Ann Thorac Surg 2002;73:635-636
© 2002 The Society of Thoracic Surgeons
Case report
Transsternal transpericardial closure of a postlobectomy bronchopleural fistula
Yael Refaely, MDa,
Michael Paley, MDa,
David A. Simansky, MDa,
Yeudit Rozenman, MDb,
Alon Yellin, MD*a
a Department of Thoracic Surgery, Tel Hashomer, Israel
b Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
Accepted for publication February 14, 2001.
* Address reprint requests to Dr Yellin, Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Israel
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Abstract
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We report a case of chronic empyema and bronchopleural fistula after lobectomy for tuberculosis. The patient had undergone four different surgical procedures to correct his bronchopleural fistula during an interval of seven years. Finally, he had a successful closure of the fistula using the transsternal transpericardial approach.
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Introduction
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Bronchopleural fistula (BPF) after pulmonary resection is associated with substantial mortality and morbidity. The incidence of BPF after pulmonary resection varies from 0.5% to almost 10% in different series and has reached 28% after pneumonectomy for tuberculosis. Its successful treatment is a major challenge to the thoracic surgeon.
Puskas and collegues [1], in their series of 42 patients with chronic BPF, reported an average of 3.3 surgical procedures to correct the fistula during a mean interval of 1 year before closure of the bronchial stump with a vascularized pedicle flap was attempted [1]. Successful treatment of a BPF requires closure of the fistula and handling of the empyema. This can be achieved with either one or two stages. The empyema can be managed either by tube drainage or by open window thoracostomy alone, or as the first step of Clagett procedure. Fistula repair can be performed using a vascular flap (ie, omentum, various muscles, or pleura).
Transpericardial closure of BPF is another effective approach. Anterior transpericardial closure of BPF was first introduced in North America by Padhi and Lynn [2] in 1960, and then 23 years later by Anderson and Li [3]. This approach involves anterior parasternal thoracotomy and multiple cartilage resection. The transsternal, transpericardial closure was first described by Abruzzini [4] in Italy in 1961 and has been used extensively in the Soviet Union. In 1985, its use was renovated in North America by Baldwin and Mark [5]. This method has been used for cases of BPF after pneumonectomy. We report here a case of chronic BPF after lobectomy successfully closed via the transsternal transpericardial approach.
A 47-year-old man presented to our department in 1998 with a history of treated pulmonary tuberculosis 20 years ago.
In 1991, reactivation of the disease occurred, manifested with right-sided pneumothorax, peripheral bronchopleural fistula, and empyema, and was treated by drainage. In 1992, he underwent open window thoracostomy, but the fistula and pus persisted. In 1994, he was planned to undergo a right pneumonectomy, but eventually he had a right middle and lower lobectomy without closure of the window. This, as well, did not solve the problem. In 1997, he underwent another unsuccessful attempt to close the fistula with intercostal and pectoralis muscle flaps.
On admission he complained of persistent unbearable odor and secretions coming from the window thoracostomy. He also complained of severe dyspnea and aphonia after walking 15 meters or climbing 3 steps. The patient underwent spiral computed tomographic scan that demonstrated a normal size proximal bronchus intermedius with a wide opening to the right pleura, a small contracted right upper lobe, and several cavitations in the left lung (Fig 1).
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Fig 1. Minimal intensity projection of the chest shows a wide trachea and proximal bronchus intermedius with an opening (arrow) to the right pleura. The reconstruction also demonstrates a small contracted bronchiectatic right upper lobe and a large cavity in the left upper lobe.
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The patient was operated on in February 1998 under general anesthesia with a double lumen endotracheal tube. We used a complete median sternotomy. The anterior pericardium was opened. The superior vena cava and ascending aorta were mobilized and retracted. The right main pulmonary artery was identified as intrapericardial and then divided between two ligatures and two vascular staplers. The posterior pericardium was incised. Major airways were identified and dissected. Two 30-mm linear staplers were applied, one in the right tracheobronchial junction and the other on the distal right bronchial stump, and the bronchus was divided between them. A pericardial flap was sutured over the proximal stump. A 24 French drain was left in the anterior mediastinum and a flat silicone drain near the bronchial stump.
The postoperative course was uneventful except for difficulties in removing bronchial secretions that required repeated tracheal suctions and physiotherapy. The patient was discharged on the tenth postoperative day. On follow-up visits up to 17 months after the operation, the bronchopleural fistula remained closed and the patient reported immediate and sustained improvement in his quality of life and performance.
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Comment
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The transsternal, transpericardial (TSTP) approach for repair of BPF has been used infrequently in the western hemisphere and always after pneumonectomy [5–8]. This approach has valid theoretical advantages: a relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and chronic sepsis, and the avoidance of chest wall deformity. The single disadvantage is that the residual empyema space is not dealt with at the same session, unlike thoracoplasty or thoracomyoplasty. There are no clear indications regarding the use of this technique. Baldwin and Mark [5] recommended it only in cases where the stump is at least 10-mm in length. Others did not consider a short bronchial stump to contraindicate this approach. Classically re-amputation is done, but when the stump is too short, a complete or wedge tracheal resection can be performed. Alternatively an omental patch was added when total closure of the stump could not be achieved since there was a lateral opening in the trachea.
While the transsternal transpericardial approach is used mainly in cases of chronic BPF, Beltrami [6] recommended its use even in early postoperative fistula. Ginsberg and collegues [7] suggested that the transsternal transpericardial approach is the most effective method for BPF closure when other strategies have failed, or when a direct approach through the thoracotomy space is not warranted.
In a review of selected publications, the collective success was 77% (35 of 45 patients). Failures were noticed mainly when the bronchial stump was stapled and not divided. Reinforcement of the new stump can be achieved with viable tissue (ie, thymus, omentum, or a pericardial flap as we used).
In the case presented here, all other methods attempted including drainage, open window thoracostomy, transposition of myovascular flaps and resection have failed. In the presence of a collapsed and nonfunctioning residual lobe many years after a lobectomy in a cachectic and high-risk patient, we decided to disregard the residual lung and empyema space and direct our efforts toward the stump. Therefore, we used the transsternal transpericardial approach, re-amputating the main bronchus and main pulmonary artery.
Although unconventional a chronic BPF after less than pneumonectomy can be managed in selected cases by the transsternal transpericardial approach.
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References
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Puskas J.D., Mathisen D.J., Grillo H.C., Wain J.C., Wright C.D., Moncure A.C. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109:989-995.[Abstract]
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Padhi R.K., Lynn F.B. The management of bronchopleural fistula. J Thorac Cardiovas Surg 1960;39:385-393.
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Anderson R.P., Li W. Anterior transpericardial closure of a main bronchus fistula after pneumonectomy. Am J Surg 1983;145:630-632.[Medline]
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Abruzzini P. Tratamento chirugico delle fistulae del broncho principale consecutive pneumonectomia tuberculosi. Chir Torac 1961;14:165-171.
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Baldwin J.C., Mark J.B. Treatment of bronchopleural fistula after pneumonectomy. J Thorac Cardiovas Surg 1985;90:813-817.[Abstract]
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Beltrami V. Surgical transsternal treatment of bronchopleural fistula postpneumonectomy. Chest 1989;95:379-382.[Abstract/Free Full Text]
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Ginsberg R.J., Pearson F.G., Cooper J.D., et al. Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach. Ann Thorac Surg 1989;47:231-235.[Abstract/Free Full Text]
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Stamatis G., Martini G., Freitag L., Wencker M., Greschuchna D. Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy. Eur J Cardiothorac Surg 1996;10:83-86.[Abstract/Free Full Text]
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Abstract
Introduction
