Bronchopleural fistula after lobectomy for lung cancer

Bronchopleural fistula after lung resection is a fatal complication. The aim of this study was to determine the risk factors for bronchopleural fistula after lobectomy for lung cancer. Clinical records of 767 patients who underwent lobectomy or bilobectomy for lung cancer in our institution were reviewed. Twelve patients (1.6%) suffered a bronchopleural fistula, of whom 5 died because of this complication (mortality rate, 41.7%). Multivariate analysis revealed squamous cell carcinoma, preoperative chemotherapy, lower lobectomy, and middle and lower lobectomy were risk factors for bronchopleural fistula. In such cases, particular care must be exercised to maintain blood flow through the bronchial stump during surgery, and reinforcement, such as stump coverage, must be employed.     

Fibrin glue administration to support bronchial stump line

Bronchopleural fistula is an important cause of mortality and morbidity after pulmonary resection. The use of fibrin glue to reduce the tension and number of sutures in the bronchial stump was assessed in this prospective study of 20 patients between June 2002 and May 2003. They all had a high risk of bronchopleural fistula development because of bronchiectasis, tuberculosis, lung abscess, diabetes mellitus, preoperative neoadjuvant radiotherapy, or residual tumor at the surgical margin. After pulmonary resection, the bronchial stump was closed with separate nonabsorbable sutures supported with fibrin glue. Bronchopleural fistula was observed in only 1 (5%) patient during 6.45 +/- 3.09 months of follow-up. There was no postoperative mortality. Closing the bronchial stump with an appropriate technique and supporting it with fibrin glue were considered effective in preventing bronchopleural fistula development after pulmonary resection in high-risk patients.     

Surgical management of late postpneumonectomy bronchopleural fistula: the transsternal, transpericardial route

BACKGROUND: Late postpneumonectomy bronchopleural fistula (LBPF) is a serious complication. Surgical repair of the bronchial stump through a lateral thoracotomy is a dangerous attempt due to mediastinal fibrothorax and the risk of pulmonary artery stump damage. OBJECTIVES: The goal of this study was to estimate the effectiveness of the transsternal, transpericardial approach for bronchial stump repair in case of LBPF. METHODS: From 1996 to 2002, 1,294 lung resections for non-small cell lung cancer were performed at our department. Out of 412 pneumonectomies, 16 patients (3.8%) presented with LBPF after right pneumonectomy for non-small cell lung cancer. Thirteen of these patients were subjected to transsternal, transpericardial bronchial stump repair. They were followed postoperatively, and morbidity and mortality rates were recorded. RESULTS: The interval between pneumonectomy and fistula diagnosis lasted from 12 to 85 months. The estimated sizes of the fistulae ranged from 5 to 21 mm, and the length of the bronchial stump was >1 cm only in 2 patients (15.3%).Due to persistent empyema, open-window thoracostomy was performed for definite treatment immediately after the operation for bronchial stump reamputation in 6 cases (46.1%). One patient (7.6%) died 3 months postoperatively due to bronchopleural fistula recurrence. This was also the only case of fistula recurrence. CONCLUSION: LBPF usually needs definite management to save the patient's life. The transsternal, transpericardial approach is a safe and effective method.     

Reinforcement of a bronchial stump in VATS lobectomy

Bronchial stump reinforcement is sometimes required for patients who have a high risk of developing a bronchial fistula. A lobectomy by video-assisted thoracic surgery (VATS) is widely used for the treatment of both stage I primary lung cancer and metastatic central lung cancer, but there has been no report on reinforcement of a bronchial stump in a VATS lobectomy. We report an aged patient with stage I primary lung cancer concomitant to diabetes mellitus who was successfully treated by VATS lobectomy with reinforcement of the bronchial stump using a pericardial fat pedicle flap. A Harmonic scalpel was very useful and effective in harvesting the fat pedicle.     

Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy

This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.     

Omental pedicle flap used to treat a bronchopleural fistula after diaphragma--pericardio-pleuropneumonectomy

In a 47-year-old male patient a bronchopleural fistula was apparent 22 days after extended right-sided diaphragma-pericardio-pleuro-pneumonectomy for pleuramesothelioma. The thoracic cavity was infected. Rethoracotomy was performed and the fistula was closed using an omental pedicle flap. The bronchial stump became tight and the cavity fluid became sterile. No abdominal complications were seen. The patient died 8 months later from malignant pericardial infiltration. The ability of greater omentum to revascularize ischemic tissue, to absorb fluid and to resist local infection is proved and used in several subspecialities of surgery. Nevertheless the use of the greater omentum in the management of bronchopleural fistula has been rarely published. The reported case shows that the closure of a large bronchopleural fistula is possible by using the attributes of the omental tissue.     

Preventive diaphragm plasty after pneumonectomy on account of lung cancer

Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.     

Treatment of postpneumonectomy empyema

Postpneumonectomy empyema with or without (bronchopleural) fistula is an infrequent but serious, and often life-threatening complication. In 20 of our patients postpneumonectomy empyema was discovered. The time interval between original operation and discovery of the empyema varied from 9 days to 9 years. In two cases, the empyema had been found and treated initially at another hospital but not adequately, so that at the time of treatment by us the bronchopleural fistula had already been present for 8 and 19 years. In 13 cases a bronchial stump fistula was discovered. In five patients the fistula was successfully closed endoscopically with glue. In one patient closure was performed by transmediastinal stump resection, in three patients with a fistula thoracoplasty was performed. In three patients we achieved closure by transposition of pedicled muscle flaps. In one of these patients a septic condition could be mastered by performing window thoracotomy. Two patients without fistula were successfully treated with irrigation, and two further patients with thoracostomy. In one patient recovery was achieved by medication after puncture. Two patients died of sepsis and after thoracoplasty. If a fistula is present, drainage with irrigation and endoscopical glueing should be the initial treatment. This should be followed by resection of the bronchial stump. If there is no fistula or if the stump is too short thoracostomy is the treatment of choice. If it is not successful thoracoplasty has to be performed.     

Postpneumonectomy empyema

Empyema is a serious complication after pneumonectomy. It is often associated with a bronchopleural fistula. Several risk factors have been associated with an increased incidence of these two challenging complications. Therapy aims at simultaneously treating the infected pleural space and the fistula. The authors describe their favorite methods which include repeated open debridements of the pleural space, primary closure of the fistula, and covering of the bronchial stump using intrathoracic transposition of extrathoracic skeletal muscle followed by delayed closure of the chest wall after instillation of an antibiotic solution (Clagett and modified Clagett procedures). The goals of treatment remain a healthy patient with a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients. Failure is often associated with a persistent or recurrent bronchopleural fistula.     

Late postpneumonectomy bronchopleural fistula

OBJECTIVE: The incidence of late postpneumonectomy bronchopleural fistula (PBPF) is very small after the 3rd postoperative week due to the existence of fibrothorax providing an effective natural protection against fistula formation. However, the development of late PBPF is a serious complication characterized by high morbidity and mortality. We present our modest experience in treating 11 patients with late PBPF using the transsternal transpericardial approach. MATERIAL: Between 1996 and 1999, 11 male patients with a mean age of 61 years were treated in our department for late PBPF (diameter > 5 mm). The interval between pneumonectomy and fistula creation ranged from 1 to 10 years. The initial operation was right pneumonectomy in all cases due to lung cancer. pTNM stage was either II or IIIA. Bronchoscopically no recurrence was observed and empyema was present in all cases. RESULTS: The initial treatment consisted of tube thoracostomy. We proceeded to direct bronchial stump repair transpericardially with omental flap coverage and finally open window thoracostomy. Neither deaths nor major complications occurred perioperatively. The ICU and hospital stay ranged from 5 to 10 and 30 to 45 days, respectively. During a follow-up of 10 to 28 months no recurrence was observed. CONCLUSIONS: 1. The management of late large PBPF can be only surgical. 2. Fibrothorax and empyema makes the approach through thoracotomy impossible and dangerous for dissection and repair. 3. Bronchial stump repair through the transpericardial approach by median sternotomy is very effective in late PBPF cases where the patient's general condition is good, allowing a major intervention.     

Triple reinforcement of bronchial stump

Various methods are used to prevent bronchopleural fistula following anatomical lung resection, as bronchopleural fistula constitutes a life-threatening complication. Pleural flaps are less vascularized, whereas an intercostal muscle flap, although well vascularized, does not offer enough strength for repair. We describe here the use of pleural flaps to strengthen a bronchial closure and cover the defect. Subsequently, an intercostal muscle flap is buttressed over the bronchial stump.     

福建省高致病性禽流感A/H5N1病毒感染并支气管胸膜瘘患者的救治体会

目的 总结重症高致病性禽流感A/H5N1病毒感染(简称人禽流感)患者的临床特点、治疗经验以及合并支气管胸膜瘘的处理方法.方法 对2007年2月福建省建瓯市立医院成功救治的1例重症人禽流感并发右侧支气管胸膜瘘患者的临床资料和诊治过程进行回顾性分析.结果 患者女,44岁,发病前3 d有病死鸡接触史,以发热、气促为主要症状,经呼吸道分泌物检测A/H5N1病毒核酸阳性确诊.患者住院第7天发展为急性呼吸窘迫综合征,病情重、进展快,病程中出现呼吸机相关肺炎、双侧气胸、右侧支气管胸膜瘘等多种并发症.经奥司他韦抗病毒、糖皮质激素抗炎、输注康复期血浆、机械通气、抗感染等治疗,病情有所缓解,但支气管胸膜瘘持续存在并形成脓胸,导致脱机困难.经纤维支气管镜下气囊探查加选择性支气管封堵术、经纤维支气管镜右侧支气管胸膜瘘OB胶粘堵术等介入治疗,患者痊愈,发病第99天出院.结论 人禽流感并发难治性支气管胸膜瘘患者在采取抗病毒、抗感染、机械通气支持、输注康复期血浆等综合治疗的基础上结合介入治疗是可行的.     

肺结核全肺切除近期并发症的治疗

目的 探讨肺结核全肺切除后并发症的诊断和治疗.方法 对北京胸科医院胸外科2000年9月至2010年9月经全肺切除治疗的206例肺结核患者术后近期手术并发症及其治疗效果进行回顾性分析.结果 206例中发生近期手术并发症的26例,术前病变类型:毁损肺12例,肺叶切除后余肺毁损4例,结核性支气管狭窄1例,肺结核合并脓胸2例,肺结核合并支气管胸膜瘘3例(经支气管镜检查证实),空洞型肺结核2例,肺结核合并大咯血2例.26例中左肺15例,右肺11例.入院查痰为痰菌阳性7例.26例中术后14个月内急性呼吸衰竭5例,经呼吸机治疗,3例治愈,2例死亡;术后3个月ARDS 2例,经呼吸机治疗,1例治愈,1例死亡;术后20 d胸腔内出血7例,2例治愈,5例死亡;术后4年脓胸8例,全部治愈;术后50 d支气管胸膜瘘4例,2例治愈,1例未愈,1例死亡.结论 药物治疗是结核病的重要治疗方法,但部分肺结核患者仍需要外科手术治疗,全肺切除可以提高重症肺结核的治愈率,绝大多数手术并发症均可治愈.

Abstract：

Objective To explore the diagnosis and management of short-term complications after pneumonectomy for pulmonary tuberculosis.Methods The clinical data and management of short-term complications in patients with pulmonary tuberculosis after pneumonectomy were retrospectively reviewed and analyzed.Results From September 2000 to September 2010, 206 patients with pulmonary tuberculosis underwent pneumonectomy, of whom 26 experienced complications shortly after the surgery.Postoperative acute type Ⅱ respiratory failure occurred in 5 within 14 months post-operation, acute respiratory distress syndrome (ARDS) in 2 within 3 months post-operation, chest hemorrhage in 7 within 20 days postoperation, empyema in 8 within 4 years post-operation, and bronchopleural fistula in 4 cases within 50 days post-operation.Of the 7 cases with chest hemorrhage, 2 were cured and 5 dead.All the 8 cases with empyema were cured.Of the patients with bronchopleural fistula, 2 were cured, 1 failed, and 1 was dead.Conclusions Pneumonectomy for pulmonary tuberculosis carries a higher risk of developing serious complications such as chest hemorrhage, acute type Ⅱ respiratory failure and bronchopleural fistula.Most complications can be managed successfully if diagnosed and treated early.     

Post pneumonectomy empyema with bronchopleural fistula--a successful management using pedicled intercostal muscle flap on an atypical mycobacteriosis following the irradiation

A 48-year-old woman underwent a right pneumonectomy for advanced mycobacterial disease (M. avium Complex), which followed the postoperative radiotherapy against a malignant schwannoma of the right lower chest wall treated seven years ago. On the 13th postoperative day, re-suture of the bronchial stump was performed urgently because of early bronchopleural fistula development. On the heels of that, reclosure of the bronchial fistula with coverage of the stump by parietal pleural flap was performed on the forty-first post operative day. On the 110th day, however, open drainage with thoracoplasty was performed because development of insidious aspergillous empyema was detected. Since then, local instillation of amphotellisin B, with an oral administration of antifungus drug was started. After succeeding to control the mycotic infection, reclosure of the bronchofistula, covered with pedicled intercostal muscle flap were performed on the 280th postoperative day and extraperiostal air-plombage for reducing empyema cavity. Postoperative course was uneventful and the patient was discharged one year later. With respect to pathogenetic relationship between radiation pneumonitis and feasibility of infection to atypical mycobacteria, preoperative radiotherapy and concurrence of postoperative bronchofistula, and some problems on management of empyema bronchofistula were briefly discussed.     

Use of the greater omentum for treatment and prophylaxis of anastomotic and stump dehiscence in major airway surgery.

In 6 patients suffering from anastomotic dehiscence following bronchoplastic procedures of the central airways or from acute bronchial stump fistula following pneumonectomy, the therapeutic efficiency of omentopexy in the management of the fistula was investigated. In 5 other patients with an increased risk of anastomotic leakage after sleeve pneumonectomy or pneumonectomy with carinal resection the omentum was effectfully used to prevent such complication. 4 out of 5 evaluable patients had successful treatment of the anastomosis and stump fistula. Complications arising from the additional laparotomy were not observed.     

The extrapleural treatment of main bronchial stump fistulae using a contralateral approach

When dealing with a left main bronchial stump fistula with chronic empyema, a contralateral extrapleural approach is recommended for reamputation and closure at both the proximal and distal sections. By these means a secure closure can be achieved and, at the same time, infection of the pleural cavity on the right side can be avoided, the preserved and unopened mediastinal pleura reliably covers the operative site, and postoperative respiratory disturbances can also be avoided.     

Alternative for primary pericardial closure: sentry for re-entry

BACKGROUND: Redo cardiac surgery is considered high-risk surgery as accidental injury to the aorta, the innominate vein, the ventricles and the atria is a possibility. Such accidental injury occurs when the cardiac chamber is adherent to the undersurface of the sternum. Closure of pericardium at the time of primary surgery can prevent adherence of cardiac chambers to the sternum, but may increase the risk of tamponade. This study aimed to show that covering heart with a pedicled pericardial fat pad not only serves the purpose of cover but also avoids the adverse haemodynamic effects of primary pericardial closure. METHODS: Forty patients undergoing elective cardiac surgery were randomised into two groups depending on the way pericardium was managed. Both techniques were already in routine use in our unit and in other units around the country. One method is to leave the pericardium widely open, the other is to loosely oppose the pericardial fat pad over the surface of the aorta and right ventricle. Twenty-three patients had a pedicled pericardial fat pad covering the heart: Closure Group. Seventeen patients had no pericardial fat pad cover over the heart: Open Group. A haemostasis clip was used as a radio-opaque marker over the epicardium in both groups. Post-operation heart rate, central venous pressure, pulmonary artery diastolic pressure, mean arterial pressure and cardiac index were measured and recorded 1, 3 and 8h after surgery. The distance between the haemoclip and the posterior table of the sternum was measured at 6 days and 6 months post-operation. Haemodynamic parameters and the retrosternal space depth were compared between the two groups. RESULTS: There were no important differences in haemodynamic parameters between the two groups. Post-operative lateral chest Roentgenograms showed that the distance between epicardial surface and the posterior table of sternum was larger in the Closure Group compared to Open Group on post-operative day 6, 17.5+/-1.0mm versus 13.4+/-1.3mm (P=0.0013) and 6 months later, 12.3+/-0.8mm versus 6.0+/-1.2mm (P<0.001). There was no mortality in either group. CONCLUSION: Pedicled pericardial fat pad cover is a good alternative to primary pericardial closure as there are no adverse haemodynamic effects in early post-operative period and the long-term benefit of protection of heart at the time of re-sternotomy can be expected.     

Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter

OBJECTIVE: Side- and sex-related differences were analysed to explain the occurrence of bronchopleural fistula (BPF) after pneumonectomy on the right-hand side in men. PATIENTS AND METHODS: Surgical pathology reports on 209 patients (15 with BPF) were retrospectively reviewed regarding sex, age, side, TNM stage, outer diameter of the resection margin (mm) and intrabronchial distance between tumour and resection margin (mm). Patients without macroscopic bronchial invasion were categorised as peripheral tumours. The t-test, U-test (Mann-Whitney) and cross-tabulation using the chi 2-test were performed for univariate statistical analysis. A logistic stepwise backwards regression model was used for multivariate analysis. RESULTS: Women were significantly younger than men, had a smaller resection margin and fewer central tumours. Stage 4 was overrepresented in women, stage 2 in men. On the right-hand side, the distance was significantly shorter, the resection margin longer and the patients younger. Fistula patients showed a longer resection margin and a shorter distance, men were dominant. Multivariate analysis only identified length of the resection margin as an independent risk factor for BPF (p = 0.024, OR 1.177 CI: 1.033 - 1.356). Gender and side significantly influenced the diameter of the resection margin (p = 0.00). CONCLUSION: The diameter of the bronchial stump is a major risk factor in the occurrence of post-pneumonectomy BPF, and explains the predominance of the male sex, the right-hand side and pneumonectomy. Where it exceeds 25 mm, prophylactic stump coverage with viable tissue should be performed.     

Bronchopleural fistulas after pneumonectomy. A problem with surgical stapling

After multiple reports demonstrating excellent results and improved healing of the bronchial stump in cases of pneumonectomy performed with standard reusable parallel firing stapling devices, there has been an isolated report from Europe of increased incidence of bronchopleural fistulas with the use of the modified reusable hinged stapling device. Our report confirms and extends that observation. Review of 42 successive pneumonectomies revealed one case of bronchopleural fistula with the use of the standard reusable parallel firing stapling device; there were six cases of bronchopleural fistulas in 36 successive pneumonectomies performed with the modified hinged stapling device (four with reusable and two with disposable instruments). Improperly formed staples were identified by x-ray examination or reoperation. We recommend that only the standard reusable parallel firing stapling devices be used for bronchial closure in pneumonectomy.     

Pericardial Fat Pad and Thoracic Aortic Surgery

Pericardial fat pads have been successfully used for many years by thoracic and cardiac surgeons for a number of applications. We recently used a pedicled and well-vascularized pericardial fat pad in a patient who underwent replacement of a distal aortic arch aneurysm with a Dacron tube graft, in order to avoid contact between the anastomoses and the oesophagus in an effort to reduce the risk of subsequent infection and fistula formation. This simple technique may provide a source of vital tissue that may be useful for protecting anastomoses after thoracic aortic surgery, particularly in cases requiring re-operation. To our knowledge the use of pericardial fat pads has not been previously reported in the English literature for this purpose.