Ann Thorac Surg 1997;64:959
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Robert J. Ginsberg, MD
Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021.
See also page 954.
A bronchopleural fistula after pneumonectomy can be a daunting problem to solve, especially if it presents in the chronic stage. The options for obliterating these chronic fistulas include "conservative" measures (eg, stump cauterization, fibrin glue, thoracostomy window and packing) or direct surgical closure. In many instances, I have found that a large thoracostomy window and repeated full thoracotomy packing for a period of 4 to 6 weeks will close many of these fistulas without a direct surgical approach. However, when an operation is required, whenever possible, the initial surgical approach should be through the ipsilateral hemithorax with dissection of the stump and use of a vascularized pedicle to buttress the closure. This approach can be combined with closure of the pneumonectomy cavity using interposed vascularized pedicles of muscle, omentum, or both, thus accomplishing a single-stage procedure to deal both with the fistula and space.
In the present report a transpericardial approach was the preferred choice of the surgeons in all cases. There are only certain circumstances when this approach is preferable, especially when rethoracotomy is contraindicated or has failed so frequently that a different approach is required. Occasionally, a concomitant carinal resection will be required and, in this context as well, this certainly is the approach of choice.
Every thoracic surgeon should have the capability of approaching the carina transsternally. Surgeons planning to transsternally close a postpneumonectomy bronchopleural fistula should remember that a major shift of the mediastinum to the left after left pneumonectomy may make a median sternotomy less than an optimal incision. In very selected cases, this transsternal approach will prove to be the best method of closing an intractable chronic postpneumonectomy bronchopleural fistula.
The operative mortality rate in this series is of concern. Especially in malnourished patients, a "conservative" approach with a large thoracostomy window and repeated packing may maintain the patient for months while the patient regains nutritional status. This may have avoided some of the hospital deaths that produced a 25% mortality rate.
Related Article
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Transsternal Closure of Bronchopleural Fistula After Pneumonectomy
- Aart Brutel de la Riviere, Joseph J. Defauw, Paul J. Knaepen, Henry A. van Swieten, Roland C. Vanderschueren, and Jules M. van den Bosch
Ann. Thorac. Surg. 1997 64: 954-957.
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