Video-mediastinoscopic resection of a long bronchial stump and reclosure of bronchial insufficiency after pneumonectomy

Bronchial stump insufficiency after pneumonectomy is a severe problem and there is still debate about the appropriate method (transthoracic or transsternal) for reclosure. Access through a sterile operative field for a successful redo-procedure seems to be important so an alternative to the open methods could be the video-mediastinoscopy as it allows approaching the bronchial stump via the mediastinum. Previously in 1996 Azorin performed the first mediastinoscopic reclosure by stapling an early insufficiency after left pneumonectomy. We report the first case to our knowledge of resection and reclosure in bronchial stump insufficiency via mediastinoscopy. An HIV-positive man presented with late bronchial stump insufficiency after left pneumonectomy for lung cancer. The cause was a long bronchial stump and there was no sign of tumour recurrence. Decision was made for a video-mediastinoscopy and resection and reclosure successfully performed by using an endostapler device. Postoperative bronchoscopy at six months revealed a well-healed stump and two years postoperatively the patient is doing well. The mediastinoscopic approach is a novel option in highly selected patients. It warrants minimal surgical trauma; however, one has to be prepared to convert to an open technique immediately.     

Prophylaxis and treatment of primary insufficiency of bronchial stump after pneumonectomy

Efficacy of gel DAM+ in bronchial surgery was evaluated in experimental and clinical studies. In clinical practice DAM+ was used for treatment of 22 patients with insufficiency of bronchial stump, and in 12 patients with high risk of stump insufficiency this gel was administered into submucosal layer before stump closure. It is demonstrated that administration of DAM+ gel into submucosal layer is simple and effective method of treatment and prophylaxis of bronchial stump insufficiency.     

Closure of the bronchial stump: suturing or stapling? (author's transl)]

In 1016 pulmonary resections we had 2,6% bronchial fistulae. 447 times we used interrupted suture (2,9% of bronchial stump insufficiency) and 542 times we used the Soviet bronchus stapling machine UKB 25 or 16 with 2,2% of fistulae.     

肺切除机械缝合法闭合支气管断端562例报告

目的探讨应用支气管闭合器机械缝合支气管断端的临床效果和技术要点。方法在562例肺切除术中应用支气管闭合器机械缝合支气管断端。结果全组均未发生支气管胸膜瘘及脓胸,554例均一次成功闭合支气管,仅有8例支气管断端有少许漏气,予以间断加强缝合。结论应用支气管闭合器机械缝合支气管断端临床效果可靠,可以降低支气管胸膜瘘的发生。     

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.     

The endoscopic treatment of bronchial fistulas by submucosal injections

A total of 21 patients (aged 30-72) with bronchial stump fistulas (307 mm) were treated by a newly developed method of treatment of purulent-destructive pulmonary diseases. This technique represents a gradual narrowing of the bronchial fistula lumen due to infiltrate formation in the submucosal bronchial layer. The volume formation substance biopolymer "DAM+", hydrogenous biopolymer with ions of silver "Argiform" for endoprosthesis of the soft tissues, is injected into the submucosal bronchial layer. It is necessary to make 5-20 fibrobronchoscopies for bronchial fistula healing. No complications occurred as a result of this treatment. The healing of bronchial fistula and bronchial stump epithelization were found in 18 patients.     

Value of radiotherapy for tumour on the bronchial stump after resection for bronchial carcinoma.

Two groups have been selected from 1000 patients who had lobectomy or pneumonectomy for bronchial carcinoma. The first group was of 26 patients with tumour affecting the mucosa of the resected bronchial margin reported histologically at the time of surgery. Twelve of these were given postoperative radiotherapy but with no apparent benefit, either in the incidence of recurrence of tumour at the bronchial stump or in five-year survival. The second group was of 17 patients who developed recurrence of tumour at the bronchial stump, bronchoscopically confirmed, some time after surgery. In six of these cases the recurrence was detected while it was confined to the bronchial stump region, and these patients were then given radiotherapy. Five of the six survived five years after radiotherapy, with complete eradication of the tumour recurrence confirmed by repeat bronchoscopy. In 11 cases the tumour recurrence was not detected until it had become more extensive. Radiotherapy may also have prolonged survival in some of these patients, although none survived five years.     

Evaluation of the blood supply to the bronchial stump following resection of the lungs using a mechanical suture in the diagnosis and treatment of pulmonary hemorrhage

The authors analysed angiograms of 34 patients who had been operated on the lungs with the use of mechanical suturing instruments to determine the effect of the mechanical suture (MS) of the bronchial stump on the development of hemoptysis and pulmonary hemorrhage. They studied the possibility of applying transcatheter endovascular occlusion (TEO) of the bronchial arteries (BA) in the management of hemoptysis of this etiology. In 70% of patients hyperplasia of the BA developed in the MS region in the late postoperative period; which was the source of pulmonary hemorrhage in 75% of cases. Among the patients, 19 were subjected to BA TEO for pulmonary hemorrhage. In 13 cases the bronchial stump with MS was the source of hemorrhage. Hemoptysis is a late complication of lung resection with the use of MS. Preference should be given to BA TEO in the management of this complication.     

Mortality rate after lung resection for bronchial carcinoma (author's transl)]

1351 patients with lung resection were analyzed. Lethality during hospital treatment was 6.2%. 11 patients, who died during the 6 first weeks after the resection, had occult metastases. The causes of death among these 6.2% were pulmonary embolism (40.5%), insufficiency of the bronchial stump and following complications (17.9%), pneumonia (10.7%), cardiorespiratory failure (9.5%) and intraabdominal complications (8.3%). Improving these figures should begin with reducing the cases with pulmonary embolism.     

Application of greater omentum for regeneration of bronchial stump

The regeneration processes in bronchial stump with participation of the great omentum tissue, located in pleural cavity with preservation of vascular peduncle of created strand were studied in experiment. The data concerning the course of healing of bronchial stump under condition of nonviable great omentum tissue are adduced.     

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.     

肺切除术后支气管残端瘘的处理(附2例报告)

目的 探讨肺切除术后发生支气管残端瘘的原因、临床表现、手术时机及处理原则.方法 回顾分析2例肺癌根治术后并发支气管残端瘘的临床表现、诊断、治疗经过及方法.结果 两例患者均痊愈出院,1例采用常规胸腔内闭合支气管残端治愈,1例经纵隔心包内闭合支气管残端得到治愈.结论 支气管残端瘘应尽早诊断、并予以持续胸腔冲洗,抗感染、营养...     

Effects of preoperative chemotherapy and radiation therapy on human bronchial blood flow

OBJECTIVE: We investigated the relationship between bronchial mucosal blood flow around the area of lung resection and the state of healing of the bronchial stump in patients after chemotherapy with or without radiation therapy. METHODS: Ninety patients with primary lung cancer were divided into the following 3 groups: group A, 72 patients who had no preoperative therapy; group B, 10 patients who had chemotherapy; and group C, 8 patients who had chemoradiation (60 Gy) therapy. Bronchial mucosal blood flow was measured preoperatively, intraoperatively, and postoperatively (days 8-10) with a laser Doppler flowmeter. RESULTS: In groups A and B bronchial mucosal blood flow was preserved sufficiently around the surgical site, and the healing of the bronchial stump was satisfactory. On the contrary, preoperative blood flow in group C was 70% of the preoperative value in group A and decreased further intraoperatively. Healing of the bronchial stump was poor, and a bronchopleural fistula occurred in one patient of group C. CONCLUSION: Preoperative chemoradiation therapy may adversely affect bronchial mucosal blood flow and healing of the bronchial stump, although lymphadenectomy and preoperative chemotherapy had little effect. It is recommended that the bronchial stump should be covered with pedicled viable tissue after chemoradiation therapy for prophylaxis against bronchial complications.     

Surgical treatment of bronchial fistulas after pneumonectomy

The results of surgical treatment of 9 patients with bronchial fistulas after pneumonectomy have been analysed. During the reoperation the bronchial stump was wrapped by the omental flap with vascular pedicle (omentoplasty). In 6 patients omentoplasty was used in urgent repeated transpleural operations, in 3--during the late operations from transsternal transpericardial approach. Wedge resection of the tracheal bifurcation with omentoplasty from transsternal transpericardial approach was performed in 2 patients with a short bronchial stump. 2 patients died after surgery: one--from cardiopulmonary failure, the other one--from the relapse of bronchial fistula. Omentoplasty in patients with primary bronchial fistulas proved to be effective. It is advisable to perform reoperations during the 1st day after complications developed.     

Videothoracoscopy and muscle flaps in the treatment of bronchial stump fistula.

The aim of the paper is to report our surgical technique applied for treatment of broncho-pleural fistula (BPF) as well as the results of the treatment. From 1992 to 1998 we performed 127 pneumonectomies for lung cancer. In 5 cases (3.9%) bronchial stump insufficiency developed postoperatively. Three patients were treated by means of videothoracoscopy (the Multifire Endo Hernia Stapler was used to clipped the fistula). Rethoracotomy with myoplasty was performed four times in 3 patients. In one patient both the methods were employed. In 2 out of 3 cases videothoracoscopic treatment was successful and the patients were discharged without signs of BPF and pleural empyema. In one case the recurrence of the fistula occurred and the stump of the bronchus was successfully covered with the pectoral musce flap 3 days later. In two cases after rethoracotomy and myoplasty (one of them was reoperated twice) the recurrence of BPF occurred and both the patients died due to cardiopulmonary failure. Despite the limited experience, we think videothoracoscopy is worth considering as a tool for treatment of BPF.     

Tracheobronchography in the diagnosis of bronchial fistulas following pulmonectomy]

The authors present an analysis of contrast investigations of the trachea and the main bronchus stump in patients subjected to pneumonectomy (35 patients), the first group--with the presence of bronchial fistula and pleural empyema, the second group--with a suspicion to fistula in the stump. Tracheobronchography proved to be considerably more informative with respect to the diagnosis of bronchial fistula, than tracheobronchoscopy in patients of both groups. Contrast studies of the stump gave objective evidences as to the length and form of the stump, its communication with the pleural cavity, in 1/4 of patients it enabled the investigators to reveal the presence of cavaties adjacent to the stump in the mediastinum and to pinpoint further in indications to surgery. A more wide application of tracheobronchography for diagnosis of bronchial fistulas after pneumonectomy in largely advocated.     

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.     

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.     

支气管闭合器在肺切除术的应用——附397例经验总结

目的探讨器械缝合法在肺切除术中闭合支气管残端的作用。方法回顾分析638肺切除术患者用器械缝合法闭合支气管残端的疗效。结果全组无支气管胸膜瘘发生,均顺利恢复。结论采用器械缝合法闭合支气管残端省时、安全,能减少术后并发症,明显提高手术疗效。     

Recurrence at the bronchial stump after resection of lung cancer.

OBJECTIVE: Recurrence at the bronchial stump frequently is difficult to diagnose before the disease progresses. Patients with recurrence at the bronchial stump after surgical treatment were studied to clarify characteristics. SUMMARY BACKGROUND DATA: Reports on this type of recurrence are few. METHODS: Between January 1979 and December 1988, 625 primary lung cancers were resected. Fourteen patients (2.2%), in whom recurrence occurred at the bronchial stump, were studied pathologically and clinically. RESULTS: Eight tumors (57.1%) were squamous cell carcinomas, five (35.7%) were adenocarcinomas, and one (7.1%) was small cell carcinoma. Pathologically, six tumors (42.9%) were stage I, four (28.6%) were stage II, two (14.3%) were stage IIIA, and two (14.3%) were stage IV. Eight patients had bloody sputum at recurrence; two cases were asymptomatic. Submucosal tumors were observed bronchoscopically at recurrence in 11 patients. Considering lymphadenopathy on chest x-ray, the submucosal type recurrence may have been direct invasion from metastatic lymph nodes. The periods from the operation to the recurrence were 7 to 102 months (mean 28.8 months). In 8 of 14 patients, recurrence was observed within 24 months. All but one patient died within 24 months of recurrence detection. CONCLUSIONS: Long survival could be expected only if there were no metastases in the mediastinal lymph nodes. If the tumors were detected earlier, it was possible to cure the tumors by intensive therapy, even in submucosal type recurrence. Regular bronchoscopic examination is needed to diagnose the recurrence at the bronchial stump as early as possible.