Ann Thorac Surg 1995;60:1419-1421
© 1995 The Society of Thoracic Surgeons
Case Reports
Pedicled Pericardial Patch Repair of a Carinal Bronchogenic Cyst
Richard N. Pierson, III, MD,
Douglas J. Mathisen, MD
General Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
Accepted for publication May 19, 1995.
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Abstract
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Bronchogenic cysts should be completely removed. Small communications with the tracheobronchial tree occur, but extensive involvement is rare. A case of bronchogenic cyst replacing the carina and the medial wall of the right and left main bronchi is presented. Resection and reconstruction was accomplished by using a pedicled pericardial patch to close the defect created by removal of the bronchogenic cyst. Follow-up at 2 years shows an excellent result.
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Introduction
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Bronchogenic cysts frequently arise in close proximity to the major airways [1–3]. Small communications to the bronchus may occur, but replacement of the wall occurs rarely. The goal of treatment should be complete excision of the cyst and lung conservation. Extensive involvement of the airway may require complex reconstruction or innovative bronchoplastic procedures to repair the resultant defect. We report reconstruction of the carina using pedicled pericardium buttressed by pericardial fat.
A 47-year-old patient had a paroxysmal cough productive of small amounts of thick mucous. There was no history of smoking, hemoptysis, significant prior respiratory symptoms, or diminished exercise tolerance. Physical examination was notable for wheezing on forced inspiration and expiration. The forced expiratory volume in 1 second was 2.5 L (61% predicted); total lung capacity, 6 L (85% predicted); residual volume, 2.56 L (117% predicted), and flow to 50% vital capacity, 1.9 L/s (34% predicted). Peak inspiratory flow rate was decreased at 3 L/s. A chest roentgenogram revealed a subcarinal mass. Computed tomography and magnetic resonance imaging confirmed the presence of a solitary fluid-filled structure caudad to the carina, compressing it and both main bronchi (Figs 1, 2
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Fig 1. . (A) Bronchogenic cyst located in the inferior portion of the carina. (B) Resultant defect after removal of the cyst as seen from below. (C) Patch of pedicled pericardium used to close the defect.
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Fig 2. . Position of the pedicled pericardial patch under the superior vena cava (SVC). (IVC = inferior vena cava.)
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Flexible bronchoscopy revealed a large cyst compressing the medial wall of both main bronchi and the inferior and posterior aspects of the carina. The mass involved one half of the left main bronchus and involved the right main bronchus opposite the takeoff of the upper lobe bronchus. The mass reduced the cross-section area of the airway by 50%, and on deep inspiration or cough essentially obliterated the airway.
The mass was removed through a right posterolateral thoracotomy. A 4 x 3-cm cystic mass was identified adjacent to the undeside of the carina (see Fig 1A
). Ventilation was maintained by using a long endotracheal tube in the left main bronchus. The wall of the cyst replaced the cartilaginous portion of the carina and the medial aspect of the cartilaginous portion of both main bronchi and rendered them paper-thin in places. Resection of the lesion left a saddle-shaped defect in the carina (see Fig 1B). Satisfactory cartilage and membranous wall was present over approximately 75% of the normal bronchial circumferences. A long, superiorly based pedicled pericardial flap was raised, tunneled behind the superior vena cava, and brought anterior to the carina (see Fig 2). The smooth inner aspect of the pericardium was oriented to lie within the airway. A combination of interrupted and continuous 4-0 polydioxanone sutures were used to secure the pericardium to the edges of the airway defect. The repair was airtight to 40 cm H2O pressure. The pericardial patch was reinforced with a pedicled pericardial fat pad. Endoscopy at the conclusion of the operation revealed a stable airway without collapse on inspiration or expiration.
The patient made an uneventful recovery. Tracheal tomograms reveal a nearly normal carina and proximal main bronchi. Bronchoscopy 12 months postoperatively demonstrated good healing, a stable airway, and mild contraction of the pericardial patch.
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Comment
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This case is unusual in that a significant portion of the cartilaginous wall of both main bronchi was replaced by the cyst. The wall of the airway had become so attenuated that it was impossible to save. It was thought important to completely remove the whole cyst, including the lining, which is capable of secreting mucous [3]. Failure to do so may lead to early recurrence, a draining sinus, or infection. A saddle-shaped defect of the carina resulted after resection. The defect was too large to close primarily without compromise of the airway, and too extensive to safely perform carinal resection and reconstruction without sacrificing the left lung. A superiorly based, pedicled pericardial flap was used to reconstruct the defect. This provided autologous tissue and an airtight seal. Complications associated with foreign material or free grafts were avoided. The repair was buttressed with a pericardial fat pad for added protection. At 2-year follow-up, the result is excellent.
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Footnotes
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Address reprints requests to Dr Mathisen, Massachusetts General Hospital, Warren Bldg, Rm 1109, Boston, MA 02114.
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References
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- Sirivella S, Ford WB, Zikria EA, et al. Foregut cysts of the mediastinum: results in two consecutive surgically treated cases. J Thorac Cardiovasc Surg 1985;90:776–82.[Abstract]
- Coselli MP, de Ipolyi P, Bloss RS, Diaz RF, Fitzgerald JB. Bronchogenic cysts above and below the diaphragm: report of eight cases. Ann Thorac Surg 1987;44:491–4.[Abstract]
- Suen HC, Mathisen DJ, Grillo HC, et al. Surgical management and radiologic characteristics of bronchogenic cysts. Ann Thorac Surg 1993;55:476–81.[Abstract]
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Abstract
Introduction
