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Ann Thorac Surg 2000;70:248-251
© 2000 The Society of Thoracic Surgeons

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Original articles: General thoracic

Role of surgical resection in broncholithiasis

^a Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Address reprint requests to Dr Miller, Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St SW, Rochester, MN 55905
e-mail: miller.danielmd{at}mayo.edu

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Broncholithasis is an uncommon problem with life-threatening complications. The purpose of this study was to update our experience in patients with broncholithiasis managed by surgical intervention.

Methods. From January 1984 to January 1998, 118 patients were diagnosed with broncholithiasis at our institution. We reviewed the medical records of those patients who underwent surgical treatment.

Results. There were 47 patients (19 men and 28 women). Median age was 58 years (range, 18 to 90 years). Indications for operation were symptoms in 44 patients and abnormal roentgenograms in 3 patients. Operative procedures included lung resection in 30 patients, broncholithectomy with or without bronchoplasty in 16, and segmental bronchial resection in 1 patient. There were no operative deaths. Postoperative complications occurred in 16 patients (34%). Follow-up was complete in 46 patients (98%) and ranged from 11 to 165 months (median, 74 months). The 15-year actuarial survival did not differ significantly from that of a matched control group (p = 0.774). At follow-up, 28 patients (68.3%) were asymptomatic. Symptoms continued in 12 patients. Recurrent or persistent disease was documented in 6 patients (14.6%). The site of recurrence was in a new location in 3 patients, a previous site in 2, and unknown in 1 patient. Subsequent management included observation in 3 patients, bronchoscopic removal in 2, and bilobectomy in 1 patient.

Conclusions. Surgical resection for broncholithiasis is an effective method of management for this disease and can be done with low mortality and morbidity. Progression of the disease may lead to recurrence and further surgical intervention.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Broncholithiasis is defined as the presence of calcified material within a bronchus or within a cavity communicating with a bronchus [1]. The majority of broncholiths are peribronchial lymph nodes that have undergone dystrophic calcification subsequent to an inflammatory process, most frequently histoplasmosis or tuberculosis [2].

Broncholithiasis usually presents with cough, hemoptysis, and dyspnea. Life-threatening complications, such as massive hemoptysis or bronchoesophageal fistula, may develop [3]. As a consequence, surgical treatment is warranted. This report updates our recent experience with the surgical treatment of broncholithsis and determines the long-term outcome of surgical intervention for broncholithiasis.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From January 1984 to January 1998, 118 patients with broncholithiasis were evaluated at Mayo Clinic. Criteria for inclusion were (1) symptoms or complications secondary to broncholithiasis; (2) radiologic findings consistent with broncholithiasis; (3) bronchoscopic findings consistent with broncholithiasis; and (4) surgical and pathologic findings consistent with broncholithiasis. Treatment of these 118 patients consisted of observation in 45, partial or total removal of the broncholithiasis by flexible or rigid bronchoscopy in 26, and surgical removal in 47 patients. These latter 47 patients (39.8%) form the basis of this report.

Survival probabilities were calculated using the Kaplan-Meier method [4]. Operative deaths included patients who died within the first 30 days after operation or during the same hospitalization. Operative deaths and late deaths due to any cause were included in the survival statistics. Expected survival curves were used as controls and were based on deaths from all causes from the West North Central United States 1990 Life Table data and were matched for age and sex. Statistical significance was p value equal to 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Clinical findings
There were 19 men and 28 women. Median age was 58 years (range, 18 to 90 years). Forty-four patients were symptomatic and are as follows: cough, 35; hemoptysis, 26; recurrent pneumonia, 11; lithoptysis, 5; and dysphagia, 1 patient. Thirty-five patients presented with a cough (32 were productive and 3 were nonproductive), 26 had hemoptysis, 11 had clinical evidence of recurrent obstructive pneumonitis, 5 had documented lithoptysis, and 1 patient had dysphagia secondary to an esophageal fistula. The 3 remaining patients were asymptomatic and underwent surgical exploration because of roentgenographic findings indistinguishable from malignancy. Nineteen patients (16%) had a preoperative diagnosis of histoplasmosis. None had documented tuberculosis.

Diagnostic studies
Chest roentgenograms were abnormal in 44 patients and are as follows: hilar or peribronchial calcifications, 26; calcified granulomas, 13; pulmonary infiltrates, 9; parenchymal nodule or mass, 3; normal findings, 3; Ghon complex, 2; emphysematous changes, 1; and bronchiectatic changes, 1 patient. Computerized tomography was performed in 45 patients and was abnormal in 40 patients; 35 had hilar or peribronchial calcifications, 24 had calcified granulomas, 8 had infiltrates, 3 had parenchymal mass suggestive of malignancy, 2 patients had bronchial distortion, and 1 patient each had bronchiectatic and emphysematous changes.

Bronchoscopy was performed in 44 patients and was abnormal in 41. Broncholiths were found in 38 patients (endobronchially in 20 and submucosally in 18), bronchial stenosis and distortion in 35, active bleeding in 3, and a bronchoesophageal fistula in 1 patient. The predominant locations of the abnormal bronchoscopic findings were on the right side in 30 patients (64%), on the left side in 9 (19%), and on the carina in 8 patients (17%) and are summarized in Figure 1.

View larger version (31K): [in this window] [in a new window]   Fig 1. Locations of abnormal bronchoscopic findings (LLL = left lower lobe; LMS = left main stem bronchus; LUL = left upper lobe; RBI = bronchus intermedius; RLL = right lower lobe; RML = right middle lobe; RMS = right mainstem bronchus; RUL = right upper lobe).

Both pulmonary resection and broncholithectomy was performed in 30 patients (63.8%). A lobectomy was performed in 16, bilobectomy in 4, segmentectomy in 7, wedge resection in 2, and pneumonectomy in 1 patient. Broncholithectomy without pulmonary resection was done in 9 patients, broncholithectomy with bronchoplasty in 7, and sleeve resection of the left main stem bronchus in 1 patient. Five patients had concomitant repair of bronchoesophageal fistula or an esophageal diverticulum.

Intraoperative complications occurred in 6 patients (12.8%); none were fatal. Complications included lacerations of the pulmonary artery in 4 patients, esophagus in 1, and main stem bronchus in 1 patient. Two patients with pulmonary artery laceration developed further problems; 1 required completion pneumonectomy for infarction and necrosis after pulmonary artery thrombosis and the other developed respiratory insufficiency requiring multiple bronchoscopies for retained secretions. The esophageal injury was repaired primarily without further complications. The patient with the right main stem bronchus tear required two reoperations, one for evacuation of hemothorax and one for removal of retained gauze.

Surgical pathology
The location of the broncholiths varied and often involved multiple sites along the trachobronchial tree. The broncholiths were predominately on the right in 30 patients, on the left in 9, and subcarinal in 8 patients. Abnormalities identified in surgical specimens were broncholith in 40 patients, calcified granuloma in 13, bronchiectasis in 6, pneumonitis/pneumonia in 4, lung abscess in 3, esophageal fistula in 3, and esophageal diverticulum in 2 patients. Cultures of surgical specimens demonstrated Histoplasma capsulatum in 12 patients. One developed both H. capsulatum and Mycobacterium avium. Cultures failed to demonstrate any organism in 34 patients. No patient had a malignancy identified in the resected specimen.

Hospitalization
There were no operative deaths. Postoperative complications occurred in 16 patients (34.0%) and were major in 7 and minor in 9. The seven major complications included hemothorax in 2 patients, empyema in 2, wound dehiscence in 1, thrombosis of the pulmonary artery in 1, and necrosis of the lingula in 1 patient. All 7 patients required reoperation. Minor complications included respiratory insufficiency in 3 patients, confusion in 2, prolonged air lead in 2, pneumothorax in 1, and atrial fibrillation in 1 patient. Median hospital stay was 7 days and ranged from 4 to 48 days.

Follow-up
Follow-up was complete in 46 patients (97.9%) and ranged from 11 to 165 months (median, 74 months). Five patients died. Cause of death was cancer (lung, prostate, and uterus) in 3 patients, myocardial infarction in 1, and unknown in 1. Twenty-eight patients (68.3%) were asymptomatic at the time of follow-up. Symptoms in the remaining 12 patients included lithoptysis in 4, cough in 3, hemoptysis in 3, wheezing in 1, and shortness of breath in 1. Recurrence of broncholithiasis was documented in 6 patients (13%). The location of the recurrence was in a new site in 3 patients, in a previous site in 2, and in an unknown area in 1 patient. Three of the 6 patients were treated conservatively, 2 underwent successful bronchoscopic removal, and 1 required surgical intervention. There was no statistically significant difference (p = 0.774) in the 15-year survival rate (Kaplan Meier), when the patients were compared to a control group. The survival curves are depicted in Figure 2.

View larger version (8K): [in this window] [in a new window]   Fig 2. Survival of the surgically treated patients. Probability of survival (death from any cause) in 47 patients undergoing surgical resection for broncholithiasis as compared to matched patients for age and gender as expected survival. Zero time on the abscissa represents the date of last surgical intervention.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Three treatment modalities are available for the management of patients with broncholithasis: observation, endoscopic removal, and surgical intervention. In 1985, Trastek and colleagues [3] reported on 52 patients with broncholithiasis. Forty of these patients underwent surgical treatment and 12 bronchoscopic removal of the broncholiths.

In the surgical group, there were one perioperative death (2.5%) and 5 major complications (12.8%). Bronchoscopic broncholithectomy was successful in 8 of the 12 patients (67%) and major complications occurred in 2 patients. There were no treatment deaths. However, a subsequent thoracotomy was performed in 3 of the 4 unsuccessfully treated patients. At that time, Trastek and associates [3] concluded that operation was the preferred treatment. In 1975, Faber and colleagues [5] described 10 patients treated nonsurgically and 33 patients that underwent thoracotomy with minimal morbidity and no mortality. On the contrary, in 1986 Cole and associates [10] advocated for an attempt at bronchoscopic stone removal before complications develop. The surgical resection of broncholiths was successfully performed in 25 of their 40 patients (60%) without mortality. Bronchoscopic stone removal was successful only in 19% without serious complications or recurrence, whereas 21% of their patients required no treatment.

The indications for surgical treatment of broncholithiasis have been well established in the literature [5, 7, 11]. They are the complications of broncholithiasis: intractable cough, persistent or massive hemoptysis, suppurative lung disease, bronchiectasis or bronchial stenosis, bronchoesophageal or aortotracheal fistula, and uncertainty about the diagnosis. The surgical removal of the offending broncholiths and destroyed lung parenchyma or bronchi should be as conservative as possible to preserve adequate pulmonary function [3, 5, 6]. Bronchoplastic procedures such as sleeve lobectomy instead of a pneunonectomy, bronchoplastic closure of defects with autogenous tissue reinforcement, or sleeve bronchial resection should be used [3, 5].

Not infrequently the fibrocalcific reaction is so extensive that tissue planes and hilar structures are fused. Meticulous lymph node dissection needs to be emphasized once more in this disease. Not only massive hemorrhage by tearing major pulmonary vessels, but esophageal and bronchial injury as well may occur during operation. Proximal control of the pulmonary vessels ahead of time, insertion of an esophageal dilator by mouth, extreme caution, and anticipation of a more extensive operation than the originally planned should always be kept in the mind of the surgeon. In this series we had six intraoperative complications including four major pulmonary artery tears. One of these patients had to be reoperated for infarction of the lung due to thrombosis of the repaired vessel. The other two complications were esophageal and bronchial tear. They were repaired intraoperatively. There was no 30-day mortality. Postoperative complications were observed in 16 patients (34%), and they were considered major in 7 (15%) and minor in 9 (19%).

In comparison to our previous article of 1985 [3], the surgical risks were similar. There was one postoperative death (2.5%) and major complications occurred in 5 patients (12.8%). The difference was the recurrence in the surgically treated patients in the current report. It occurred in 6 patients (13%), in contrast to none in the previous study. One patient underwent bilobectomy elsewhere, two were treated bronchoscopically with success, and three are under observation without significant symptoms. It is of interest to mention that in 1971, in a study from this institution, Arrigoni and colleagues [11] advocated against the liberal use of surgery, because of " ... the significant postoperative morbidity (18%) as well as mortality (3%) for what is a benign disease."

Another difference in this report was the repair of three esophageal fistulae and resection of two esophageal diverticuli. We had concluded in the previous study that the frequent use of preoperative bronchography and esophageal contrast studies, used by other researchers may have aided in the detection of this particular complication [3]. However, in the current series, symptoms such as dysphagia and cough when swallowing liquids were indicative in 3 of the 4 patients with esophageal fistulae. They were also confirmed by esophageal contrast studies. Interposition of viable tissue such as pleural, pericardial, or muscle flaps over suture lines has been strongly recommended to prevent recurrence [3, 11]. We used the serratus anterior muscle in 2 patients that underwent bronchoplasty and fistula repair, and the rectus abdominis muscle in 1 that underwent fistula repair and broncholithectomy. Pleural flaps were used in the remaining 2 patients with esophageal fistulae and diverticula repairs.

With regard to the association of broncholithiasis with lung cancer, it still remains unanswered, although it does not seem to be substantiated in the literature. Lung cancer developed in only 1 of 47 patients in the follow-up. In the 1985 study, lung cancer developed in 3 patients (6.1%) in the follow-up. Arrigoni and colleagues [11] had 3 of 68 patients who presented with lung cancer and broncholithiasis. Follow-up on a regular basis is recommended because of an incidence of associated lung cancer.

In summary, broncholithasis is a rare troublesome disease that can cause life-threatening complications. After a thorough evaluation with computerized tomography and bronchoscopy, surgical intervention should be performed with resection of the broncholith and conservative pulmonary resection. The risk of surgical intervention is low and the long-term benefit is excellent.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Dixon G.F., Donnerberg R.L., Schonfeld S.A., Whitcomb M.E. Advances in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis 1984;129:1028-1030.[Medline]
2. Bhagavan B.S., Rao D.R.G., Weinberg T. Histoplasmosis producing broncholithiasis. Arch Path 1971;91:577-579.[Medline]
3. Trastek V.F., Pairolero P.C., Ceithaml E.L., Peihler J.M., Payne W.S., Bernatz P.E. Surgical management of broncholithiasis. J Thorac Cardiovasc Surg 1985;90:842-848.[Abstract]
4. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
5. Faber L.P., Jensik R.J., Chawla S.K., Kittle C.F. The surgical implications of broncholithiasis. J Thorac Cardiovasc Surg 1975;70:779-789.[Abstract]
6. Ryberg A.A., Gengler J.S., Angelillo V.A., Scott W.J. Broncholithiasis. Nebraska Med J 1996;81:14-17.
7. Schmidt H.W., Clagett O.T., McDonald J.R. Broncholithiasis. J Thorac Cardiovasc Surg 1950;19:226-245.
8. Kelley W.A. Broncholithiasis. Postgrad Med 1979;66:81-90.
9. Igoet D., Lynch V., McNicholas W.T. Broncholithiasis. Respir Med 1990;84:163-165.[Medline]
10. Cole F.H., Cole F.H., Jr, Khandekar A., Watson D.C. Management of broncholithiasis. Ann Thorac Surg 1986;42:255-257.[Abstract]
11. Arrigoni M.G., Bernatz P.E., Donoghue F.E. Broncholithiasis. J Thorac Cardiovasc Surg 1971;62:231-237.[Medline]

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