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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Aart Brutel de la Riviere Paul J. Knaepen Henry A. van Swieten Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by de la Riviere, A. B. Articles by van Swieten, H. A. Search for Related Content PubMed Articles by de la Riviere, A. B. Articles by van Swieten, H. A.

Ann Thorac Surg 1998;65:1199-1200
© 1998 The Society of Thoracic Surgeons

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Correspondence

Reply

^a Department of Cardiopulmonary Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands

To the Editor

We appreciate the interest of our colleagues from the University of Parma in our article.

Successful video-assisted closure of a postpneumonectomy bronchopleural fistula was reported by Azorin and associates [1]. An endoscopic stapler was introduced into the mediastinum in a similar way as a mediastinoscope. The pleural cavity was cleaned using video thoracoscopy. The technique described by Spaggiari and associates basically uses the same approach. Apparently, they have no human experience with this technique.

A "transmediastinal" approach to a bronchopleural fistula after pneumonectomy is only safe if no previous mediastinoscopy was performed, which will be rare. The stapler device is rather large, and will therefore require extensive dissection, with risks involved (eg, recurrent nerve, pulmonary artery). Moreover, just stapling the main bronchus will leave tension on the "suture" line, as the bronchus is not divided. Also, actively secreting mucosa will be left in the chest.

No proper vascular control is possible: dense adhesions, present more often than not, will make the procedure hazardous, particularly for the main pulmonary artery. The risks involved in transsternal closure are mostly determined by the usually severely debilitated patients, with long-standing infection (ie, empyema), having only one lung, after a cancer operation—not by the approach itself. We have not encountered mediastinitis or major bleeding complications in the recent time frame.

As indicated by Ginsberg in the invited commentary to our article [2], getting the patient in an optimal nutritional status is the main focus of early treatment. The operation should be tailored to the pathology (eg, long versus short stump).

At present, we think that either transsternal closure or an ipsilateral, transpleural approach with liberal use of muscle and omental flaps is the treatment of choice in these patients.

References

1. Azorin J.F., Francisci M.P., Tremblay B., Larmignat P., Carvaillo D. Closure of a postpneumonectromy main bronchus fistula using video-assisted mediastinal surgery. Chest 1996;109:1097-1098.[Abstract/Free Full Text]
2. Ginsberg R.J. Invited commentary to Brutel de la Riviere A, Defauw JJ, Knaepen PJ, van Swieten HA, Vanderschueren RC, van den Bosch JM. Transsternal closure of bronchopleural fistula after pneumonectomy. Ann Thorac Surg 1997;64:954-959.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Aart Brutel de la Riviere Paul J. Knaepen Henry A. van Swieten Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by de la Riviere, A. B. Articles by van Swieten, H. A. Search for Related Content PubMed Articles by de la Riviere, A. B. Articles by van Swieten, H. A.