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Ann Thorac Surg 1997;63:1214-1215
© 1997 The Society of Thoracic Surgeons
Service de Chirurgie Thoracique, Institut Mutualiste Montsouris Choisy, 6, Place de Port-au-Prince, 75013 Paris, France
To the Editor:
Bronchopleural fistula (BPF) is a lifethreatening complication after lung resection, and its treatment is a major challenge for thoracic surgeons. Therefore, efforts must be made to avoid this critical event, mainly respecting recommendations repeatedly reported [1–3] or adopting hand suture techniques as recently advocated by some authors [1, 2, 4]. Once BPF has developed, however, a suitable treatment must be urgently undertaken.
The management of BPF is complex and depends mainly on whether it is an early or late complication of lung resection, the type of fistula (necrosis of the bronchial wall, failure of the bronchial healing, technical complication of staplers device), and finally the general state of health of the patient. Regarding early postoperative BPF, we believe that the most important principle of the treatment is the prevention of bacterial contamination of the pleural space by immediate appropriate closure of the bronchial defect. The literature frequently reports new techniques of repair, all worthy of being known. In the last 2 years we have adopted a hand-suture technique that allowed us to successfully repair early BPFs despite the fragility of the bronchial wall, so it appears to us of interest to add our experience to this important discussion concerning BPF repair.
From January 1995 to June 1996, 4 early BPFs after lung resection for bronchogenic carcinoma were treated by hand-suture technique. There were two BPFs after pneumonectomy (1 right and 1 left) and two after right lower lobectomy. All patients were more than 66 years old. Bronchial stumps were at the time of first resection closed in 3 cases by staplers (PI-55 Large, 4.8 mm x 2 mm; Precise 3M Medical–Surgical Division, Minneapolis, MN) and once by hand suture (lobectomy). All patients were reoperated on early, and the operative findings were partial necrosis of the membranous part of the bronchial stump for pneumonectomies and complete dehiscence of the suture in lobectomies.
All were early postoperative fistulas (days 1, 7, 10, and 13) and were operated on the day of the diagnosis. All patients were immediately treated by chest drainage at the time of diagnosis of BPF. No patients had empyema.
A double-lumen endotracheal tube for one-lung anesthesia was always used. The hemithorax was explored through the previous thoracotomy, and the bronchial stump was isolated and dissected; subsequently, it was opened and the previous suture removed. Then a hand-suture technique was performed; it consisted of several separated, nonabsorbable 3-0 braided threads (TI-CRON; Davis+Geck, France) running through the bronchial stump wall in a U fashion and transfixing two separate absorbable bands 7.5 mm in width (PDS-Band; Ethicon, Somerville, NJ) (Fig 1
). The suture was done as far as possible from the fistula and progressively tied beginning at the lateral edges. Figure 2 shows the bronchial stump after the hand-suture technique. After this, the bronchial stump was buried under fibrin glue (Tissucol; Immuno, France) and a previously dissected intercostal muscle. The chest was always closed with drains (one for pneumonectomy), and antibiotics were given until their removal.
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After pneumonectomy, BPF may occur at a rate of 1.3% [1] in the best series, and the percentage can increase to 3% when lobectomies are also considered [2]. At present, different strategies for the treatment of BPF have been proposed [2, 5, 6]. According to other authors, efforts must be made to prevent this complication [1]; however, one of the major problems remains the extreme fragility of the bronchial stump tissue. We believe that in early BPF after lung resection an immediate attempt at direct closure of the fistula should be always tried.
Four patients are not enough to analyze the efficacy of a technique; nevertheless, our good results are encouraging and we believe that other thoracic surgeons may find this simple technique useful.
References
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