Eur J Cardiothorac Surg 2007;31:120-123. doi:10.1016/j.ejcts.2006.10.021
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Surgical management of bronchiectasis in childhood
Mehmet S
rmala,*,
Sezgin Karasub,
Hasan Türütc,
Suat Gezerd,
Sadi Kayad,
rfan Ta
teped,
Nurettin Karao
lanolud
a Department of Thoracic Surgery, Süleyman Demirel University Medical School, Isparta, Turkey
b Department of Thoracic Surgery, Ankara Training and Research Hospital, Ankara, Turkey
c Department of Thoracic Surgery, Kahramanmara Sütçü mam University Medical School, Kahramanmara, Turkey
d Department of Thoracic Surgery, Atatürk Training and Research Hospital for Chest Disease and Chest Surgery, Ankara, Turkey
Received 14 August 2006;
received in revised form 13 October 2006;
accepted 23 October 2006.
* Corresponding author. Address: Süleyman Demirel Üniversitesi Tp Fakültesi, Göüs Cerrahisi Anabilim Dal, Isparta, Turkey. (Email: mehmetsirmali{at}yahoo.com).
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Abstract
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Objective: Though there is a gradual decrease in the prevalence of bronchiectasis, it is still a cause of mortality and morbidity among children in developing countries such as Turkey. We reviewed the morbidity and mortality rates and the outcome of surgical treatment for childhood bronchiectasis. Patients and methods: Age, sex, etiological factors, symptoms, radiological examinations, surgical procedures, postoperative morbidity and mortality in patients aged 16 years and younger, operated for bronchiectasis between January 1991 and April 2006 in the Thoracic Surgery Clinic of Atatürk Training and Research Hospital for Chest Disease and Chest Surgery were reviewed retrospectively. Results: Between January 1991 and April 2006, 176 cases aged 16 and younger were operated for bronchiectasis. There were 95 females (54%) and 81 males (46%), with a mean age of 12.3 years (range: 3.4–16 years). The most common cause of bronchiectasis was lung infection (n: 87, 49.4%). Main symptoms were coughing (n: 167, 94.9%), sputum (n: 139, 79%), hemoptysis (n: 78, 44.3%), and fever (n: 77, 43.7%). Mean duration of the symptoms in patients who were operated was 3.8 years (range: 0–7.6 years). Cases underwent a total of 201 operations: 19 cases had bilateral surgical resection and 6 cases had completion pneumonectomy. Majority of cases had complete resection (n: 165, 93.75%) while only 11 cases (6.25%) had incomplete resection. Mean duration of hospitalization was 8.9 days (range: 5–39 days). The outcome, based on the responses of patients postoperatively, was ‘perfect’ in 129 cases (73.3%), ‘improved’ in 41 cases (23.3%), and ‘no changes’ in 6 cases (3.4%). The mean follow-up after surgery was 4.3 years (range: 14 months to 7.2 years), mortality was 0% and morbidity was 13% (n: 23). Conclusion: With acceptable mortality and morbidity rates and high chance of cure after complete resection, surgical treatment is a successful and reliable method of treatment in childhood bronchiectasis that yields marked improvement in the quality of life.
Key Words: Childhood bronchiectasis • Lung infections • Tuberculosis
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1. Introduction
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Bronchiectasis, a chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilation of these airways, was first described by Laennec in 1819 [1,2]. In industrial countries measles, pertussis, and tuberculosis are almost eradicated, thanks to the newly developed antibiotics [3,4]. Although, there are no prospective randomized trials comparing the efficacy of conservative and surgical treatment options, the indications of surgery for bronchiectasis can be considered in two main categories among children [5]. Covering all age ranges, current reports on the surgical management for bronchiectasis show that localized disease was associated with good postoperative prognosis [3,4,6–8]. However, pediatric bronchiectasis has not been widely discussed due to this decrease in prevalence [5]. There are ongoing debates how the outcome can be projected from the surgical intervention [5]. In the present study, we reviewed our criteria for surgery, rates of mortality and morbidity in patients with childhood bronchiectasis we operated over a period of 15 years.
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2. Material and methods
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Age, sex, etiological factors, symptoms, radiological examinations, surgical procedures, postoperative morbidity and mortality in patients aged 16 years and younger, operated for bronchiectasis between January 1991 and April 2006 in the Thoracic Surgery Clinic of Atatürk Training and Research Hospital for Chest Disease and Chest Surgery were reviewed retrospectively.
History, physical examination, chest X-ray, bronchography, and computed tomography (CT) were employed to establish the diagnosis of bronchiectasis. Pulmonary function tests and pulmonary ventilation/perfusion scan were performed to establish pulmonary functions when wide resection of the lung was planned. Laboratory tests were also run to determine cardiac, renal, and hepatic functions. All patients underwent bronchoscopy preoperatively to define the endobronchial pathology.
Patients with localized disease that did not respond well to antibiotic, mucolytic, bronchodilator and steroids; growth retarded patients with localized disease that did not respond well to medical treatment; patients with localized disease and frequent exacerbations that hinder school attendance and therefore affect the education; and patients with hemoptysis underwent surgical operation for bronchiectasis. Cases with hemoptysis were classified into two groups: massive hemoptysis and recurrent serious hemoptysis attacks. Massive hemoptysis was defined as expectorating more than 600 ml of blood in 24 h [3]. Rigid bronchoscopy was carried out under emergency conditions to determine the locus of hemorrhage in patients with massive hemoptysis and the bleeding bronchus was catheterized for 1 h via double lumen endotracheal tube. At that stage, an emergency high resolution computed tomography (HRCT) was performed to assess the lungs and patients were taken into the operating room. Identification of the locus of hemorrhage was accomplished bronchoscopically in patients with recurrent serious hemoptysis attacks, and, after assessing the lungs by HRCT, surgery was planned in patients who did not respond well enough to conservative treatment.
All patients had intensive chest physiotherapy in the preoperative period. Sputum culture and sensitivity tests were carried out on all patients and patients were put on prophylactic antibiotics. The bronchial aspirate was sent for microbiologic culture. Currently, routine preoperative toilet-bronchoscopy is performed after intubation.
All patients had posterolateral thoracotomy. Fourth or fifth intercostal space was used to access the lungs. During pulmonary resection, excessive bronchial dissection was avoided, and peribronchial tissues were preserved. The bronchial stump was hand-sutured with synthetic monofilament suture in some cases or closed with mechanical stapler in others. Bronchial stump was reinforced with mediastinal fat tissue or thymic remnants. Two silicon drains were placed into the thoracic cavity before the thorax was closed. All resected specimens were examined histopathologically in order to confirm the diagnosis.
Chest physiotherapy was started just after the operation and continued throughout the hospital stay. Antibiotics suitable for microorganisms isolated from sputum and bronchoscopic lavage preoperatively were used during postoperative period. Patients were followed-up in intensive care units on postoperative day 1. Following discharge from the hospital, patients were followed-up every 3 months in the first 6 months and every 6 months thereafter. Follow-up controls consist of taking the history, physical examination and PA chest radiograph. In suspicious cases, advanced techniques were used. Postoperative outcomes were assessed by asking the patients. Outcomes were categorized as ‘perfect’ if they had no symptom postoperatively; ‘improved’ if they had symptoms but milder than preoperative period and ‘no change’.
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3. Results
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One hundred and seventy-six patients aged 16 years and under were operated for bronchiectasis over a period of 15 years. The total number of cases operated for bronchiectasis during the same period was 731, with pediatric cases comprising 24% of all cases. Among 176 cases, 95 (54%) were females and 81 (46%) were males. Mean age of the patients was 12.3 years (range: 3.4–16 years). The most common cause of bronchiectasis was lung infection (n: 87, 49.4%). Other etiologies are presented in Table 1
. The pattern of bronchiectasis was cylindrical in 72 (40.9%), saccular in 95 (54%), and varicose in 9 (5.1%) cases. The mean duration of symptoms in children operated for bronchiectasis was 3.8 years (range: 0–7.6 years). Presenting symptoms of the patients are summarized in Table 2
. The most common microorganisms obtain from preoperative sputum culture were Hemophilus influenza (n: 29, 16.5%), Pseudomonas aeruginosa (n: 17, 9.6%) and Streptococcus pneumonia (n: 10, 5.7%). There was a history of massive hemoptysis in 13 of 78 cases who presented with hemoptysis. These 13 cases were taken to operation after obtaining HRCT images and bronchoscopic evaluation and intervention. In 10 of these 13 cases, the locus of hemorrhage could be clearly detected while in the remaining three cases the hemorrhage could be localized to the left or the right side. HRCT revealed signs of destroyed lung in these three cases that required left pneumonectomy in two and right pneumonectomy in one case. Bilateral hemorrhage was not observed in any of the cases with massive hemoptysis. Among 65 cases with recurrent serious hemoptysis attacks, there was unilateral hemorrhage in 59 cases while the locus of hemorrhage was bilateral in the remaining 6 cases. Bronchial artery embolization was performed when bilateral loci of hemorrhage were identified. Once the hemorrhage control was accomplished, these cases underwent resection of the bronchiectatic regions bilaterally. There was a complete agreement with the CT findings and bronchoscopy for demonstrating the locus of hemorrhage in all but seven patients with hemoptysis. In seven cases, loci of hemorrhage identified with bronchoscopy were not the ones detected by HRCT. In such cases, regions identified by HRCT and bronchoscopy as bronchiectatic were both excised.
To evaluate the patients radiologically, chest X-ray was used in all cases, bronchography in 46, and thoracic CT in 149 cases. Bronchography was used as a diagnostic method in the earliest stages of the study. Later, it was replaced by HRCT.
A total of 201 operations were carried out on 176 cases. In 19 cases, bronchiectasis was bilateral and six cases had completion pneumonectomy. Majority of the cases had complete resection (n: 165, 93.75%) while only 11 cases (6.25%) had incomplete resection. Intraoperative complication has not been encountered in any of the cases. Types of procedures are presented in Table 3
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Eight cases (4.5%) developed atelectasis postoperatively and were treated successfully with aspiration of the secretion through a fiber-optic bronchoscope. Four of these eight cases required repeated bronchoscopies for the management of atelectasis. In three cases (1.7%) there was an air leak lasting more than 2 weeks and two cases of these cases empyema developed eventually. These cases were treated with medical treatment and follow-up. Three patients (1.7%) had pneumonia and they were treated successfully with medical treatment. Five patients (2.8%) had empyema. They had tube thoracotomy and were treated successfully with medical treatment. Two patients (1.1%) had postoperative hemorrhage that necessitated revision. During revision thoracotomy, hemorrhage from the bronchial artery was observed in one case while the exact locus of hemorrhage could not be found in the other; a disseminated, seepage-type hemorrhage was observed on the parietal pleura. Morbidity rate among children operated for bronchiectasis was 13% (n: 23).
The chest tube was kept in place for a mean of 6.1 days (range: 4–23 days), with a mean hospitalization period of 8.9 days (range: 5–39 days). The outcome of the surgery was ‘perfect’ in 129 cases (73.3%), ‘improved’ in 41 cases (23.3%), and ‘no change’ in 6 cases (3.4%), based on patients’ self-evaluation. The mean follow-up after surgery was 4.3 years (14 months to 7.2 years), and mortality and morbidity rates were 0% and 13% (n: 23), respectively.
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4. Discussion
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The exact incidence of bronchiectasis is yet to be determined [4]. The prevalence of bronchiectasis decreased significantly over recent decades. Antimicrobial therapy and immunization against viral and bacterial agents significantly decreased the incidence of bronchiectasis. Early recognition of foreign bodies with bronchoscopy also decreased the incidence of post-obstructive bronchiectasis [9]. However, the incidence of bronchiectasis is still high in developing countries [5,9].
Bronchiectasis generally develops secondary to pulmonary infections or bronchial obstruction. Bronchiectasis should not be mistaken with pseudo-bronchiectasis, temporary (up to 6 months) cylindrical dilatation of the bronchi accompanying lung infection in children [2]. Nearly half of bronchiectasis patients relate the onset of their symptoms to a pediatric infection. Cystic fibrosis is the most common cause of bronchiectasis among Caucasians of North America and Europe [2]. Nonspecific lung infection was the most frequent cause of bronchiectasis in our series. Although rare, surgery can be required in pulmonary tuberculosis for residual disease, unexpandable lobe, persisting hemorrhage, or irreversibly destructed parenchyma [10]. Second most common cause of bronchiectasis surgery among our cases was tuberculosis.
First line of treatment in symptomatic bronchiectasis during childhood is to reduce the airway obstruction and eliminate the bacteria in lower respiratory tract. This is achieved by antimicrobial treatment, chest physiotherapy, inhaled bronchodilators, and corticosteroids [4]. Broad-spectrum antibiotics should be used for acute respiratory infections and acute exacerbations of chronic infections.
Generally, the aim of the bronchiectasis surgery is to improve the quality of life in patients who did not respond to medical treatment and to treat complications such as empyema, recurrent hemoptysis and lung abscess [4,11]. The indications for surgery are not fully established in children [5]. However, there seems to be an agreement that appropriate antibiotic therapy and chest physiotherapy should be tried for a period. In adults, indications for surgery are resistance to appropriate antibiotic therapy in addition to an extensive postural drainage and chest physiotherapy program for a period of at least 2 years [12]. In children, on the other hand, growth retardation due to bronchiectasis and drop in school attendance secondary to the illness should be included in the indications for surgery as well. The postoperative growth among our cases that we operated for growth retardation was striking and we have achieved the most satisfactory results in this group of patients.
The goal of surgery is to excise all diseased lung areas whenever possible and to preserve as much healthy lung parenchyma as possible. It is known that even 2 or 3 preserved segments can fill the hemithorax [9]. Another important issue regarding surgery for bronchiectasis in childhood is whether or not a complete surgical resection is carried out. Ötkün and colleagues reported that the symptoms persisted when they carried out incomplete resection [9]. We performed complete resection in 93.75% of our cases and preoperative symptoms resolved completely in 73.3% of them and improved in 23.3%, i.e. 96.6% of the cases benefited from the surgery. In the light of these findings, we suggest that complete resection should be performed for surgical treatment of bronchiectasis in childhood and that incomplete resection should only be used for palliative treatment of certain life threatening symptoms. When suspicious lung regions are not excised with the aim of sparing as much lung tissue as possible, a second operation that carries a higher morbidity and mortality might be required to remove the residual diseased tissues.
Balloon tamponade of the bleeding bronchus, which can be performed under emergency conditions is an effective method to manage massive hemoptysis in bronchiectasis patients. Embolization of the bronchial artery is a good alternative, capable of stopping the hemorrhage in 75–90% of the cases [13]. On the other hand, once the first episode of hemorrhage is stopped, preoperative assessment should be promptly undertaken because recurrence in the first month after the embolization is frequent and fatal [3,14]. Planning surgical operation in patients with hemoptysis should involve bronchoscopic as well as radiological assessments. Yielding 2% false negative and 1% false positive results, HRCT is a fairly reliable method for the diagnosis of bronchiectasis [15]. However, during hemoptysis correlation with bronchoscopy is critical since we had seven cases, which the loci of hemorrhage were different than the ones depicted by HRCT. In such cases the most appropriate approach is to excise the pathological regions both depicted by HRCT and identified by bronchoscopy.
The rate of complications in current literature varies between 9.4% and 24.6% [3]. The frequency of complications calculated in the present study (23%) is in agreement with the literature. Bronchopleural fistula (BPF) can be observed in as many as 9.1% of the cases [3]. Fujimato and colleagues [3] argued that the bronchial stump should be reinforced when the inflammation in the lung of bronchiectasis patients could not be effectively controlled. We, however, suggest reinforcement the bronchial stump in all cases. Since bronchiectasis is an inflammatory disease of the lungs the risk of developing postoperative empyema is higher than other cases. Empyema, on the other hand, is a risk factor for BPF. The fact that we did not encounter any BPF despite seven cases with empyema lends support to the appropriateness of reinforcement the bronchial stump, an approach we adopted.
Initial treatment in childhood bronchiectasis is medical. When sufficient response to medical treatment is not achieved, especially in children with growth retardation or hemoptysis, surgery can be performed with acceptable mortality and morbidity rates. Bronchopulmonary development continues during childhood and the space occupied by the resected segments would be filled by the healthy lung segments. Therefore, surgeons should not refrain from wide resection of the lung to achieve complete resection of the diseased area. Incomplete resection should not be preferred in children except for palliative treatment of life threatening complications. Surgical treatment is a successful and reliable method with high cure rate that yields marked improvement in the quality of life.
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Abstract
1. Introduction
