Clinical experience of omental pedicle flap for bronchopleural fistula

We present two patients who underwent the omental pedicle flap method for bronchopleural fistula. The first case was a 61-year-old man who developed empyema with bronchial fistula due to recurrent tuberculosis resisted to chemotherapy. He underwent complete muscle and omental flap closure of empyema space. The second case was a 63-year-old man who underwent pneumonectomy for adenocarcinoma of the lung. About two weeks after the operation, a bronchopleural fistula developed at the bronchial stump. He underwent complete omental flap closure of fistula. They are doing well 18 and 9 months following operation, respectively. The omental pedicle flap method is clinically useful as a closure method for bronchopleural fistula because of excellent blood supply of the omentum.     

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.     

Transsternal transpericardial approach for the repair of bronchopleural fistula with empyema

BACKGROUND: Numerous surgical approaches have been reported for the repair of bronchopleural fistula. Recently the transsternal transpericardial approach has shown great promise with its positive results in cases of bronchopleural fistula complicated with empyema. The aim of this retrospective study was to assess the results of bronchopleural fistula treatment using the transsternal transpericardial approach. 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.     

The Association of Vacuum-Assisted Closure Therapy with Dynamic Volume Change of a Muscle Flap Transposed in an Empyema Cavity for Chronic Empyema: A Case Report

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.     

Transsternal transpericardial closure of a postpneumonectomy bronchial fistula in a patient who underwent pneumonectomy because of a war injury

Most common causes of intrathoracic empyema include pulmonary infections and postoperative bronchopleural fistulas complicating a lung surgical resection, mainly pneumonectomy, as a result of the failure of the bronchial stump to heal. A 22-year-old Serbian patient presented with chronic posttraumatic empyema. Two years before during a war, he experienced chest injury due to a firearm wound, with massive intrathoracic bleeding and need for emergency left pneumonectomy. Empyema with a bronchopleural fistula occurred during the postoperative course. The patient underwent left open window thoracostomy with a daily bandage change. Here we report the treatment of the bronchopleural fistula using sequential surgical approach including transsternal transpericardial closure of the fistula followed by reconstruction of the chest wall with a regional muscle flap. Our case report highlights the feasibility and efficacy of the transsternal surgical approach to treat postpneumonectomy bronchopleural fistula, thereby avoiding the direct approach to the bronchial stump through the infected pneumonectomy cavity.     

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.     

A successfully treated case of empyema with a large tracheal fistula after a radical operation of esophageal cancer by fixation and plombage with major pectoral muscle flap]

We reported a successfully treated case of empyema with a large tracheal fistula which had developed after a radical operation of esophageal cancer (reconstructed with stomach). This 59-year-old male was treated by the method of fixation and plombage with major pectoral muscle flap and thoracoplasty, because we could not use the omentum that were frequently used nowadays for closure of the fistula. The size of the tracheal fistula was a large as the main bronchus bronchoscopically. Postoperative care were the following, the endotracheal tube was inserted from the tracheal stoma to the left main bronchus and 9 days left hemi-ventilation was performed. Continuous suction was performed at the same time from the right main bronchus in order to prevent secretion and blood pour into the left lung. Bronchoscopical examination done 28 postoperative day, the small fistula remained the tip of the muscle flap. But 72 postoperative day, the surface of the fixed muscle flap was replaced by normal bronchial mucomembrane and tracheal fistula was obliterated. Major pectoral muscle could be used as local flap to obliterate empyema cavity associated with tracheal fistula. We believe that utilizing an muscle flap for those who had undergone abdominal operation like our case is a valuable method.     

Closure of a large bronchial fistula with a latissimus dorsi myocutaneous flap

We describe a case of a large bronchial fistula and empyema after right upper lobectomy that was treated successfully with open window thoracostomy followed by a latissimus dorsi myocutaneous flap and limited thoracoplasty. A latissimus dorsi myocutaneous flap can provide immediate airtight closure of a large bronchial fistula, allowing lavage and curettage of the empyema cavity to reduce the chance of postoperative infection. An important aspect of this technique is that the deepithelialized skin side rather than muscle is sutured to an opening of the bronchus. As compared with other techniques, a latissimus dorsi myocutaneous flap is superior in that it requires a single incision and does not require an intraop-erative change of position. In addition, the technique causes little dysfunction of the chest and shoulder and preserves the vascular supply to ensure the viability of the flap even if it was divided in a previous operation.     

The posterior membranous flap technique for bronchial closure after pneumonectomy

Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients - 89%), small cell lung cancer (one patient - 2.2%), mixed and other types of cancer (two patients - 4.4%), and non-neoplastic etiology (one patient - 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.     

Closure method of bronchopleural fistula with omental pedicle flap in three cases following pneumonectomy

This report presents that successful closure of bronchopleural fistula was performed by using omental pedicle flap for three postpneumonectomy patients. In our department, these cases were experienced among 142 pneumonectomies from January 1984 to July 1989. The initial operations were a pleuropneumonectomy for empyema, a pneumonectomy and a sleeve pneumonectomy for lung cancer. Our technique was direct closure of bronchopleural fistula with omental pedicle flap without thoracoplasty. Although none of them had recurrence of bronchopleural fistula nor other complications in postoperative course, two patients died of cancer.     

Use of Pectoralis Skin Pedicle Flap for Closure of Large Bronchial Fistula Connected with Postpneumonectomy Empyema

In 4 patients, the postpneumonectomy empyema was connected with a large bronchopleural fistula. The empyema was in all cases treated by a permanent open window thoracostoma. The fistulae were closed later with pedicle flaps made of the pectoralis muscle and the adjoining skin. In 2 patients the closing of the bronchial fistula was successful, and the treatment of one patient is not completed. In one patient the open pneural cavity was covered completely by skin using an additional pedicle flap and free skin transplantation. The surgical technique of the pedicle flap operation is described and the cases are reported.     

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer.

OBJECTIVE: Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS: Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS: The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS: Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.     

Free deepithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula

BACKGROUND: Free deepithelialized anterolateral thigh (DALT) flaps have been used for treatment of chronic intractable empyema with bronchopleural fistula at Chang Gung Memorial Hospital since 1997. METHODS: Twelve patients with chronic empyema were treated at Chang Gung Memorial Hospital from January 1997 to January 2001. Their age ranged from 31 to 70 years (mean age 48.6 years). Left-sided involvement was predominant (left to right ratio = 9:3). All patients had bronchopleural fistula, and all were cured. The average numbers of previous thoracotomy were 5.4. The ipsilateral DALT flaps were harvested with primary closure of donor site. RESULTS: At a mean follow-up of 1 year, no recurrence was noted. All flaps survived well. The average hospital stay was 25.8 days. Complications after reconstruction included chrondritis, partial muscle necrosis, and wound dehiscence (1 patient each). There was no donor site morbidity. CONCLUSIONS: Free DALT flaps can be selected according to different situations during surgery as long as they meet the following requirements: (1) tissue of sufficient volume and good blood supply, and (2) closure of the bronchial leak. Based on this retrospective study, use of free DALT flaps with technical refinement is a reliable method for treatment of chronic intractable empyema combined with bronchopleural fistula.     

Technique of bronchial closure after pneumonectomy

Three hundred thirty-two patients had a pneumonectomy at Wythenshawe Hospital, Manchester. England, between 1974 and 1984. In all patients, the bronchus was closed with a posterior flap from the pliable membranous bronchus, leaving no stump, and with the suture line proximal to the carina. In a mean follow-up of 54 months, none of the patients had bronchopleural fistual, and 10 patients had empyema in the pneumonectomy space (3%). A fistula could not be found in any of these patients. The suture material used in closing the bronchus in all these cases was 2-0 chromic catgut, which underlines the fact that bronchial healing is not affected by the type of suture material as long as no tension exists at the suture line.     

Management of empyema cavity with the vacuum-assisted closure device

Management of empyema after pulmonary resection remains a challenging problem. Along with mandatory drainage of the thoracic cavity and investigations to rule out bronchopleural fistula, a reliable method of thoracic cavity closure is needed. The open thoracic window and Eloesser flap techniques rarely represent definitive therapy. Muscle flap and thoracoplasty procedures may provide well-vascularized tissue to close bronchopleural fistula and obliterate the empyema cavity, but they are quite complex and involve significant patient morbidity. We report a case of empyema without bronchopleural fistula after lobectomy in which the vacuum-assisted closure device was used to achieve complete wound healing after open drainage.     

Esophagopleural fistula following pulmonary resection

The development of esophagopleural fistula following pulmonary resection is an uncommon but serious complication. The fistula may appear either soon after operation, due to direct trauma to the esophagus or to its blood supply during extensive dissection, or later, in association with the development of a bronchopleural fistula and empyema following the pulmonary resection. Treatment of these fistulas is usually complicated, and the recovery period is prolonged. Control of infection, hyperalimentation, obliteration of the empyema space, and closure of the fistula with a muscle or pleural flap are recommended methods of management. The pathogenesis, treatment, results, and prevention of this complication are discussed.     

Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.     

Postpneumonectomy Empyema in Pulmonary Carcinoma Patients

The postpneumonectomy empyema of 12 pulmonary carcinoma patients was treated with open window thoracostomy and, whenever possible, with later closure of the thoracostomy. Six of the patients had no bronchial fistula and the pleural cavity of four of them remained healed after the closure of the thoracostomy. Six patients had bronchopleural fistulae. The pleural cavity of one of them remained healed after the closure of the thoracostomy following spontaneous healing of a small bronchial fistula. The cases, in which closure of thoracostomy was not undertaken on account of open bronchial fistula and those in which recurrence of empyema necessitated reopening of the thoracostomy, were managed satisfactorily with permanent open window thoracostomy.     

应用房间隔缺损封堵器封堵结核性支气管胸膜瘘的疗效分析

目的 总结分析应用房间隔缺损封堵器封堵结核性支气管胸膜瘘的治疗经验。方法 对我科在2018年至2019年20例结核性脓胸伴支气管胸膜瘘病例采用应用房间隔缺损封堵器封堵结核性支气管胸膜瘘的治疗进行回顾性分析。本组病例先行胸廓造口开窗引流术（OWT）换药引流2~4周后,残腔感染有效控制的病人选择行光导纤维气管镜下房间隔封堵器封堵支气管胸膜瘘口。结果 全组患者有效地控制胸腔感染后,封堵瘘口治疗后疗效根据临床症状、胸腔及肺部感染控制情况和瘘口闭合情况进行评价,全组20例病例封堵术后达到治愈（CR）标准：瘘口愈合,临床症状完全缓解持续1个月,被封堵器封堵瘘口,临床症状完全缓解持续;随诊6~12个月,其中8例患者封堵术后3~6个月行简单的胸廓关窗术,避免行形体改变大的胸廓改形术,7例患者全身症状改善可耐受择期手术,行余肺切除术+支气管瘘修补术,3例患者部分缓解（partial, PR）,瘘口未闭合,部分被支架封堵,临床症状部分缓解,2例患者出现移位分别在术后8月和术后12月气管镜下取出封堵器。本组患者无死亡病例,围手术期均无不良事件包括封堵器脱落,气道狭窄等并发症发生。结论 该治疗方法具有微创及性价比高的特色,因支气管胸膜瘘的瘘管解剖特殊,与房间隔缺损瘘口结构类似,使用房间隔封堵器治疗结核性脓胸伴支气管胸膜瘘在常规治疗无效的情况下,可作为一种在气管镜下特殊治疗技术应用,能快速、有效地封堵瘘口,降低再次感染风险及呼吸衰竭的发生,为结核性脓胸伴支气管胸膜瘘病人提供一个有效治疗方法选择。     

Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy.

Postpneumonectomy bronchopleural fistula (BPF) remains a serious and often life-threatening complication. Over a seven-year period, seven cases of BPF occurred in a series of 100 consecutive pneumonectomies performed for lung carcinoma by the same surgical team. The incidence increased from 3% (1/33) prior to 1993 to 9% (6/67) thereafter. The presence of tumour within the main stem bronchus and the need for postoperative mechanical ventilation correlated significantly with the occurrence of BPF. However, it is likely that other risk factors, such as the introduction of systematic mediastinal lymph nodes dissection since 1992 and bronchial stapling since 1993, were involved. In four patients, closure of BPF was achieved by transposition of pedicled latissimus dorsi (LD) muscle flap and closed-chest irrigaiton of the pleural cavity. Patients were discharged after a median stay of 19 d; fistula recurred in one case and was successfully treated with an omental flap. No complications related to the LD division were observed. In conclusion, mediastinal lymph node dissection may increase the risk of post-pneumonectomy BPF. Systematic bronchial stapling should be used cautiously, especially if the tumour is present within the main stem bronchus. Treatment with predicted LD muscle flap or omental flap associated with closed-chest irrigation proved to be simple, time-saving and efficient.