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Case reports

Postoperative perforation in the bronchus intermedius membrane after a primary lung cancer resection

Department of Cancer and Thoracic Surgery, Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama University, 2-5-1 Shikata-cho, Okayama city, Okayama 700-8558, Japan

Received 23 April 2007; received in revised form 8 September 2007; accepted 24 September 2007.

^_* Corresponding author. Address: Department of Thoracic and Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama 701-0192, Japan. Tel.: +81 86 462 1111; fax: +81 86 464 1189. (Email: yhirami{at}med.kawasaki-m.ac.jp).

	Abstract

Top Abstract 1. Introduction 2. Case reports 3. Comment References

 
We experienced 4 cases of postoperative perforation in the bronchus intermedius membrane (PBIM) after primary lung cancer resection. Three patients had undergone a right lower lobectomy and 1 patient had undergone a right upper lobectomy; as part of a systemic lymph node dissection, the subcarinal lymph node (Station 7) was dissected in all cases. Leakages were detected on postoperative days 3, 10, 11, and 26, respectively. The clinical signs of PBIM included the appearance of sputum like pleural effusion, decreased oxygenation, elevated inflammatory markers, pneumothorax, and infected pleural effusion. PBIM was confirmed by bronchofiberscopy. Direct suturing of the perforated membrane, followed by rapping with an omental flap was performed in 1 case; completion bilobectomies, followed by rapping of the bronchial stump with an omental flap or an intercostal muscle flap were performed in 2 cases; and a completion pneumonectomy, followed by rapping of the bronchial stump with an omental flap was performed in 1 case. All 4 of the cases were successfully treated.

Key Words: Bronchopleural fistula • Bronchus intermedius • Complication • Lung cancer

	1. Introduction

Top Abstract 1. Introduction 2. Case reports 3. Comment References

 
Bronchopleural fistula (BPF) is a critical complication of pulmonary resection with a fatal outcome if treatment is delayed. Although the formation of BPFs on bronchial stumps has been reported [1–4], BPFs caused by a perforation in the bronchus intermedius membrane (PBIM) have not been described. Here we report the clinical findings and course of PBIM.

	2. Case reports

Top Abstract 1. Introduction 2. Case reports 3. Comment References

 
2.1 Case 1
A 66-year-old man with a 60 pack-years smoking history underwent a right upper lobectomy and mediastinal lymph node dissection (MLND) [5] for the treatment of non-small cell lung cancer (NSCLC) (T2N0M0). On postoperative day (POD) 10, he developed decreased oxygenation and elevated inflammatory markers. A chest CT showed a right pleural effusion, requiring chest drainage. A bronchofiberscopy showed a hole in the bronchus intermedius membrane (Fig. 1 ), requiring an urgent operation. Since the tissue surrounding the perforated membrane was comparatively firm and not remarkably infected, direct suturing followed by rapping with an omental flap was performed. The postoperative course was uncomplicated, and he was discharged on POD 33. The pathological findings showed N2 disease. A recurrence was confirmed 7 months after surgery and was treated with chemoradiotherapy.

View larger version (131K): [in this window] [in a new window]   Fig. 1. Bronchofiberscopy findings show a deep hole, about 7 mm in diameter, in the proximal–lateral side of the bronchus intermedius membrane. The lesion was white in color and had a clear margin.

2.3 Case 3
A 68-year-old man with pulmonary emphysema, a history of brain infarction, and a 60 pack-years smoking history underwent an RLL with MLND for the treatment of NSCLC (T1N0M0). The postoperative course was uneventful, and he was discharged on POD 13. On POD 26, he developed mild hemosputum, decreased oxygenation, and elevated inflammatory markers. On POD 28, chest CT findings showed pleural effusion and free air around the bronchus intermedius membrane. Chest drainage was performed, and marked air leakage was observed. A bronchofiberscopy confirmed a PBIM. An urgent operation revealed a 10 mm perforation on the distal side of the bronchus intermedius membrane. A right middle lobectomy (RML) and bronchial stump rapping with an omental flap was performed. Although postoperative empyema developed, he was discharged on POD 337 with no further complications. His pathological stage was IA, and no recurrence has occurred as of 2 years after the initial surgery.

2.4 Case 4
A 78-year-old man with pulmonary fibrosis and a 27 pack-years smoking history underwent a RLL with MLND for the treatment of NSCLC (T1N0M0). On POD 8, elevated inflammatory markers, slight hemosputum, and decreased oxygenation were observed. On POD 10, free air around the right bronchus and pneumothorax were observed on a chest CT and a bronchofiberscopy confirmed a PBIM. An urgent operation revealed a 5 mm perforation on the proximal side of the bronchus intermedius membrane. A RML and bronchial stump rapping with a pedicled intercostal muscle flap was performed. The postoperative course was uncomplicated, and the patient was discharged on POD 47. He had pathological stage IA disease; no signs of recurrence have been seen for 2 years.

	3. Comment

Top Abstract 1. Introduction 2. Case reports 3. Comment References

 
Past reports of complications after pulmonary lobectomy have described the incidence of BPF to be about 1%, but PBIM has not been previously described [1,2]. In our institution, 909 patients underwent lobectomies for the treatment of lung cancer between January 1995 and December 2005. During this period, 15 patients (1.65%) developed BPFs, resulting in an incidence consistent with previous reports. Four of these 15 cases (0.44%) were PBIMs.

Subcarinal lymph node dissection may be a risk factor for the development of BPF, since the dissection of the bronchial artery can induce ischemic changes in the bronchial stump [4]. All the BPFs that developed during the course of this study, including the 4 PBIMs, occurred after subcarinal lymph node dissection.

Blood flow through the bronchus intermedius membrane is assumed to be superior to blood flow through the bronchial stump. Furthermore, the perforations occurred on the proximal side of the bronchus intermedius membrane in 3 cases. Therefore, the possible causes of the PBIMs include not only ischemic changes, but also burning with the electric scalpel during bronchial artery dissection and the lymphadenectomy. Our standard procedure for performing a lymphadenectomy is basically a sharp dissection using an electric scalpel (30–35 W). Of note, the 4 PBIMs occurred during surgeries performed by three surgeons within a recent 2-year period, during which time electric scalpel dissection was adopted at our institute. Protective handling of the bronchus intermedius membrane during subcarinal lymph node dissection may enable this complication to be avoided.

As in case 1, direct suturing is sometimes performed, especially for iatrogenous or post-traumatic tracheobronchial ruptures [6]. The other 3 cases required the excision of the perforated bronchus with additional lung resection. The conditions of these 3 cases were regarded as severe, with accompanying infection in the thoracic cavity. A unique property of the omentum is its ability to revascularize ischemic organs and to eliminate infection [7,8]. Thus, the bronchial stumps were rapping with the omental flap to prevent failure of bronchial stump and the development of infection. Indeed, Puskas et al. reported that the omentum was superior to other tissues for the closure of BPF [9].

In conclusion, PBIM is a unique type of BPF that may occur after subcarinal lymph node dissection. PBIMs may be caused by unrecognized burning with an electric scalpel. The early diagnosis and urgent surgical repair of this complication are mandatory.

	Footnotes

 
¹ Tel.: +81 86 235 7265; fax: +81 86 235 7269.

	References

Top Abstract 1. Introduction 2. Case reports 3. Comment References

 

1. Sirb H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchoplural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001;7:330-336.[Medline]
2. Nagahiro I, Aoe M, Sano Y, Date H, Andou A, Shimizu N. Bronchoplural fistula after lobectomy for lung cancer. Asian Cardiovasc Thorac Ann 2007;15123–16.
3. Lois M, Noppen M. Bronchoplural fistulas. Chest 2005;128:3955-3965.[CrossRef][Medline]
4. Satoh Y, Okumura S, Nakagawa K, Horiike A, Ohyanagi F, Nishio M, Horai T, Ishikawa Y. Postoperative ischemic change in bronchial stumps after primary lung cancer resection. Eur J Cardiothorac Surg 2006;30:172-176.[Abstract/Free Full Text]
5. Lardinois D, De Leyn P, Van Schil P, Rami-Porta R, Waller D, Passlick B, Zielinski M, Junker K, Rendina EA, Ris HB, Hasse J, Detterbeck F, Lerut T, Weder W. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Eur J Cardiothorac Surg 2006;30:787-792.[Abstract/Free Full Text]
6. Gabor S, Renner H, Pinter H, Sankin O, Mailer A, Tomaselli F, Smolle Juttner FM. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 2001;20:399-404.[Abstract/Free Full Text]
7. Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;132:301-304.[Medline]
8. Goldsmith HS, De los Santos R, Beattie EJ Jr. Relief of chronic lymphedema by omental transposition 1967;166:573–585.
9. Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for bronchopleural fistula 1995;109:989–995.

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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): Hiroshi Date Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hirami, Y. Articles by Date, H. Search for Related Content PubMed PubMed Citation Articles by Hirami, Y. Articles by Date, H. Related Collections Lung - cancer Trachea and bronchi