15 patients underwent surgical procedures preceding conservative therapy because the diameter of the BPF was larger than 5 mm.
Operative technique
The empyema present in all patients was treated by closed drainage and antibiotic pleural irrigation: no repeated needle aspiration or open thoracotomy was performed. All patients underwent preoperative bronchoscopic examination for the diagnosis and the assessment of the length of the bronchopleural stump.
Either a double lumen endotracheal tube or a long endobronchial tube allowing selective ventilation was used except in carinal resection. In all of the patients standard median sternotomy incisions were employed and the anterior pericardium was opened. After the mobilization and retraction of the superior vena cava and aorta, a vertical incision was made in the posterior pericardium. Dissection of lymphoid and areolar tissue anterior to the carina permitted exposure of both main stem bronchi and the lower trachea above the pericardial reflection was mobilized. Care was taken to avoid injury to the left recurrent nerve and esophagus. In the right BPF, the residual right pulmonary artery was transected. When feasible, the affected bronchus was dissected completely if dense adhesions precluded complete exposure: the bronchus was transected proximally from the anterior face to the posterior face. The distal stump was excised totally in all of the patients.
In 1 patient the bronchus was closed by incontinuity with two lines of staples and in the remaining patients a hand suture technique was used. The bronchial stump was covered by a pericardial fat pad to separate the suture line from vascular structures.
In the case of left BPF, surgical approach to the bronchus was made either between the aorta and vena cava superior or between the pulmonary artery and above the left atrial appendage.
In cases in which less than at least 5 mm of stump was left (Fig 1A), carinal resection and anastomosis of the unaffected bronchus to the trachea were performed. During carinal resection the endotracheal tube was pulled back a little, and after completion of carinal resection (Fig 1B) a new sterile endotracheal tube was placed into the intact bronchus (Fig 1C). A connection was established between the endotracheal tube and the anesthesia machine by a ventilation circuit. These anastomoses of the main bronchus to the trachea (Fig 1D) were done using 2-0 vicryl polyglactin 910 (Ethicon, Inc, Somerville, NJ) by single suture technique. Once the posterior sutures were completed, the endotracheal tube was removed and ventilation was carried on using the first endotracheal tube that was placed in the trachea during the initial intubation. After completion of the anterior sutures, anastomosis was completed. In this way prevention of secondary infection and safe ventilation were maintained. The anastomosis was checked for air leaks by inflating the lung after filling the mediastinum with saline solution. Irrigation of the pneumonectomy cavity through tube thoracostomy after surgical treatment for BPF was continued in all patients for 2 weeks.
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Results |
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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A variety of methods for the closure of BPF have been proposed and the ideal method is still controversial. Although Abruzzini [5] in 1961 and Perelman and Ambatiello [6] in 1970 had described the technique of transsternal transpericardial closure for BPF repair, this method was not widely accepted in the world except in a few centers. Recently this approach gained popularity among some surgeons [7–9]. We have used this technique for patients with BPF and empyema since 1982.
The basic principles of management for BPF with empyema include drainage of the empyema, closure of BPF, and obliteration of the pleural space.
Drainage of the empyema can be accomplished with tube thoracostomy or open-window thoracostomy. The empyemas that are only a few days old are usually associated with a transudate effusion and, as a result, simple tube drainage is effective and the addition of pleural space irrigation certainly facilitates healing. Pairolero [10] reported that when the empyema is a few weeks old, the effusion is thick, tenacious, and associated with a woody, indurated pleura. Therefore, simple drainage and irrigation in this chronic setting do not work. In these cases Clagett and Geraci [11] described a treatment for late empyema in which the residual cavity was sterilized by open-window thoracostomy and then a closure was performed after filling the empyema cavity with an antibiotic solution. After simple tube drainage all of our cases of BPF had radiologically proved resolved empyema, thus we did not favor open thoracostomy to drain the infected pleural space.
Advantages of transsternal transpericardial closure of BPFs are avoidance of areas of infection, scarring in previous surgical fields, devascularized bronchus, and cosmetic and functional deformities of the thorax because of thoracoplasty. This technique also is an alternative in the management of persistent fistula after repair by other techniques.
The disadvantage of this method is that the residual empyema space is not dealt with at the same time with the closure of BPF, unlike open-window thoracostomy, myovascular transpositions, or thoracoplasty [11–13]. In our clinical experience sterilization and obliteration of the pleural space are quicker after the closure of BPF by the transsternal transpericardial approach because there is no contamination of the pleural space through the fistula. However, in patients who have had a prior cardiac operation, transsternal closure of BPF is not recommended. For these patients other surgical procedures such as the Clagett and Geraci [11] method or the Pairolero and associates [13] method can be used.
We divided the bronchus close to the carina, closed it with absorbable sutures, and reinforced it with pericardial tissue. We excised the distal stump in all of our cases, keeping in mind the high failure rate in cases in which the distal stump is left in place [14].
Stamatis and colleagues [8] performed carinal resection using the transsternal approach in cases in which a short bronchial stump was present, and Riviera and coworkers [9] proposed this method in cases in which closure of the bronchus without tension using disease-free viable bronchial tissue was impossible. If a patient does not have an adequate stump and the bronchus has dehiscenced at the level of the carina, we suggest carinal resection. In our series, in three cases resection of a short stump with distal trachea was followed by anastomosis of the trachea and the left main stem bronchus. The advantages of carinal resection are the removal of the infected tissue, disabling contact between the mediastinal and pleural cavities, and a decrease of the angle formed by the shifting of the trachea to the right at the carinal level.
Baldwin and Mark [7] have reported that care must be taken not to injure the esophageal and left recurrent laryngeal nerve during the transsternal transpericardial approach. There were no deaths or clinically significant morbidity related to the transsternal approach in our cases.
Although the decision for treatment of BPF must be made on a case-by-case basis, the technique of transsternal transpericardial approach is relatively simple and effective. In cases of BPF even with late empyema, if simple tube drainage is effective and enables one single thoracic space, we suggest the transsternal transpericardial approach for repair of BPF.
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References |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Related Article
Ann. Thorac. Surg. 2000 69: 397.
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