重视肠瘘的早期诊断与快速治疗

腹部外科手术后发生肠瘘，尤如大江决堤，令人见之“色变”。紧随肠瘘之后就是感染、出血和水电解质失衡。感染和出血失控又会进一步加重脏器功能损害，导致多脏器功能障碍。整个病程中患者能量与蛋白质的摄入、消化与吸收均会不同程度地受到影响，营养不良随之发生。诸多并发症相继出现并相互影响，形成恶性循环，病程迁延，最终引起一个或多个脏器功能的衰竭，导致治疗失败。     

Remnant closure after distal pancreatectomy: current state and future perspectives

Remnant closure after distal pancreatectomy remains a surgical challenge and is still associated with a fistula rate of about 30%. Despite numerous technical modifications including the use of stapling devices, artificial patches and glue components, no important progress has been made concerning this topic within the last decade. Although tissue texture, co-morbidities and the type of resection may influence fistula rate, substantial improvement can probably be reached by further technical modifications. In addition to the avoidance of fistula development, the recognition and management of this complication is essential to achieve good postoperative outcome. The present review summarizes the currently available data on technical approaches, incidence and risk factors for failure of remnant closure, fistula-associated complications and management as well as the future perspectives in this field of surgery.     

A safe and effective method for an immediate bronchopleural fistula repair

Bronchopleural fistula (BPF) is a well recognized and potentially fatal complication of major thoracic surgery and several strategies regarding its prevention and subsequent management have been described. An immediate BPF occurring intraoperatively after bronchial closure is a rare event and is usually treated by bronchial stump reamputation and/or hand-suture reinforcement by mattress suture, or myoplasty. We report a simple and successful technique, using azygous vein flaps, to repair an intraoperative BPF associated to a small bronchial dehiscence occurred after a right pneumonectomy in a 70-year-old diabetic man receiving induction chemotherapy treatment.     

The use of automatic stapling devices in pulmonary resection

The use of mechanical automatic stapling devices for closure of the bronchus, pulmonary arteries and veins, and lung parenchyma in 349 consecutive patients undergoing various types of pulmonary resection is described. Bronchopleural fistula has occurred only 2 times in 60 patients undergoing pneumonectomy. One occurred four months and 1 six months postoperatively. In both cases recurrence of carcinoma was demonstrated in the bronchial stump. No bronchopleural fistulas occurred following 136 lobectomies. Significant parenchymal air leaks occurred 5 times in 289 patients. No complications resulted from staple closure of pulmonary vessels except the instance previously reported [13]. The use of stapling devices has greatly lessened blood loss and reduced anesthetic and operating periods, thus permitting more extensive resection in marginal-risk patients and fewer complications when compared with traditional methods of resection.     

Surgical management of ileosigmoid fistulas in Crohn's disease

Seventeen patients with ileosigmoid fistula complicating Crohn's disease are reported on. Eighty-two percent of the fistulas were diagnosed radiologically. Thirteen of the patients (76 percent) were treated by resection of the diseased ileum and cecum with primary anastomosis, division of the fistula, and simple closure of the colon. There were no anastomotic leaks, and long-term follow-up demonstrated excellent results. Segmental sigmoid resection in addition to resection of the diseased ileum and cecum should only be performed when there is radiologic or histologic evidence of Crohn's disease of the colon. Proximal diversion is generally not required, and most procedures can be performed in one stage.     

Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer.

OBJECTIVES: Despite the advances in surgical technology, bronchopleural fistulas (BPFs) still occur and are often fatal. We studied the risk factors for BPF formation after lung cancer operation to clarify the indication of preventive bronchial stump coverage. In addition, the reliability of our methods of bronchial closure was evaluated. METHODS: We reviewed 557 consecutive bronchial stumps, corresponding to 547 patients without any coverage in pulmonary resection for lung cancer between 1989 and 1998. According to nine variables, stumps that made dehiscence were compared with uneventful ones using contingency table analysis. The incidence of BPFs according to each method of bronchial closure was calculated. RESULTS: BPFs developed in ten patients (1.8%). Compared with the lobar bronchus (LB), the main bronchus (MB; P<0.01; odds ratio, 23.0) and the intermediate bronchus (IB; P=0.03; odds ratio, 10.7) carried a high risk. Previous ipsilateral thoracotomy (P<0.01; odds ratio, 37.9) and preoperative chemotherapy and/or radiotherapy (P=0.02; odds ratio, 13.2) increased the risk. The incidence of BPFs with manual suture, stapling devices only, reinforcement suture at the distal side of staplers, or reinforcement suture at the proximal side of staplers was 1.8, 5.0, 1.9 and 1.0%, respectively. CONCLUSIONS: The main and intermediate bronchial stumps, and the stumps in cases with previous ipsilateral thoracotomy or receiving induction therapy are prone to BPFs. Preventive coverage should be considered for these stumps. Our methods for reinforcement of stapled stumps are thought to be reliable.     

Surgical treatment of 'short stump' bronchial fistula.

OBJECTIVE: The optimal management of bronchial fistulae remains a surgical challenge. To assess the relative efficacy of the transsternal approach in the treatment of short stump bronchial fistula we analyzed a cohort of patients who underwent this type of surgery in our department during an almost 19 year period. METHODS: Of a series of 49 patients with short stump bronchial fistula who were treated via the transsternal approach, 15 underwent bifurcational sleeve resection and 34 had tracheal wedge resections. In 19 cases the tracheal defects was up to 30 mm in diameter, in the remaining 30 cases the length was less than 10 mm. In all cases tracheobronchial fistulae were associated with concomitant empyema. Surgical debridement of the empyema cavity was achieved by VATS application. In five patients who underwent primary surgery for lung cancer tumor recurrence was seen in distal margins of the resected defect. RESULTS: There was no intraoperative mortality. Two patients died from acute pneumonia at postoperative day 3 and adult respiratory distress syndrome (ARDS) at postoperative day 7, respectively. Two further patients died due to anastomotic dehiscence from sepsis and respiratory failure the overall hospital mortality being 8 (16%). Major complications included one right pulmonary artery injury (2%), two healing disturbances after tracheal wedge resection and five after sleeve resection of the bifurcation. Late complication occurred in six patients (13.3%) with delayed healing at the suture site who later required treatment, two of these required additional stent applications. CONCLUSIONS: Surgical treatment of patients with short stump tracheobronchial fistulae by means of a transsternal approach allows reliable closure with low mortality and morbidity.     

Management of bronchopleural fistula following pneumonectomy

Bronchopleural fistula developed in 28 (12.5%) of 225 pneumonectomies performed for pulmonary carcinoma of non-small cell types during a 10-year period. The incidence of fistula apparently decreased significantly when chromic catgut was replaced by Dexon for closure of the bronchial stump. The fistula presented as an emergency in nine cases and was subacute in 19. The overall mortality from bronchopleural fistula was 28.6%. Conservative treatment, i.e. bronchoscopic application of silver nitrate to destroy the epithelium in the bronchial stump and induce granulation, achieved closure of fistula in all the surviving patients. In the seven patients with sterile pleural cavity the pleura was not drained. The results justified our principle of conservative management when a bronchopleural fistula does not present as an emergency. In emergency situations, however, or if the pleural fluid is purulent, pleural drainage should be instituted.     

Management of empyema after lung resections (pneumonectomy/lobectomy)

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.     

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.     

The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients

Nineteen patients with bronchopleural fistulas associated with tuberculosis and 2 patients with fistulas following resection for bronchiectasis underwent closure of the fistulas with pedicled flaps of chest wall muscle. The muscle grafting was combined with a limited thoracoplasty in 13 patients. The initial myoplasty produced prompt fistula closure in 15 patients and delayed closure in 2 others. A repeat myoplasty was successful in 2 patients in whom the initial myoplasty failed. Compared with other methods of treating bronchopleural fistulas used during the same period, muscle grafting carried a higher rate of successful fistula closure and a lower mortality rate.     

Postoperative bronchial stump fistula after lobectomy: response to occlusion with polyglycolic acid mesh and fibrin glue via bronchoscopy

Bronchial stump fistula after resection of lung cancer is an extremely difficult to treat postoperative complication. Endoscopic fistula closure is a favorable alternative, potentially avoiding major surgical intervention. an 80-year-old man underwent curative resection of squamous cell carcinoma by left upper lobectomy of the lung. The patient suddenly developed massive subcutaneous emphysema on postoperative day 10. Bronchoscopy revealed a fistula about 3 mm in diameter at the lateral edge of the bronchial stump. Concentrated fibrinogen 0.5 ml (fluid A) was sprinkled on the bronchial fistula initially, and then pieces of polyglycolic acid mesh presoaked in fluid A or fluid B (thrombin) of the fibrin glue were pushed with biopsy forceps into the fistula in an alternating fashion (A→B→A→B) under endotracheal local anesthesia. Air leakage was stopped, and the patient did not develop empyema. Particularly for patients in poor general condition, our noninvasive technique seems to serve as a therapy of first choice.     

Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

BACKGROUND: Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed. METHODS: All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis. RESULTS: Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis. CONCLUSIONS: Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.     

Double suture technique of bronchial closure following pulmonary resection

Double suture technique of the closure of bronchial stump, following pulmonary resection, has been tried with success in our centre. Additional interrupted horizontal sutures, just proximal to the main suture line, protect the latter from the effect of increased intrabronchial pressure and minimize the incidence of bronchopleural fistula.     

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.     

Vascular occlusion device closure of bronchial stump fistulae: a straightforward approach to manage bronchial stump breakdown

Post lung resection surgery bronchopleural fistula (BPF) continues to be a dangerous complication associated with very high mortality and morbidity. Traditional treatments have included primary closure of the fistula with muscle flaps and thoracic window formation. New techniques for secondary stump closure have included glues, stents and coils. We report another bronchoscopic treatment of BPF using an atrial septal closure/vascular occlusion device combined with bioglue.     

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).     

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.     

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.     

支气管胸膜瘘31例临床分析

总结３１例支气管胸膜瘘治疗经验。自１９８０～１９９２年间共施行肺切除４３２５例，发生支气管胸膜瘘３１例，发生率０．７％。其中全肺切除１９例，发病率１．８％（１９／１０３９）。住院死亡率３２％（１０／３１）。术前放射治疗４１２例，发生支气管胸膜瘘５例，发生率１．２％。作者强调预防支气胸膜瘘发生及早期处理的重要性，提出５点预防措施以降低支气管胸膜瘘的发生率。