Ann Thorac Surg 1997;63:552-554
© 1997 The Society of Thoracic Surgeons
Case Report
Postpneumonectomy Stump Fistula in a Ventilated Patient
Mark De Groot, MD,
Walter Douie, MB, ChB
Department of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
Accepted for publication September 27, 1996.
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Abstract
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The development of a postpneumonectomy stump fistula in a ventilated patient is a feared and frequently fatal event. Furthermore, the necessity of a pneumonectomy from sequelae of blunt trauma is rare. We describe the salvage of a young patient with a combination of the above events. The method involves the use of a simple intravenous bag "plombage" in combination with a regional thoracoplasty to buttress a resutured bronchial stump.
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Introduction
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An 18-year-old man was admitted to Groote Schuur Hospital after being struck by a transit bus. Clinical examination revealed him to be awake, orientated, and hemodynamically stable. He was in marked respiratory distress, with his chest radiograph showing fractures of ribs 2 through 9 on the right with an associated hemopneumothorax. An intercostal drain was inserted, and he was intubated and placed on a ventilator. The intercostal drain evacuated 1,300 mL of blood initially and then curtailed. A diagnostic peritoneal lavage was positive, and a laparotomy revealed minor superficial liver lacerations. He was stable throughout the procedure and was transferred to an intensive care unit for elective ventilation.
The patient's initial course in the intensive care unit was uneventful. Mild hypoxemia that was initially present rapidly resolved, and he was extubated on day 3. Later the same day he started to expectorate purulent hemorrhagic sputum, and respiratory distress rapidly developed, requiring reintubation and ventilation. The intercostal drain that had stopped leaking air began to leak again, and progressive general deterioration occurred (Fig 1
). Computed tomography of the chest showed extensive lung consolidation with cavitation consistent with pulmonary gangrene. At thoracotomy the right lung was found to be virtually trisected by lacerations caused by the rib fractures. Extensive lung necrosis had occurred, and a pneumonectomy was performed with staple closure of the bronchial stump.
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Fig 1. . Initial chest radiograph taken after endotracheal intubation and tube thoracostomy showing fracture of ribs 2 to 9 on the right with pulmonary contusion.
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Postoperatively septic shock and adult respiratory distress syndrome developed, requiring increased ventilatory and inotropic support. Blood and sputum culture grew Acinetobacter species with clinical and radiologic signs of left lung consolidation. The patient initially improved but on day 9 after pneumonectomy the bronchial stump dehisced, requiring immediate insertion of an intercostal drain and left-sided bronchial intubation. The patient was returned to the operating room for suture closure of the stump buttressed with strips of Teflon felt. An eight-rib thoracoplasty was fashioned and a sterile 1-L intravenous solution bag was left external to the muscle layer to support the bronchial stump and buttress the mediastinum (Fig 2).
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Fig 2. . Chest radiograph taken after resuture of the stump fistula and thoracoplasty. The straight lateral margin of the intravenous infusion bag can be seen clearly. The left lung field shows increasing pneumonia/adult respiratory distress syndrome.
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Subsequently the patient slowly improved. A small stump fistula developed on day 7 secondary to closure, but this did not hinder ventilation. He was eventually weaned from the ventilator on day 46 after injury. The patient returned to the operating room on day 48 for removal of the intravenous bag, which was achieved through a small incision by puncturing the bag to deflate it. The patient was discharged to the ward on day 50 with a small draining sinus. The sinus closed spontaneously, and he is functionally well 7 months after discharge (Fig 3).
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Fig 3. . Chest radiograph taken after weaning from the ventilator and removal of the intravenous bag through a mini-thoracotomy.
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Comment
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The majority of civilian chest trauma can be managed nonoperatively with observation and supportive therapy with or without tube thoracostomy. Extensive pulmonary lacerations are rare in blunt trauma and are often attributable to displaced rib fractures [1]. Tominaga and colleagues [2] cite a 12% incidence of thoracotomy for civilian chest trauma, of which only 3.5% required pulmonary resection. High mortality rates are reported with emergency pulmonary resection ranging from 27% to 100% and varying with the extent of the resection [2, 3].
The development of a postpneumonectomy bronchopleural fistula is a dreaded complication and constitutes a major therapeutic challenge. This complication is uncommon under normal circumstances but occurs with increased frequency in ventilated patients and is often fatal [4, 5]. In our patient the size of the fistula complicated management because of the "steal" of the ventilator's preset tidal volume. Some researchers have suggested maintaining single-lung ventilation for an extended period thus allowing time for mediastinal fixation and weaning from the ventilator [6]. We believe this approach is not without significant practical problems and instead we have opted for our method of management. The purpose of the intravenous bag "plombage" was to dissipate the pressure transmitted to the stump by positive pressure ventilation and thus limit or prevent stump dehiscence as well as stabilizing the mediastinum. In this patient the second dehiscence was not unexpected and is well documented in the literature after fistula closure, usually occurring in association with pleural sepsis [7, 8]. The buttressing of the mediastinum with the thoracoplasty and saline bag prevented this from being of clinical significance.
Prevention of bronchopleural fistula development is of utmost importance as it results in multiple surgical procedures, prolonged hospital stay, and significant morbidity and mortality. When fistula development occurs, we believe this simple, cheap, and readily available technique has a role in the salvage of such situations.
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Footnotes
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Address reprint requests to Dr De Groot, Department of Cardiothoracic Surgery, University of Cape Town, Medical School, Observatory 7925, Cape Town, South Africa.
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References
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- Hankins JR, McAslan TC, Shin B, Ayella R, Cowley RA, McLaughlin JS. Extensive pulmonary laceration caused by blunt trauma. J Thorac Cardiovasc Surg 1977;74:519–27.[Medline]
- Tominaga GT, Waxman K, Scannell G, Annas C, Ott RA, Gazzaniga AB. Emergency thoracotomy with lung resection following trauma. Am Surg 1993;59:834–7.[Medline]
- Thompson DA, Rowlands BJ, Walker WE, Kuykendall RC, Miller PW, Fischer RP. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988;28:276–80.[Medline]
- Hirschler-Schulte CJ, Hylkema BS, Meyer RW. Mechanical ventilation for acute postoperative respiratory failure after surgery for bronchial carcinoma. Thorax 1985;40:387–90.[Abstract/Free Full Text]
- Williams NS, Lewis CT. Bronchopleural fistula: a review of 86 cases. Br J Surg 1976;63:520–2.[Medline]
- Pomerantz AH, Derasari MD, Sethi SS, Khan S. Early post-pneumonectomy bronchial stump fistula. Chest 1988;93:654–7.[Abstract/Free Full Text]
- Hoff SJ, Shotts SD, Eddy VA, Morris JA, Jr. Outcome of isolated pulmonary contusion in blunt trauma patients. Am Surg 1994;60:138–42.[Medline]
- Reed CE. Pneumonectomy for chronic infection: fraught with danger? Ann Thorac Surg 1995;59:408–11.[Abstract/Free Full Text]
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[Full Text]
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Abstract
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