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Eur J Cardiothorac Surg 2000;17:2-7
© 2000 Elsevier Science NL

Surgical treatment of ‘short stump’ bronchial fistula

Krasnyh partizan 6/2, City Hospital 2, Regional Thoracic Surgery Center, Krasnodar 350047, Russia

Corresponding author. Tel.: +7-8612-50-89-98; fax: +7-8912-50-55-16

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
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.

Key Words: Tracheobronchial defect • Main bronchus fistula • Short bronchial stump

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The occurrence of main bronchus stump fistula requires special tactics of management, in particular when concomitant chronic empyema is complicating this event. At an early stage resuturing could be considered to close an uninflamed fistula margin with additional coverage by a vascularized flap [1]. In cases of small fistulae an attempt at non-surgical treatment might be considered [2].

The presence of a wide-open bronchial stump is an inevitable indication for surgical treatment. Access to the stump could be achieved via the same pleural cavity through the contralateral pleural cavity in the case of left stump fistula [3] and by means of transmediastinal VATS application [4]. Transpericardial approach helps to avoid surgery within the infected tissues. The advantages of this method were first described by Padhi and Lynn [5] and later thoroughly developed by Abruzzini [6], Perelman [3], and Bogush [7]. There are recent reports of the successful application of this from different groups [8–10]. However, specific difficulties and the high risk of intra- and perioperative complications exist when the stump fistula of main bronchus is less than 1 cm or when the tracheal wall itself is affected in the absence of a bronchial stump [8,10]. In the latter case the resection of the fistula bearing main bronchus is obviously impossible. The closure of the defect in those cases can only be achieved by means of a tracheoplastic suture or by the formal resection of the bifurcation including the margins of the defect. Since 1979 we have advocated this approach and in the following we present our clinical experience.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
From February 1979 to December 1998 49 patients presented with post pneumonectomy stump fistula with a short or totally absent bronchial stump. Thirty-seven cases (69.3%) had the primary operation performed in other hospitals In 12 patients the primary original pneumonectomy had been performed in our own department. There were 42 (85.7%) males and females (14.3%) females with a mean age of 52 years (range 18–62 years). Thirty-nine patients (79.6%) had a right-sided fistula and ten (21.4%) a left-sided. The indication for pneumonectomy was pulmonary tuberculosis in 12 patients (24.4%), non-specific suppurative pulmonary disease in 27 (55.2%), chest trauma in two (4.1%), and lung cancer in eight (16.3%). Signs of fistula developed from 14 days to 38 months (average 42 days); all were associated with pleural empyema. In 30 cases (61%) of still existing short stump the length varied from 1 to 10 mm (average 3 mm) (Fig. 1). In 19 cases the defect was located at the level of the tracheal wall meeting the criteria of a short or absent stump fistula (Table 1). Twelve patients had fenestration of the chest wall measuring from 25 to 200 cm². All patients suffered from malnutrition and weight loss from 10 to 30% of normal.

View larger version (131K): [in this window] [in a new window]   Fig. 1. CT scan of a 43-year-old male who have undergone right-sided pneumonectomy due to the cavernous tuberculosis and complicated with bronchial fistula associated with pleural empyema. Later he has undergone consecutive transpleural surgical interventions for reamputation of RMB which were inefficient. CT shows wide open short main bronchus stump fistula and residual pleural space.

2.2. Surgical technique
For the exposure of the tracheal bifurcation the method previously described by BOGUSH [7] was used with slight modification. Following longitudinal sternotomy the thymic tissue was mobilized and retracted to the left brachiocephalic vein. The upper pericardium was incised longitudinally approximately 5 cm in length. The right pulmonary artery stump was resected through the aortocaval space. The posterior pericardium was incised thereafter exposing the right main bronchial stump, the tracheal bifurcation and the subcarinal area. For left sided lesions the method comprised a wide incision of the pericardium division of the left pulmonary artery stump and, sometimes, also the upper pulmonary vein for exposure of the main bronchial stump. This step was abandoned sparing the incision of the pericardium in the case of left tracheobronchial exposure. The left-sided stump was treated through the aortocaval space.

The following details are observed: two or three stay sutures were placed in the lateral tracheal wall via the aortocaval space for upward traction of the trachea. No resection of the left pulmonary artery stump was considered. Nor was it necessary to expose the posterior wall of the subcarinal trachea, and/or the bronchial stump since vitality of the tissue is compromised by scar changes. All manipulations on the posterior tracheal wall were accomplished under direct vision unlike the proposal of Perelman [3] and Bogush [7].

After traction of the left tracheobronchial angle into the aortocaval space the stump when present, was divided from the trachea or, alternatively, wedge (Fig. 2) or sleeve resections of the distal trachea was performed. Clear margins at the resection sites were ensured by frozen section examinations in those patients who had previous pneumonectomy for lung cancer. The tracheoplastic closure of the defect after wedge excision was achieved with single sutures in one layer. Before tightening the knots, the endotracheal tube was withdrawn for better mobility of the edges. In the case of tracheal sleeve resection the anastomosis was begun at the posterior wall either under jet ventilation or across the field conventional ventilation via thin flexible tube. In other cases the posterior sutures were placed during apnea with the standard endobronchial tube being retracted, suture material for the anastomosis was Prolene or PDS 3-0 atraumatic both interrupted or continuous, the latter proving more convenient. Protection of the anastomosis was achieved by wrapping with a pedicled thymus fat pad, pericardial flaps, or pedicled omentum majus flap. A drainage tube was placed to the operative site followed by the standard sternal closure. In cases with a closed pleural cavity a chest tube was inserted for 24–48 h avoiding early exsudate accumulation. Thereafter intermittent thoracocenthesis were employed if necessary, and fibrothorax was allowed to develop. When thoracic fenestration was present the pleural cavity continued to be irrigated or packed. In four cases the chest fenestration was closed simultaneously. In all other cases this was carried out between 2 and 3 weeks later as a second stage.

View larger version (70K): [in this window] [in a new window]   Fig. 2. Scheme of left mainstem bronchus wedge resection.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

Thirty-four patients (69%) underwent wedge resection of the bifurcation; seven for left sided and 27 for right side fistulae. In 15 (31%) cases sleeve resection of the bifurcation was necessary. The extent of the resection was up to 3 cm in five, up to 4 cm in nine and up to 6 cm in one patient. For coverage of the suture line an omentum flap used in 31, thymus fat in 15 and a pericardial flap in 3 cases. The operation time for wedge resection at the tracheal site was 65±7 min and for sleeve resection, 110±10 min. All patients were extubated immediately or within 3 h. Chest tube removal was achieved between 2 and 10 days. Margins and disease lymph nodes were dissected.

At discharge from hospital the empyema had been cured in 31 (69%) of the patients. In the remaining 14 patients treatment was continued on an outpatient basis. The median postoperative hospital stay for patients without chest wall defect was 16 days and for the patients with persisting chest wall defect 38 days. There was no intraoperative mortality. One patient died from acute pneumonia and one from respiratory distress syndrome on days 3 and 7 after surgery, respectively. Two patients died from sepsis and respiratory failure on day 6 and day 12, respectively due to dehiscence of the anastomosis resulting in an overall hospital mortality of 8.16%.

Besides these fatalities one major complication resulted in injury to the right pulmonary artery and blood loss of 400 ml. This patient had an otherwise uneventful intra- and postoperative course. In two of the 34 cases in whom wedge technique was used and in five patients with tracheobronchial sleeve, anastomotic problems were seen. Two of these were fatal as mentioned above. In the remaining three cases mucosal defects up to 3 mm healed spontaneously, apart from the two fatal cases of pneumonia and ARDS. Two more patients developed pneumonia of the remaining lung responded to antibiotic treatment (Table 2).

In all of the 14 patients discharged with persisting infection of the post pneumonectomy space complete cure was achieved within 2 months. None of the surviving patients relapsed with empyema or fistula formation during the follow-up period.

Of the patients with primary lung cancer two with stage pT2pN2 died from progression after 25 and 31 months, one with pT3pN1 after 26 months. Two patients (pT3N0, pT2N2) are alive 9 and 16 months, respectively since fistula repair.

The longest survival of 18 years refers to a patient with benign disease who is still being followed-up.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
A variety of procedures for the treatment of post pneumonectomy stump fistula have been proposed. Each individual case requires special consideration taking into account concomitant disease, previous chest operations, duration of disease. performance and nutritional state being among the criteria for consideration [4–6,10–12,16]. Also of importance is the length of the bronchial stump. Having personal experience with the surgical treatment of 151 patients with main bronchus fistulae we have used different techniques. Considering the high rate of intraoperative bleeding caused by injury to the great vessels during stump exposure (up to 12% and fistula relapse up to 35%) we have abandoned those methods and from 1979 on have only employed the transsternal approach thereby avoiding a variety of problems. The most apparent advantage of this access consists of resection within uninfected, anatomically intact structures. The success of treatment is based on complex therapy, an important stage, being the preparation of patients for surgery, including empyema debridement which can be achieved by VATS which also allows the proper placing of the chest tube under direct visual control. In case of unsuccessful chest drainage, limited thoracostomy could be used allowing the insertion of the thoracoscope during routine dressings to control healing. The major benefit of these maneuvers is that they are less traumatic and more effective when compared with thoracomyoplastic procedures and can be used in patients who otherwise are unable to tolerate more aggressive surgical intervention.

Fiberoptic bronchoscopy is beneficial, not only to assess the size and the length of a stump [8] but also for fistula margin sampling to exclude microscopic involvement by cancer and also as a therapeutic modality for the concomitant management of purulent bronchitis.

Short bronchial stump induces some specialities for transsternal procedure. We always used the transpericardial approach for right stump resection but not for the left side. We favor this because, due to the proximity to the empyema cavity, the pericardium is often covered with adhesions and its division often causes bleeding and myocardial and left pulmonary artery injury. Furthermore, the left main bronchus stump is short and may be seen completely without pericardium dissection. We do not advocate left stump exposure via the right pleural cavity [2] since in our experience it may cause some functional disorders of a single lung. Some other methods [13] of left main bronchus stump exposure such as left parasternal approach [14] are rather traumatic and technically more difficult.

We have found that the best single-lung ventilation could be achieved with a long, thin and flexible endotracheal tube inserted into mainstem bronchus. During suture placement to the deepest aspect of the anastomosis this can be easily pulled aside without ventilation being discontinued. Alternatively across the field ventilation could be used.

There was a direct relation between mortality and morbidity and stump and defect size (Tables 1 and 2). We also observed that this index was higher in a group of patients with malignancy that could be referred to more extensive resection. It was found that tracheobronchial resection up to 4 cm does not cause significant increase in morbidity and mortality rates and could be considered as a safe and effective procedure [15].

Hospital stay was longer in a group of patients with chest wall defect which it was not possible to close in one stage. Limited thoracostomy facilitated spontaneous defect closure and did not have a significant impact on hospital stay. All the thoracomyoplastic procedures were performed only for chest wall defect closure but not for the empyema management.

All late complications associated with surgery occurred within 6 months and were caused by anastomotic stricture. We believe that resection is not required as it could induce high risk of morbidity [10]. At an early stage anastomotic stricture may be treated non-surgically and the follow-up period should include check bronchoscopy once a month during first half-year for all patients. Complications that developed later were not associated with the surgery or with long term survival.

We would like to emphasize that the transsternal technique provides excellent functional result, requires short operative time and causes neither significant blood loss nor trauma to the remaining lung. It can, therefore, be employed in patients who are unable to tolerate aggressive treatment [17].

We conclude that short main bronchus stump fistula associated with chronic pleural empyema be can successfully managed by means of a combined treatment including preoperative VATS application for empyema debridement followed by transsternal wedge or sleeve resection of the bifurcation. It is advisable to cover the anastomosis by available vascularized tissue flap to prevent the development of complications.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Associaton for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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