Mediastinal reinforcement after induction therapy and pneumonectomy: comparison of intercostal muscle versus diaphragm flaps.

OBJECTIVE: Prospective non-randomised comparison of full-thickness pedicled diaphragm flap with intercostal muscle flap in terms of morbidity and efficiency for bronchial stump coverage after induction therapy followed by pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: Between 1996 and 1998, a consecutive series of 26 patients underwent pneumonectomy following induction therapy. Half of the patients underwent mediastinal reinforcement by use of a pedicled intercostal muscle flap (IF) and half of the patients by use of a pedicled full-thickness diaphragm muscle flap (DF). Patients in both groups were matched according to age, gender, side of pneumonectomy and stage of NSCLC. Postoperative morbidity and mortality were recorded. Six months follow-up including physical examination and pulmonary function testing was performed to examine the incidence of bronchial stump fistulae, gastro-esophageal disorders or chest wall complaints. RESULTS: There was no 30-day mortality in both groups. Complications were observed in one of 13 patients after IF and five of 13 after DF including pneumonia in two (one IF and one DF), visceral herniations in three (DF) and bronchopleural fistula in one patient (DF). There were no symptoms of gastro-esophageal reflux disease (GERD). Postoperative pulmonary function testing revealed no significant differences between the two groups. CONCLUSIONS: Pedicled intercostal and diaphragmatic muscle flaps are both valuable and effective tools for prophylactic mediastinal reinforcement following induction therapy and pneumonectomy. In our series of patients, IF seemed to be associated with a smaller operation-related morbidity than DF, although the difference was not significant. Pedicled full-thickness diaphragmatic flaps may be indicated after induction therapy and extended pneumonectomy with pericardial resection in order to cover the stump and close the pericardial defect since they do not adversely influence pulmonary function.     

Isolierte Lymphknotenmetastase im perikardialen Fettlappen nach Bronchusstumpfdeckung

The occurrence of bronchopleural fistulas is a serious complication after pneumonectomy because of lung cancer and additional bronchial stump coverage within right-sided and left-sided pneumonectomy therefore constitutes the operative standard. This is a case report on the early diagnosis of a lymph node metastasis within the pedicled pericardial fat flap used for bronchial stump coverage. Primary resection of the left lung was carried out 8 months previously because of cancer. Early diagnosis was possible using FDG-PET/CT in the post-operative treatment. The recurrence was successfully treated by en bloc resection and adjuvant radiation.     

Lymph node metastases in a pedicled pericardial fat pad flap

Routine use of pedicled thymus or pericardial fat pad flap for prophylactic bronchial stump coverage in neoadjuvant treated non-small cell lung cancer (NSCLC) is challenged by the observation of synchronous lymph node metastases to the flap. As a consequence, we suggest local muscle flaps, and histological examination of the pericardial fat pad.     

Experience with thoracoscopic surgery for primary bronchial stump fistula after pneumonectomy

After a left pneumonectomy, thoracoscopic closure with fibrin glue was performed for a fistula on the bronchial stump and the postoperative state progressed favorably thereafter. In this paper, we report on this successful case.Case: A 61 year-old male, who underwent a left pneumonectomy on January 17, 1996 for pulmonary carcinoma (T 3 N 1M 0 stage III A). The bronchial stump was covered with anterior serratus muscle flap. On April 1 (the 76th postoperative day), after two courses of Carboplatin and Vindesine treatment, the patient suddenly developed a fistula on the bronchial stump. Bronchofiberscopic closure with fibrin glue was attempted, but failed to close the fistula. Thoracoscopic surgery was then performed on May 15 (the 45th day after the onset of the fistula). After the intrathoracic opening of the fistula was found with a contrast medium, fibrin glue was injected to fill up to the bronchial stump, and communication with the thoracic cavity was blocked. Owing to coverage with a myocutaneous flap, the patient’s general postoperative state remained relatively stable. Thoracoscopic surgery is useful as a treatment for some cases of bronchial stump fistula after pneumonectomy.     

Impact of different coverage techniques on incidence of postpneumonectomy stump fistula

Objective: Postpneumonectomy bronchial stump fistula (PBSF) is a serious complication with a reported incidence between 0 and 12%. The aim of this retrospective study was to investigate the effectiveness of different coverage techniques of the bronchial stump applied in a consecutive series of pneumonectomies in avoiding this particular problem. Methods: Between 1/87 and 10/97, 129 patients (90 male, 39 female, mean age 57.8 years, range: 15–78 years) underwent pneumonectomy by one surgeon (W.K.). In 14 patients, additional resection procedures were performed (aorta n=6, vena cava n=5, thoracic wall n=3). In all patients with malignancies (n=123), mediastinal lymphadenectomy was routinely added to the procedure. Bronchial stump closure was performed by means of stapling devices in all patients. Coverage of the bronchial stump was performed with a generous pedicled pericardial flap and concomitant reconstruction of the pericardium with Vicryl mesh (n=50), with a portion of the posterior pericardium (n=16), with the azygos vein (n=12), with surrounding mediastinal tissue (n=25), with pleura (n=16), or with intercostal muscle flap (n=3); no coverage at all was performed in seven patients. In all patients with high risk for development of PBSF, i.e. patients who received any form of neoadjuvant therapy or had extended resections, the pericardial flap technique was used. Results: Perioperative mortality was 5.4% (n=7) and five patients (3.9%) experienced significant perioperative complications, with one of them directly related to the method of bronchial stump coverage (cardiac tamponade due to the use of a too small Vicryl mesh for reconstruction of the pericardium). Follow-up was 96.1% complete (five patients were lost to follow-up). Fourty-seven patients (36.4%) died late after operation (mean 19±13 months, median 17 months), mainly due to recurrence of their underlying malignant disease. PBSF occurred in one patient only (0.8%), 2 weeks after operation (coverage with pleura). No PBSF was seen in the long term follow-up period. Conclusion: Coverage of the bronchial stump contributes to a low incidence of PBSF. In view of the fact, that this serious complication was completely avoided in the pericardial flap group (used in patients with expected higher risk for PBSF), this particular technique seems to offer the best results.     

Tissue adhesive in bronchial closure

Monomeric n-butyl-2-cyanoacrylate was used in 25 patients undergoing pulmonary resections to strengthen the bronchial stump after pneumonectomy (n = 11) and to aid bronchial (n = 13) and tracheal anastomosis (n = 1) after sleeve resections. Neither group had any incidence of bronchopleural fistula. Bronchial anastomosis was accomplished in patients who underwent sleeve resection, reducing the number of sutures required to four apposing sutures, with the tissue adhesive ensuring an airtight closure. There was no incidence of bronchial stenosis. The efficacy of n-butyl-2-cyanoacrylate in preventing fistula formation after bronchial resections makes it an ideal agent in pulmonary surgery. Its use obviated the use of pedicled pleural flap, thus ensuring pleural integrity for extrapleural continuous intercostal nerve blockade for postoperative analgesia.     

The incidence, etiology, and prevention of postresectional bronchopleural fistula

Bronchopleural fistula (BPF) is a life-threatening complication after pulmonary resection. The incidence varies from 4.5% to 20% after pneumonectomy and is only 0.5% after lobectomy. Certain patient characteristics increase this incidence. These include preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised host, and insulin-dependent diabetes. Certain surgical techniques also increase the incidence. These include pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience. The best treatment of a BPF is prevention. Prevention centers around meticulous surgical technique and the liberal use of prophylactic, pedicled muscle flaps for the patient at increased risk. Survival of BPF depends on a high index of suspicion, early diagnosis, and aggressive surgical intervention.     

Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report.

An 80-year-old man underwent middle and lower lobectomy of the right lung to treat squamous cell carcinoma (SCC) (4 cm in diameter) originating from the right B4 bronchus. On the 4th postoperative day, a massive air leak from the thoracic drain was noted. At that time, a diagnosis of bronchial stump fistula was made on the basis of the bronchoscopic findings. Continuous thoracic drainage, aspiration of sputum via a tracheostomy and intravenous administration of antibiotics were performed immediately after the diagnosis. However, the patient's condition was complicated by aspiration pneumonia. On the 11th postoperative day, bronchoscopic procedure to close the bronchial fistula was performed via the tracheostomy. During this procedure, metallic coils were first inserted into the fistula to serve as the core for occlusion. Then, instead of directly infusing fibrin glue, several small beans-sized pieces of Surgicell cotton (Johnson & Johnson Co., Cincinnati, OH) soaked in fluid A (concentrated fibrinogen) and the same number of Surgicell cotton pieces soaked in fluid B (thrombin) were alternately inserted into the fistula, to allow closure of the bronchial fistula. After this procedure, the embolus created remained in place without being expectorated, and the aspiration pneumonia entered remission, allowing the patient to be discharged from the hospital on the 24th postoperative day. At preset, 14 months after surgery, the patient is in good condition. This technique allows simple and reliable closure of a fistula if a tracheostomy is available. It should be selected as a therapy of first choice when dealing with patients with a postoperative bronchial stump fistula in poor general condition. Patients undergoing right pneumonectomy or middle and lower lobectomy of the right lung should be considered as belonging to a high risk group for bronchial fistula and as requiring preventable measures (e.g., covering the stump with an intercostal muscle flap).     

The use of pedicled pleural flaps for the repair of pericardial defects, resulting after intrapericardial pneumonectomy.

We report our technique for the repair of large pericardial defects resulting after intrapericardial pneumonectomy for locally advanced non-small cell lung carcinoma, using pedicled pleural flaps. Creation of a pedicled pleural flap, large enough to cover the pericardial defect, performing blunt dissection of parietal pleura from the inferior edge of the thoracotomy incision and suturing it in the defect margins, is an easy, safe and effective technique for the prevention of cardiac herniation. Pedicled pleural flaps are an excellent material, not very popular nowadays, for the repair of pericardial defects resulting after intrapericardial pneumonectomy, when it is possible to create a pleural flap.     

The diaphragmatic flap: A multiuse material in thoracic surgery

BACKGROUND: The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages. METHODS: Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours. RESULTS: No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions. CONCLUSIONS: We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.     

Bronchial anastomotic stricutre caused by ossification of an intercostal muscle flap

We report a case of heterotopic ossification of a pedicled intercostal muscle flap that had been wrapped circumferentially around a bronchial sleeve anastomosis. This ossification caused severe bronchial stenosis and recurrent pneumonias. Stent insertion failed, and the patient ultimately required completion pneumonectomy. We recommended that caution be used when wrapping intercostal muscle around any important lumen.     

Reoperation for left main bronchial stump fistula developing after pneumonectomy

We report the case of a 71-year-old male patient who underwent reoperation for bronchial stump fistula developing after left pneumonectomy for adenocarcinoma of the left lung (clinical stage IIB). After surgery, he developed persistent, severe cough and chest X-ray films taken on the 23rd postoperative day showed a drop in the air-fluid level in the left lung field, which, along with bronchoscopic findings, strongly suggested the bronchial stump fistula and subsequent reoperation was performed. Both superior pulmonary vein and main pulmonary artery were dissected again proximally in pericardium, and the left main bronchus was separated from the surrounding tissue. Bronchial stump was closed with a stapler as close to the carina as possible, and additional resection was performed. After reoperation, the patient had an uneventful course, and was discharged in the second postoperative week. Shorter length of bronchial stump may be the most important factor to prevent the bronchial stump fistula developing after pneumonectomy.     

The use of a Dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.     

Experimental study of the effects of different stapling devices in healing of the mechanically sutured bronchial stump.

OBJECTIVE: The invention of the mechanical suture of the bronchial stump resulted in the significant decrease of the incidence of bronchial fistulas. Bronchial fistula constitutes the most dangerous complication of the pulmonary resection. In connection with some negative opinions in world literature regarding the safety of applying some types of mechanical suture, the multi-factor analysis of efficacy of bronchial stump closure following the total pneumonectomy by two different types of stapling devices was performed. METHODS: The experimental study was performed on 22 sheep. Each sheep underwent left pneumonectomy. In group I the bronchus was closed by the hinged-jaw stapling device (TA-Premium, Auto-Suture). In group II the bronchus was closed by the stapling device of parallel pattern (RLV 30 Ethicon). The macroscopic parameters (i.e. linear structure of staples, degree of staples closure, the symmetry of staples closure in the medial and lateral part of bronchial stump) as well as microscopic parameters (i.e. degree of inflammatory reaction, degree disorder in collagen fibers system, degree of disorders in cartilaginous system, degree of vascular proliferation and nervous regeneration) were evaluated. RESULTS: In three cases of group I the serious abnormalities in staples closure in the medial part of the bronchial stump were revealed. Abnormalities were found also in microscopic evaluation of the specimens. In the whole group the inflammatory reaction predominated in the medial part of bronchial stump near the hinge of the cartridge (P value <0.05). The disorder in the collagen fibers system as well as in the stratified structure of muscular fibers and cartilaginous system was proved. On the other hand, in group II all staples were properly closed in adequate linear structure, without any symmetry in both medial and lateral end of the bronchial stump. The microscopic findings were only the subtle inflammatory process and a slight disarrangement in muscular, collagen and cartilaginous systems. CONCLUSION: The listed abnormalities of mechanical, hinged-jaw suture of bronchial stump seem to be due to the inaccurate placement of staples, their incomplete closure, and excessive damage to the sutured tissues. We conclude that the application of the hinged-jaw mechanical suture of the bronchial stump might result in higher incidence of bronchial fistula after pneumonectomy.     

Treatment of bronchopleural fistula after pneumonectomy

Breakdown of the closure of the main-stem bronchus after pneumonectomy is a dreaded complication, and empyema and bronchopleural fistula frequently develop in patients who survive. Management of these fistulas remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. We report our experience with anterior transpericardial closure, emphasizing the ability to expose either main-stem bronchus by this approach. The case histories of three patients who had bronchopleural fistula after pneumonectomy are presented. The first patient had left pneumonectomy for complicated tuberculosis; the second had right pneumonectomy for neoplasm; and the third had right pneumonectomy for trauma. All fistulas were treated surgically via a median sternotomy and transpericardial approach to the distal trachea. The posterior pericardium was divided between the superior vena cava and aorta. In-continuity staple closure (with two lines of staples) of the proximal main-stem bronchus was employed in all cases. Two patients remain clinically well 21 and 17 months after the operation. The third patients did well initially but developed a recurrent bronchopleural fistula 2 1/2 months after the operation and has required repeat closure with pedicled muscle flaps. In postpneumonectomy bronchopleural fistula, the anterior, transpericardial approach to bronchial closure has several advantages: the relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and the devascularized bronchial stump, the avoidance of areas of chronic sepsis, and the avoidance of thoracoplastic surgical deformity of the chest wall, with possible associated compromise in pulmonary function. Our experience also indicates that either main-stem bronchus is accessible through an approach between the superior vena cava and aorta, without division of either pulmonary artery.     

Bronchial stump reinforcement in right pneumonectomy with fascia lata and gelatin resorcin formalin (GRF) glue: case report.

We reinforced the bronchial stump with fascia lata and Gelatin Resorcin Formalin (GRF) glue in a right pneumonectomy. This method was found to be simple and useful. We describe our case and the method herein. A 62-year-old woman had a malignant polypoid lesion which completely occluded the introitus of the right main bronchus and deviated to the introitus of the left main bronchus. Right pneumonectomy was done but materials (pleura, pericardium, intercostal muscle, etc.) obtained from the thoracic cavity were insufficient for bronchial stump reinforcement due to severe adhesion caused by prior tuberculosis. Therefore, we reinforced the bronchial stump using the fascia lata and GRF glue. Fascia lata is a superior material for reinforcement in terms of strength and ease of molding, as well as harvesting. GRF glue is a superior adhesive with rapid and strong fixation. We consider this method of reinforcing the bronchial stump with fascia lata and GRF glue to be feasible, in particular, for pneumonectomy or lobectomy without adequate material in the thoracic cavity because of severe adhesion or lesions.     

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis.

BACKGROUND: The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication. METHODS: We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses. RESULTS: Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation. CONCLUSIONS: Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.     

Results of pneumonectomy for bronchial carcinoma

615 patients suffering from lung cancer underwent pneumonectomy from 1966 to 1975 (standardized operation: 379; radical pneumonectomy: 236). Evidently the rate of postoperative insufficiency of the bronchial stump and pulmonary embolism was on the increase in cases of radical surgery. The postoperative mortality rate (including 30th postoperative day) was double as high in the radical group as in standardized operations. The 5 years survival rate following radical surgery came up to 13.1% (standard group 27%). This justifies radical pneumonectomy because there is no alternative left for the patients afflicted.     

Postoperative perforation in the bronchus intermedius membrane after a primary lung cancer resection.

We experienced 4 cases of postoperative perforation in the bronchus intermedius membrane (PBIM) after primary lung cancer resection. Three patients had undergone a right lower lobectomy and 1 patient had undergone a right upper lobectomy; as part of a systemic lymph node dissection, the subcarinal lymph node (Station 7) was dissected in all cases. Leakages were detected on postoperative days 3, 10, 11, and 26, respectively. The clinical signs of PBIM included the appearance of sputum like pleural effusion, decreased oxygenation, elevated inflammatory markers, pneumothorax, and infected pleural effusion. PBIM was confirmed by bronchofiberscopy. Direct suturing of the perforated membrane, followed by rapping with an omental flap was performed in 1 case; completion bilobectomies, followed by rapping of the bronchial stump with an omental flap or an intercostal muscle flap were performed in 2 cases; and a completion pneumonectomy, followed by rapping of the bronchial stump with an omental flap was performed in 1 case. All 4 of the cases were successfully treated.     

Brochial stump closure techniques following pneumonectomy: A serial comparative study.

Three methods of closing bronchial stumps were evaluated in 90 dogs undergoing left pneumonectomy:interrupted 3-0 silk sutures, interrupted 3-0 nylon sutures, and stapling with an automatic device. The dogs were sacrificed at 24 hours, 3, 5, 7, 10, and 14 days after pneumonectomy. Brochial stump leakage pressures and histological studies were performed on all specimens. Differences in the exudative reaction between silk and staple closures were significant on day 5(238.19+/- 23.28 SD PMN's/HPF in silk closures, 34.95+/- 20.37 SD PMN's/HPF in staple closures) and therafter(P less than 0.001). The reaction to nylon was intermediate between silk and staple. Collagen levels were highest at all periods for staple closures. Staple leakage pressures were greater than silk or nylon(day 5: 145.3 mm Hg +/- 64.9 SD in staple closures, 40.2 mm Hg +/- 15.4 SD in silk closures). These results have clinical relevance to the selection of suture materials for stump closures.