| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Eur J Cardiothorac Surg 2006;29:9-13
© 2006 Elsevier Science NL
Section of Chest Surgery, Fukujuji Hospital, 3-1-24 Matsuyama, Kiyose, Tokyo 204-8522, Japan
Received 4 September 2005; received in revised form 14 October 2005; accepted 19 October 2005.
* Corresponding author. Tel.: +81 424 91 4111; fax: +81 424 92 4765. (Email: yujishi{at}mvb.biglobe.ne.jp).
 |
Abstract |
|---|
 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Key Words: Aspergilloma • Muscle flap • Pneumonectomy • Postoperative complications
|
1. Introduction |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
|
2. Materials and methods |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
|
The surgery was performed under general anesthesia with the use of a double-lumen endobronchial tube. The chest was opened via a posterolateral thoracotomy and the fifth or sixth rib was removed. Pneumonectomy was performed either extrapleurally or intrapleurally, depending on the degree of pleural adhesions. For extrapleural dissection, we used electrocautery and/or bipolar scissors (PowerStar Bipolar Scissors, Ethicon Inc., Somerville, NJ, USA) to reduce blood loss [11]. In six patients, a supplementary incision via the seventh or eighth intercostal space was performed to facilitate the mobilization of the lower lobe and the diaphragmatic surface of the lung. Great care was taken to avoid entry into the infected cavities. The bronchus was divided and closed with staples in 10 patients, except in a patient for whom sutured bronchial closure was used. The bronchial stump was covered with a latissimus dorsi muscle flap in all patients. The latissimus dorsi muscle flap was constructed as described by Pairolero et al. [12]. In patients who had undergone a posterolateral thoracotomy, the proximal portion of the latissimus dorsi that had been divided during a previous thoracotomy was used as a flap. Meticulous hemostasis was again achieved using electrocautery and an argon beam coagulator. The pleural cavity was irrigated with at least 10 L of saline and povidone iodine, and then the chest was drained. All patients were extubated before leaving the operating room.
Follow-up data were obtained from outpatient or hospital charts, or by direct contact with patients or relatives. Postsurgical follow-up was completed on March 31, 2005. The duration of follow-up ranged from 0.4 to 5.8 years (median, 1.9 years). Operative mortality included all deaths clearly related to the operation, regardless of the postoperative interval. Because complications such as bronchopleural fistula and empyema might have the potential to occur as late as 1 month after surgery, all complications occurring during the surgical follow-up period were considered postoperative complications.
|
3. Results |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
We performed six pneumonectomies (two right and four left) and five completion pneumonectomies (one right and four left). Operations were elective in all patients. A patient having had aspergilloma in the post-tuberculous cavity underwent a cavernostomy at first because of his poor respiratory function (forced expiratory volume of 0.87 L in 1 s). As he continued to present with hemoptysis, we chose to perform pneumonectomy 2 months later. Operating time ranged between 361 and 781 min (median, 432 min). The median intraoperative blood loss was 1050 ml (range, 200–2910 ml) (Table 2 ). Intrapericardial dissection was required in two patients undergoing a completion pneumonectomy. One vascular tear occurred (right pulmonary artery), but was easily controlled. The diaphragm was severed in three patients; all tears were recognized and repaired intraoperatively. The chest wall with three ribs adjacent to the obliterated pleural space was resected concomitantly in two patients in whom the pleural adhesion was very intense for extrapleural dissection. Tailored thoracoplasty was performed as a supplementary procedure in two other patients. Despite careful dissection, a small amount of the contents of aspergilloma was spilt into the operative field in four patients.
|
One patient died of cachexia 6.7 months after the operation with no sign of recurrence of aspergillosis. All survivors were free from aspergillosis at the time of follow-up.
|
4. Discussion |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
When surgical resection is performed, lobectomy is the most common procedure [4–8,13–16]. Pneumonectomy is preferred over less aggressive procedures for patients with multiple lobes affected by aspergilloma or with a totally destroyed underlying lung. However, previous studies have reported that pneumonectomy for complex aspergilloma is associated with extremely high complication rates [7–10]. During the pneumonectomy procedure for complex aspergilloma, surgeons encounter dense fibrosis with obliteration of the pleural space, extension beyond the extrapleural plane of dissection, and distortion of hilar structures [9]. These structural alterations due to the inflammatory disease process make dissection extremely difficult. Many investigators experience excessive blood loss in patients undergoing a pneumonectomy for complex aspergilloma [8,13,14]. Following the surgery, a high incidence of dreadful complications, such as empyema and bronchopleural fistula, should be anticipated. Massard et al. [8] reported that empyema developed in four of the five patients undergoing pneumonectomy. In the report by Babatasi et al. [13], two empyemas with bronchopleural fistula occurred after seven pneumonectomies. Regnard et al. [14] experienced two empyemas following 10 pneumonectomies. In the report by Kim et al. [15], post-pneumonectomy empyema occurred in two of the three patients undergoing pneumonectomy.
Therefore, prevention of intraoperative and postoperative complications is crucial to an improved outcome of this high-risk procedure. Techniques employed in pneumonectomy for mycobacterial diseases can be applied in pneumonectomy for complex aspergilloma: meticulous extrapleural dissection and bronchial stump reinforcement with the muscle flap [17,18]. Meticulous extrapleural dissection can minimize the risk of contamination of the operative field and reduces blood loss. Stump reinforcement with the muscle flap can prevent bronchial stump disruption. We have taken these preventative measures in all cases undergoing pneumonectomy for complex aspergilloma since 1999.
In all the cases of this report, extrapleural dissection was carried out using diathermy. An argon beam coagulator was used for hemostasis of the pleural wall at the conclusion of the operation. Moreover, in two patients we concomitantly resected the adjacent chest wall where it was extremely difficult to perform extrapleural dissection because of dense adhesion. This technique avoids entering the infected cavities, reduces chest wall ooze, and decreases the size of the post-pneumonectomy space. Tailored thoracoplasty was performed on two other patients undergoing a right-sided operation in an attempt to decrease the size of the post-pneumonectomy space.
As previously pointed out [10,19,20], left-sided disease was predominant among patients with cavities secondary to tuberculosis (four of six) in our study. We also confirmed left-side predominance among patients with post-lobectomy destroyed lung (four of five). This phenomenon has not been previously reported. The median operating time was 432 min and the median intraoperative blood loss was 1050 ml. These figures are comparable with figures from previous studies. In the report by Reed [9], in which 8 of the 13 patients requiring a pneumonectomy had aspergilloma, the mean operating time was 5.7 ± 0.6 h and the mean estimated blood loss was 2083 ± 519 ml (range, 800–7000 ml). Massard et al. [10] demonstrated intraoperative blood loss averaging 2148 ± 1220 ml in patients with aspergilloma undergoing a pneumonectomy.
We have achieved no operative mortality. Our morbidity included empyema in one patient and chylothorax in another patient. Empyema developed in one patient in whom no pleural contamination occurred grossly, i.e., rupture of the infected cavity did not occur during dissection. In this patient, both the pleural lavage at the initial operation and the pleural fluid at the re-operation were positive for B. fragilis. Therefore, microscopic contamination might have occurred during the pneumonectomy procedure, resulting in empyema. Chylothorax was due to the incidental injury of the thoracic duct tributaries during extrapleural dissection. The injury was not recognized during the initial operation, and re-operation was finally required to stop the chylous leakage. Administration of cream before pneumonectomy might be recommended for patients in whom extrapleural dissection in the posterior mediastinum is anticipated.
A few limitations to this study should be pointed out. First, this was a retrospective single-arm study. The patients in this study were a highly selected group. Even though we performed pneumonectomy on patients with relatively marginal respiratory functions, we offered cavernostomy to patients who were too ill for pneumonectomy. Second, the number of patients enrolled in this study was small. Previous studies, however, included 7–10 patients [9,10,13,14]. To the best of our knowledge this study is one of the largest published series.
In conclusion, pneumonectomy for symptomatic complex aspergilloma can be performed with no mortality and low morbidity. The favorable results of this potentially deleterious procedure hinge on the efforts to prevent postoperative complications.
|
Appendix A |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Dr A. Turna (Istanbul, Turkey): I would like to know if you used antifungal therapy, intracavitary or systemically, in your patients.
Dr Shiraishi : Yes, of course we did antifungal therapy before surgery, but in almost all patients antifungal therapies did not achieve good results.
Dr Turna : You did it in every patient?
Dr Shiraishi : Every patient.
Dr Turna : And the second question, the empyema patients, were they aspergilloma empyema or nonspecific empyema patients?
Dr Shiraishi : The empyema was caused by anaerobic bacteria, like Enterobacter, and in this patient, no gross contamination occurred during dissection, but actually the patient had empyema, so we don’t know why this patient had empyema.
Dr H. Shennib (Montreal, Canada): I have also noticed that you had 2 patients who had completion pneumonectomy, and I would assume that those patients underwent sort of a lesser resection before. I would like to get from you your strategy as to the choice of procedure, particularly that we all kind of struggle with the extent of the disease in a particular lung and how much should we resect. So how do you sort out the patients, and when do you decide to do a limited lobectomy, for example, versus a pneumonectomy in your group of patients? The other question is, in those patients who had completion pneumonectomy, did you notice an increased morbidity as a result of the delay of a pneumonectomy in those patients?
Dr Shiraishi : Regarding the first question, of course we tried to leave as much lung parenchyma as possible. So at first we tried to do lobectomy, but in this series patients had a totally destroyed lung or multiple lobes affected by aspergilloma, and in that case we had to do pneumonectomy. In terms of comparison of pneumonectomy with completion pneumonectomy, actually we didn’t see any difference in complication rates between pneumonectomy patients and completion pneumonectomy patients.
Dr C. Paleru (Bucharest, Romania): I’m thinking about the average mean time of operation, 700 minutes of operation. One, do you plan in such an operation to use two teams of surgeons? Two, how can you prevent the spillage of aspergilloma in a reoperation?
Dr Shiraishi : Regarding the first question, actually we have only 4 surgeons on our staff, so usually we do this kind of operation with 2 surgeons.
I don’t understand your second question.
Dr Paleru : The second question was about how you free the lung after the first operation without spilling aspergilloma.
Dr Shiraishi : What do you mean?
Dr Paleru : When you are trying to do a reoperation after a first aspergilloma and the aspergilloma is still in the lung and you have some very dense adhesions, how can you prevent the spill of the fungus in the pleural cavity by technical means?
Dr Shiraishi : We prefer to do extrapleural dissection instead of intrapleural dissection, and we sometimes resect the chest wall together with the lung.
Dr M. Zielinski (Zakopane, Poland): I would like to ask you if you would consider any lesser procedure in high-risk patients. In our department, in very high-risk patients we prefer not to do any resection but to do a cavernoscopy or cavernomyoplasty, which is a much lesser procedure. Do you have an opinion on those kinds of procedures?
Dr Shiraishi : Yes, I agree with you. If a patient has very poor pulmonary function, we do a cavernostomy instead of pulmonary resection.
|
Footnotes |
|---|
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005. |
References |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  K. J. Scholten, V. Kulkarni, and J. B. Brodsky Isolation of the Right Upper-Lobe with a Left-Sided Double-Lumen Tube After Left-Pneumonectomy Anesth. Analg., August 1, 2007; 105(2): 330 - 331. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
