Eur J Cardiothorac Surg 2002;22:1020-1022
© 2002 Elsevier Science NL
Sleeve resection of the right main bronchus for postlobectomy broncho-pleural fistula
Alper Toker*,
Serhan Tanju,
Sukru Dilege,
Goksel Kalayci
Department of Thoracic Surgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey
Received 26 June 2002;
received in revised form 2 September 2002;
accepted 4 September 2002.
* Corresponding author. Inönü Cad, Yildiz Sok, STFA Bloklari B/6 Blok, No: 13, 81090 Kozyatagi, Istanbul, Turkey. Tel.: +90-216-416-6426; fax: +90-216-338-4380
e-mail: aetoker{at}superonline.com
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Abstract
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In this case report we present a novel treatment for bronchial fistula after lobectomy. The patient had right upper lobectomy for T1 N0 M0 peripheral adenocarcinoma and he had been reexplored 4 days later for massive air leak in another chest surgery department. After the reoperation the bronchial fistula persisted and the patient was admitted to our department. Nineteen days after the reoperation, bronchoscopy confirmed that the bronchial stump was totally opened. A sleeve resection to the right main broncus including the fistulous stump of right upper lobe was performed.
Key Words: Postlobectomy • Bronchopleural fistula • Sleeve resection
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1. Introduction
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The incidence of bronchopleural fistula after a lobectomy operation was reported to be 1.1% after 1083 lobectomies [1]. The bronchopleural fistula incidence after non-small cell lung carcinoma surgery has decreased in recent years due to new surgical refinements and better understanding of bronchial healing process but the mortality rate is still high [2]. The treatment of bronchopleural fistula changes according to the physical condition of the patient, stage of the tumor, the age of the bronchial fistula, associating empyema and type of the resection [2]. If the size of the fistula is small, endoscopic treatment can be chosen [3]. Otherwise reoperation with transposition of muscle, omentum, pericardium and even diaphragma is offered. When repair is not successful, the completion pneumonectomy is the last choice which has high morbidity and mortality. The poor physical status and limited survival expectency are important determinants for open thoracostomy. Sleeve resection had not been offered yet in any case of postlobectomy bronchial fistula probably because the main claimed pathology was generally bronchial vascularization disorder and infection.
Here we report a patient who had sleeve resection of the right main bronchus for the treatment of bronchial fistula of the right upper lobe bronchus.
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2. Case report
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A 55 year-old male patient had a right upper lobe tumor (adenocarcinoma, T1 N0 M0) which had been treated with right upper lobectomy in another chest surgery department. Massive air leakage had started in early postoperative period and the surgeon had performed a second operation on the 4th day. He had tried to close the fistula with debritement of the bronchus and primary sutures. After revision, massive air leakage had persisted. We admitted the patient to our clinic with symptoms of dyspnea and tachypnea. Radiologically he had a large space with a trapped and atelectatic lung (Fig. 1)
. He did not have fever or leucocytosis. Flexible bronchoscopy was performed to evaluate the bronchial stump. Bronchial stump was noticed to be completely opened. On the 23rd day after the primary operation, the patient was reoperated. Pleural fluid was taken for microbiological analysis and no preliminary sterilization of the thoracic cavity was employed. Since the patient had partial stomach resection for a benign disease 10 years ago, omental pedicle was not prepared. There was not any right upper lobe stump due to previous debritement. The resection line of the upper lobe bronchus was just on the wall of intermediate and main bronchus; technically there was not any margin to suture the defect. A completion pneumonectomy would be the choice. So we performed a sleeve resection of the right main and intermediate bronchus, including the fistulous segment of the right upper lobe bronchus and a decortication procedure to the middle and lower lobes. We used separated suture technique with 4/0 polyglycolic acid material. We transposed a pediculed latissimus dorsi muscle flap over the anastomosis line and into the apical space. He was prescribed a broad spectrum intravenous antibiotic until the microbiological analysis of the pleural fluid revealed Staphylococcus aureus. The patient was prescribed a culture specific antibiotic from then on for 9 days. The chest tubes were pulled out on postoperative days 2 and 3. He was discharged on postoperative day 12 without any complication. The chest X-ray and bronchoscopy on the 4th postoperative month revealed healed anastomosis without a space problem. The patient had a perfect physical condition after a month's holiday to the Far East (Fig. 2)
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Fig. 2. Chest X-ray on the 4th postoperative month. Muscle transposition to the apex of the hemithorax seems opaque.
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3. Discussion
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The early postoperative fistula is the result of a technical failure and a reoperation is mandatory. This period is believed to be up to 7 days [4]. When the bronchial leak occurs later in the postoperative course, usually days 8 or 10, it may be caused by failure of healing [4]. The factors affecting bronchial healing is well documented [4]. In case of a technical failure, bronchial suture line is prepared, cleaned and resutured with supportive tissue. Obliteration of the residual pleural space with muscle transposition and support of the bronchial sutures with a vascularized pedicle flap would commonly manage the problem. But when the fistula line has no margins to repair, a pneumonectomy should be considered. In a series, it was reported that all of the postlobectomy bronchopleural fistula patients (nine patients) necessitated completion surgery [2]. But this completion pneumonectomy has the risk of more serious complications. The mortality rate of completion pneumonectomy, if it is employed for an early complication of a primary operation, is reported to be 37.5% [5]. The explanation for these complications could be a potential infection in residual great pneumonectomy space and compromised pulmonary and cardiac functions. Bronchopleural fistula after a sleeve resection was reported to be 5.6% in 112 patients with lung cancer [6]. A sleeve resection for a non-stump postlobectomy bronchial fistula was not mentioned yet at least for technical errors. But sleeve resections after a postpneumonectomy bronchial fistula was employed for short stump bronchial fistula [7]. Fifteen patients had carinal sleeve resections for treatment of postpneumonectomy bronchial fistula with some complications which could be acceptable for a group of patients having no better alternative treatment [7]. Sleeve resection after a postlobectomy bronchial fistula would not cause any deterioration in pulmonary and cardiac functions when compared to completion pneumonectomy. And moreover, space infection problem would be managed with the reexpansion of residual lung after a decortication procedure.
We would like to outline the strict criteria for this procedure: patients with good performance status, in the absence of frank empyema, in technical feasibility, with healthy remnant lung, without residual tumor and in case of a necessity for completion pneumonectomy; especially when the bronchial fistula is the result of a technical failure after upper lobectomies. The quality of life is preserved with remnant lung's remaining and functioning. Decortication of the lung was a must since the lung was completely trapped. This technique supplies better postoperative period and long term life quality when compared to completion pneumonectomy.
Nevertheless evaluation and management of these patients should proceed in a logical stepwise fashion from diagnosis to pulmonary rehabilitation [8]. We hope this procedure would find a place in the algorithm of treatment of postlobectomy bronchopleural fistulas.
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References
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Abstract
1. Introduction
