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Eur J Cardiothorac Surg 2003;24:699-702
© 2003 Elsevier Science NL

Surgical management of bronchiectasis: analysis and short-term results in 238 patients

Department of Thoracic Surgery, GATA Military Medical Academy, 06018 Etlik, Ankara, Turkey

Received 8 April 2003; received in revised form 28 July 2003; accepted 30 July 2003.

^* Corresponding author. Fax: +90-312-321-2055
e-mail: drogenc{at}yahoo.com

	Abstract

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

 
Objective: Bronchiectasis is defined permanent dilatations of bronchi with destruction of the bronchial wall. It is still a major cause of morbidity and mortality in developing countries. The aim of this retrospective study is to present our surgical experiences, the early and long-term results of 238 patients with bronchiectasis during a 10-year period. Methods: We reviewed the medical records of 238 patients who underwent surgical resection for bronchiectasis between January 1992 and December 2001, at Gülhane Military Medical Academy (GMMA) Thoracic Surgery Department. Variables of age, sex, symptoms, etiology, and type of operation, mortality, morbidity and the result of surgical therapy were analyzed. Results: There were 205 (86.13%) male and 33 (13.87%) female patients with an average age of 23.7 and a range of 15–48 years. The presenting symptoms were productive cough in 133 (55.88%), fetid sputum in 116 (48.73%), recurrent infections in 84 (35.29%), and hemoptysis in 39 (12.18%) patients. The disease was bilateral in 31 patients (13.02%) and mainly confined to the lower lobes in 162 (68.06%). The surgical treatment was as follows: pneumonectomy in 13 patients (5.46%), lobectomy in 189 (79.40%), lobectomy+segmentectomy in 31 (13.02%), and wedge resection or segmentectomy in five (2.1%). Staged bilateral thoracotomy was used in 14 patients. There was no operative mortality. Complications occurred in 21 patients and the morbidity rate was 8.82%. Complete resection was achieved in 154 (64.7%) patients. Follow-up data were obtained for 229 (96.21%) of the patients. Nine patients were lost to follow-up. The mean follow-up of these patients was 9 months (range, 3 months to 4 years). The symptoms disappeared in 189 patients (79.41%) and 29 patients (12.18%) had improved, whereas 11 patients (4.62%) had no improvement. Significantly better results were obtained in patients who had undergone a complete resection. Conclusions: Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality at any age. The involved bronchiectatic sites should be resected completely for the optimum control of symptoms.

Key Words: Surgical management • Bronchiectasis

	1. Introduction

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

 
Bronchiectasis is defined permanent dilatations of bronchi with destruction of the bronchial wall. Bronchiectasis was first described by Laenec in 1819 and, before the antibiotic era, was considered a morbid disease with a high mortality rate from respiratory failure and cor pulmonale.

After the advent of antibiotics the effective treatment of pulmonary infections in childhood, as well as the incidence and surgical importance of bronchiectasis has decreased in industrialized countries over the last half century. However, it is still a major cause of morbidity and mortality in developing countries [1]. The clinical features of the disease may vary widely from a sputum expectoration to a massive hemoptysis.

Current reports about the surgical management for bronchiectasis show that limited localized disease was associated with good postoperative prognosis [2–6].

The aim of this retrospective study is to present our surgical experiences, the early and long-term results of 238 patients with bronchiectasis during a 10-year period.

	2. Material and methods

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

 
We reviewed the medical records of 238 patients who underwent surgical resection for bronchiectasis between January 1992 and December 2001, at Gülhane Military Medical Academy (GMMA) Thoracic Surgery Department. Variables of age, sex, symptoms, type of bronchiectasis, type of operation, mortality, morbidity and the result of surgical therapy were analyzed for 238 patients.

Patients were admitted to the department from either the Chest Disease Department or our outpatient clinic. All patients were examined after a detailed history and blood tests were studied. Chest radiography, computed tomography of the chest (HRCT) (Fig. 1) and pulmonary function tests were carried out. Two weeks before the surgery, chest physiotherapy was initiated at the outpatient department. Preoperative and postoperative bronchoscopic toilet of the tracheobronchial tree was applied. The bronchial aspirate was sent for microbiologic culture analysis. Fiberoptic bronchoscopy (FOB) was also performed for all patients to determine the endo-bronchial pathology. Prophylactic antibiotics given for 48 h prior to surgery prepared all patients undergoing surgery. Patients were chosen as candidates for surgical treatment using the following criteria: localized bronchiectasis which is documented by HRCT; adequate cardiopulmonary reserve; symptoms such as chronic productive cough, repeated or significant hemoptysis, and recurrent pulmonary infections; failure of medical treatment.

View larger version (116K): [in this window] [in a new window]   Fig. 1. HRCT scan showing bronchiectasis.

Complete resection is defined as an anatomic resection of all affected segments. The bronchial stump was stapled by using a mechanical stapler. Usually we do not use a flap (mediastinal pleura or tissue) for covering the bronchial stump. Chest physiotherapy was reinitiated and continued for 2 weeks after discharge. All patients had specific or wide-spectrum antibiotic therapy for 1 week.

Follow-up information was obtained by periodic outpatient visits for all patients except nine. We were unable to contact these patients to invite them for their control examination.

	3. Results

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

 
There were 205 (86.13%) male and 33 (13.87%) female patients with an average age of 23.7 and a range of 15–48 years (our patients are mainly young males who are on military service).

The presenting symptoms were productive cough in 133 (55.88%) patients, fetid sputum in 116 (48.73%), recurrent infections in 84 (35.29%), and hemoptysis in 39 (16.38%). Ten patients (4.2%) presented without any symptoms (Table 1). The mean duration of symptoms was 2.4 years (range, 1–18 years). One hundred and sixty-three of 238 patients (68.4%) had previous medical therapy before admission to our department.

The most frequent microorganisms were Pseudomonas aeruginosa in 21 (8.82%), Hemophilus influenzae in 16 (6.72%), Klebsiella pneumoniae in nine (3.78%), Staphylococcus aureus in eight (3.36%), and Mycobacterium tuberculosis in seven (2.94%) (Table 3).

	4. Discussion

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

Patients with bronchiectasis typically present with recurrent pulmonary infections, productive cough, bronchial suppuration and purulent bronchorrhea [1]. This fetid sputum is also a psychological indication for surgery. Similar to our series, cough, purulent and fetid sputum, and hemoptysis are the most common symptoms in other series [2,6,7].

Although plain chest radiographs are usually the first line of examination, the diagnostic importance is fairly limited. Before the advent of HRCT, the bronchogram was the most important procedure for diagnosis [1,2]. HRCT scan is currently the best technique to establish the presence, severity and distribution of disease, by a sensitivity of 66% and specificity of 92% with 10-mm sections [8,9]. The preoperative diagnosis was based on HRCT scan findings in all our cases.

Pulmonary function studies were performed for all patients in our series and found to be normal in patients with localized brochiectasis. In patients with severe bronchiectasis a mixed obstructive and restrictive pattern with hypoxemia has been observed [1].

Preoperative bronchoscopy should be routinely done to rule out benign or malignant cause of obstruction [5].

In general, bronchiectasis affects most dependent portions of the lung, which includes posterior basal portions of the lower lobes, middle lobe and lingula. Overall one third of bronchiectasis is unilateral and affects a single lobe, one third is unilateral but affects more than one lobe, and one third is bilateral [1]. The disease was mainly confined to the lower lobes in 124 (68.8%) of our patients.

The initial treatment strategy for all patients with this disease should be conservative. Infection control, bronchodilatation and chest physiotherapy (postural drainage) are the main components of conservative treatment.

Hodder et al. stated the criteria for patients who are candidates for surgical resection. Those criteria are generally accepted today and are given in Section 2 [10]. The goals of surgical treatment are complete resection of affected segments while preserving maximum function, therefore every type of resection is possible for this purpose. Ultimately, a minimum of two lobes or six pulmonary segments must be spared to ensure adequate pulmonary function. Dense adhesions sometimes cause technical difficulties during operation. One has to be very careful in mobilizing the adhesions over the diaphragmatic surface because occasionally the bronchiectasis will be due an undiagnosed intralobar sequestration, and the aberrant systemic artery may be injured during the maneuvers [1,11,12].

Most of our patients had limited disease and complete resection was achieved in 154 patients (64.7%). Complete resection was achieved in 83% and 87.8% of patients in series carried out by Fujimoto et al. [2] and Kutlay et al. [5]. However, bilateral bronchiectasis does not present a contraindication to surgery in selected patients; the results of surgery in patients with diffuse and multi-segmental disease are less predictable and medical treatment should be preferred [11].

Complication occurrence is 9.4–24.6% in the current literature, therefore our result of 8.8% is rather better [5,13–15]. Since ours is a continuous series, some of the patients will be seen in the next few years and we will have the opportunity to evaluate morbidity over the long-term follow-up period.

Complete resection of the diseased parenchyma is the most important significant prognostic factor; the others are type of bronchiectasis and absence of sinusitis [5,13]. Significantly better results were obtained in patients who had undergone a complete resection in our series.

In conclusion, surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality at any age. The involved bronchiectatic sites should be resected completely for the optimum control of symptoms.

	References

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

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Onur Genç Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Balkanli, K. Articles by Yücel, O. Search for Related Content PubMed PubMed Citation Articles by Balkanli, K. Articles by Yücel, O. Related Collections Lung - other Trachea and bronchi