Ann Thorac Surg 1999;68:235-237
© 1999 The Society of Thoracic Surgeons
Case Reports
Bronchial obstruction after upper lobectomy: kinked bronchus relieved by stenting
Marc Van Leuven, MDa,
Julie A. Clayman, MDa,
Norman Snow, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
Address reprint requests to Dr Snow, Department of Cardiothoracic Surgery, University of Illinois, Chicago, 849 S Wood St, Suite 417(M/C 958), Chicago, IL 60612-7322
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Abstract
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Post resectional kinking of the lower lobe bronchus caused obstructive symptoms in 2 patients following upper lobectomy. Exaggerated upward displacement of the remaining lower lobe seemed to be causative. Intrabronchial stenting relieved the obstruction in each case with satisfactory intermediate term results.
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Introduction
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Bronchial obstruction following lobectomy is unusual. We recently encountered 2 cases of postoperative atelectasis secondary to kinking of the airway subsequent to upper lobectomy for lung cancer, both of which responded to intrabronchial stent placement.
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Case reports
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Patient 1
A 61-year-old woman underwent a right upper and middle lobectomy for a T1NOMO adenocarcinoma. The postoperative period was complicated by persistent atelectasis of the remaining lower lobe. Figure 1 is the chest roentgenogram of the patient on the 4th postoperative day. It demonstrates volume loss and minimal air entry on the right side, a cut-off sign at the level of the intermediate bronchus, elevation of the right hemidiaphragm and an ipsilateral shift of the mediastinum.
Therapeutic flexible bronchoscopy was performed on the 1st, 2nd and 4th postoperative days. The bronchoscope easily passed through an area with apparent erythematous mucosal swelling or folds. The segmental bronchi were easily aspirated. Kinking of the intermediate bronchus was noted.
On the 15th postoperative day stent placement was performed under general anesthesia with fluoroscopy. Extreme angulation of the bronchus secondary to upward displacement of the remaining lobe was noted. Two Wall-stents (Boston Scientific Microvasive, Natick, MA) across the angulation were required to ensure patency of the intermediate and lower lobe bronchus. Figure 2 shows the curve in the bronchus as displayed by the expandable metal stents. Recovery ensued and was sustained at 16 months. The Wall-stent is thought to have particular advantage in tortuous lesions since it seems to adapt well to acute angulation [1].
Patient 2
A 71-year-old male underwent a left upper lobectomy and had an uneventful postoperative course. The histology of the tumor was adenocarcinoma, T2N2.
Three weeks later he showed signs of bronchial obstruction. An intermittent high-pitched whistling sound was traceable to the left chest. At first a conservative approach was chosen since the patient was reluctant to undergo a repeat bronchoscopy. He subsequently complained of increasing dyspnea. An infiltrate in the remaining left lower lobe was noted. Repeat endoscopy demonstrated kinking of the junction between the left main bronchus, and the left lower lobe.
A silicone stent was inserted in the left main bronchus. After this procedure his symptoms disappeared and the patient remained well until he was readmitted with evidence of generalized metastasis. He expired approximately 5 months after the lung resection, with no signs of bronchial obstruction.
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Comment
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Benign bronchial obstruction after conventional partial lung resection is uncommon. Keller and colleagues reported a series of bilobectomies but no cases of angulation of the remaining bronchus are described [4]. Obstruction without torsion after resection may be due to an anatomic "rearrangement" of the remaining lung, or flattening of the bronchus due to stapling technique or staple application [3, 4]. Kinking or bending of a remaining ipsilateral bronchus has rarely been reported. In one patient the right middle lobe bronchus was obstructed, presumably due to stiffening of the airway by sutures placed across the longitudinal axis of the remnant bronchus (Overholt’s method). A right middle lobectomy was subsequently performed [5]. Occasionally, technical misadventures such as "tenting" of an upper lobe bronchus during transection with resultant narrowing of the remaining bronchus can cause obstructive atelectasis[6]. This may require surgical revision and enlargement of the bronchial lumen. Severe post lobectomy atelectasis (SPLA) may be due to anatomic rearrangement or kinking of the bronchus. A study which detailed a 7.8% incidence of SPLA (17 patients) did not address the bronchoscopic findings [3].
We recently treated 2 patients with bronchial obstruction due to kinking of the lower lobe bronchus and resultant distal obstruction by endobronchial stenting. After symptoms were assessed and radiographic studies obtained, bronchoscopy demonstrated the presence of a slit-like, or folded appearance of the narrowed bronchus that obscured the view beyond the affected area. Typically however, the flexible adult bronchoscope could be passed distally after which the segmental bronchi could be identified.
This kinking of the bronchus probably occurs as a result of the upward displacement of the diaphragm and remaining lobe, possibly also with some torsion of the bronchus. In both cases reported here, those changes probably surpassed a critical threshold resulting in lobar obstruction to clearance of secretions. It is a rare complication, but may well be under-reported. In a review of the literature concerning the use of stents for benign bronchial stenosis after lung resection no similar cases of bronchial stenosis secondary to kinking of the airway after conventional upper (and middle) lobectomy were reported. We would like to draw attention to the possible complication of kinking of the main and/or intermediate bronchus after partial upper (lobectomy or bilobectomy) lung resection. The problem was solved by the insertion of an endobronchial stent. Certainly consideration should be given to this treatment option prior to completion pneumonectomy, given the increased morbidity and mortality attendant to that operation, especially when performed for benign (postoperative complication) disease [7, 8]. Choice of stent is usually personal preference based on experience. The Wall-stent may be more feasible for severe angulation. Although complications associated with stenting (migration and erosion) occur, they are rare and were not observed in our medium term follow-up.
The timing of stent insertion is predicated on the pathophysiology. When kinking is suspected, stenting seems appropriate. Our first patient probably experienced avoidable delay due to our unfamiliarity with this condition.
Intrabronchial stenting of distorted postoperative bronchial anatomy producing obstruction may reestablish patency of the airway, facilitate removal of secretions, and avoid more invasive surgical options[2].
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References
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Zannini P., Melloni G., Chlesa G., et al. Self-expanding stents in the treatment of tracheobronchial obstruction. Chest 1994;106:86-90.[Abstract/Free Full Text]
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Tsang V., Goldstraw P. Self-expanding metal stent for tracheobronchial strictures. Eur J Cardiothorac Surg 1992;6:555-560.[Abstract]
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Korst R.J., Humphrey C.B. Complete lobar collapse following pulmonary lobectomy. Chest 1997;111:1285-1289.[Abstract/Free Full Text]
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Keller S., Kaiser L.R., Martini N. Bilobectomy for bronchogenic carcinoma. Ann Thorac Surg 1988;45:62-65.[Abstract]
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Konaka M., Kadokura M., Tanio N., et al. Middle lobe bronchial obstruction after right upper lobectomy. Jnl Bronchol 1997;4:307-309.
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Fox R.A., Stanbridge R.D.L., Brown J. Expandable metal stents for non-malignant bronchial obstruction. Thorax 1996;51:963-964.[Abstract/Free Full Text]
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Accepted for publication November 20, 1998.
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Abstract
Introduction
