| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1997;64:958
© 1997 The Society of Thoracic Surgeons
DR ROBERT J. CERFOLIO (Birmingham, AL):
I am just wondering why you are using a sternotomy which risks the sternum to infection, why you are reresecting the bronchus, and why you are using two operations (a Clagett procedure and a sternotomy) when you can accomplish all the surgical principles with one operation. At the University of Alabama at Birmingham our approach has been to do a redo thoracotomy, harvest the serratus anterior muscle, debride the pleural space, and then cover the bronchopleural fistula with the muscle. The bronchopleural fistula only needs to be plugged with muscle; a carinal resection or reresection of a long bronchial stump is not necessary. The chest is then aggressively debrided and filled with an antibiotic solution and closed. This technique has been very successful. Have you ever used this approach?
DR BRUTEL DE LA RIVIERE:
These comments are well taken. However, when we see these patients, who are usually referred to us rather late, then they have serious infection in their pleural space, and first we try to get rid of the infection by making a large window, and at that time, it would be highly unsuitable to go to the airway and try to close it, as this is really an infected area. Therefore, once you have opened the chest and you have packed it with gauzes, and changed these every day to get rid of the infection, then you have this enormous fibrous peel around the bronchus, and we think it is very difficult to get a nice, safe bronchial reclosure of that stump. That is the main reason to adopt this technique. I have alluded to the fact that when you have a patient who comes in early, you can easily resuture the bronchus and you can cover it, preferably with omentum, but that is a completely different set of patients.
DR ROBERT J. GINSBERG (New York, NY):
I have two questions. You mentioned that you did not reinforce the stump, and yet you had a 25% fistula rate. Would you rethink that considering that you had such a high fistula rate?
Was this technique a sternotomy or was this a transverse sternal incision?
DR BRUTEL DE LA RIVIERE:
First of all, this study covers a longer period of time and the magnificent applicability of the omentum became clear only in the last decade, particularly because of the work from the Massachusetts General Hospital. Therefore, in recent times we indeed are much more liberal in the use of the omentum, as it is so easy to take from the abdomen through the pericardium to the bronchus. I think that you are right, we are rethinking the use of the omentum enormously.
Your second question refers to the approach, and this is certainly the classic midsternal split, as we do in cardiac surgery.
DR THOMAS R. J. TODD (Toronto, Ontario, Canada):
This is an incredible experience and we all thank you for bringing this large series to our attention. I, too, want to address what Bob is after and that relates to the high recurrence rate. You indicated that you believed that it may be related to the length of the stump. You also mentioned that there may be some difference in recurrence in the pre-Clagett era and the Clagett era. Could I also ask you whether it is related to how you handled the residual stump? You indicated that on occasion you removed it and on other occasions you cauterized the mucosa. Certainly others have indicated that nonremoval of the residual stump may indeed lead to a higher incidence of recurrence. Were you able to determine in your review whether the incidence of recurrence was different depending on whether you removed the residual stump or simply cauterized the mucosa?
DR BRUTEL DE LA RIVIERE:
Thank you so much. The first thing is that the recurrences were much more frequent, as we showed, in very short stumps, and once you have a very short stump and you try to reamputate it, and I am hesitating to use the word "amputation," as there is not usually very much tissue left, then you cannot remove anything. If you have a long bronchial stump, it is very easy to remove that stump, therefore the problem is not there, but if it is a short stump, it is more difficult. We used the electrocautery just to destroy the mucosa, as it has been shown from your institution, from Dr Pearson's experience, that you could get some secretions. We have not seen any relation between a recurrent fistula and the staying in situ of the residual bronchial stump. We have not seen any relationship between opening of the pleural space and a recurrent fistula. We have the impression that this is mainly related to the condition of the patient, the nutritional status, and these secondary factors, and obviously a tension-free reclosure of the bronchus.
DR CLAUDE DESCHAMPS (Rochester, MN):
Congratulations for your courageous approach to a difficult problem. We also have found out that the highest, most significant factor for recurrence was a persistent fistula. We have found also through the years that the name Clagett has been associated with a variety of procedures, and I would like to know whether your procedure, which you call Clagett, is a staged packing of the thoracic cavity with debridement, closure, and antibiotic solution.
DR BRUTEL DE LA RIVIERE:
What we understand by the Clagett procedure is, first of all, take a few ribs out and make a large window so that you really have an open chest that allows the best possible drainage of the empyema. We pack that each day either with povidone or gauze pads with chlorhexidine. Once the patient is in good condition, we close the bronchus through the midline, then we wait another 2 to 3 weeks and close the chest. At that moment we do not fill the chest with antibiotic solutions, as Dr Clagett originally had described. Neither do we try to fill it up with muscle or something else. We just close it.
DR CAMERON D. WRIGHT (Boston, MA):
I just wanted to address the short bronchial stump issue, which is a real problem in patients in this particular group. I would suggest that there is another solution that you have not alluded to and that is just plugging the hole. There is a big difference between plugging the hole and a carinal resection. Carinal resection ought to be performed rarely for this particular problem. Perhaps an analogy can be made to a dam and a little Dutch boy; you could rebuild the whole dam and repair it that way or you could just plug it with your finger. A short rigid open bronchus can be closed with the omentum or muscle. We have done that many times with good results.
DR BRUTEL DE LA RIVIERE:
Well, coming from Holland and having these problems with dikes, I am familiar with the concept, and I think you are right, this is a very good solution, and certainly this will allow us to better treat these patients.
Related Article
Ann. Thorac. Surg. 1997 64: 954-957.
This article has been cited by other articles:
|
|
 |
|
  V. Porhanov, I. Poliakov, V. Kononenko, A. Selvaschuk, V. Bodnya, S. Semendiaev, M. Mamelov, and L. Marchenko Surgical treatment of 'short stump' bronchial fistula Eur J Cardiothorac Surg, January 1, 2000; 17(1): 2 - 7. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
