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Ann Thorac Surg 2003;75:382-387
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Limited operation for severe multisegmental bilateral bronchiectasis

^a Department of Pulmonary Diseases, Rangueil Hospital, University of Toulouse, Toulouse, France
^b Department of Radiology, Purpan Hospital, University of Toulouse, Toulouse, France
^c Department of Thoracic Surgery, Purpan Hospital, University of Toulouse, Toulouse, France

Accepted for publication August 24, 2002.

* Address reprint requests to Dr Mazières, Service de Pneumologie, Centre Hôpitalier Universitaire Rangueil, 1 avenue Jean Poulhes, 31403 Toulouse, France
e-mail: mazieres.j{at}chu-toulouse.fr

	Abstract

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BACKGROUND: Some patients exhibiting severe multisegmental bilateral bronchiectasis are no longer improved with antibiotic treatment and drainage and, most of the time, operation is contraindicated. In our institution, limited operation has been offered to select patients for this indication. We report our data regarding the feasibility and utility of such a procedure.

METHODS: We studied 16 patients who underwent surgical removal of nonlocalized disease between 1990 and 1999. We report the mortality and morbidity rates of this surgical procedure and the clinical, bacteriological, and functional data for each patient.

RESULTS: There was no mortality and the morbidity was low (18%, all with favorable outcome). Symptoms such as hemoptysis, sputum production, or dyspnea were also improved. The recurring infections decreased in frequency in 8 patients and disappeared completely in 5 others. The bacteriological data assessment revealed disappearance of germs in 4 patients and persistence of chronic colonization in others. Postoperative spirometric data were not worsened and postoperative computed tomographic scans did not show progression of lesions not removed.

CONCLUSIONS: These results suggest that, in properly selected patients, lasting symptomatic improvement can be achieved by resection. Limited operation may be indicated in nonlocalized bilateral bronchiectasis, provided that a target can be identified. This procedure is supported by physiopathologic arguments and is particularly relevant to patients with bronchiectasis with cystic and functionless territories.

	Introduction

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Operation has been proposed in bronchiectasis since the end of the 1930s [1, 2]. Its indications have decreased during the past 20 years because of vaccination and progress in antibiotic therapy. There is a broad consensus concerning the indications for surgical removal. Most pneumologists and thoracic surgeons reserved this treatment for localized bronchiectasis, especially in patients with severe or recurrent complications [3–7]. The surgical treatment is based on two physiopathologic hypotheses. First, the resection involves removal of lung tissue with destroyed bronchi that are no longer functional. Second, it permits the removal of a localized area of bronchiectasis, which could otherwise be involved in the infectious contamination of adjacent territories.

Multiple or bilateral bronchiectasis is generally regarded as a contraindication to operation. Nevertheless, we are confronted, in daily practice, with bronchiectasis involving multiple segments and lobes, no longer improved by antibiotic treatment and postural drainage, for which surgical removal can be discussed. This therapeutic option has been performed in our institution on 16consecutive patients with bilateral bronchiectasis. Surgical indications were offered to patients with multisegmental and severe bronchiectasis if (1) optimal medical treatment and physiotherapy were no longer efficient, (2) bleeding and sputum production were recurrent and abundant, (3) severely damaged territories could be identified, and (4) performance status and pulmonary function were compatible with the anesthetic risk. We reviewed the preoperative and postoperative symptoms, bacteriological data, computed tomographic scans, and, when available, spirometric data for all patients to determine the feasibility of such a procedure.

	Material and methods

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Patients
Between January 1990 and January 1999, 176 patients underwent pulmonary resection for bronchiectasis in our institution. Among them, 16 patients (11 women and 5 men) underwent operation for multiple, bilateral, and nonlocalized lesions according to our criteria. The mean age at the first resection was 44 years with a range of 16 to 71 years. In 7 patients, bronchiectasis was due to acute childhood bronchopathy (including whooping cough in 6). One patient exhibited 1-antitrypsin deficiency, and 3 had primary ciliary dyskinesia. The etiology in 5 patients could not be determined and bronchiectasis was considered primitive (Table 1).

Bronchoscopic data
Bronchoscopy was performed for each patient before operation to determine the segments involved in bleeding or in sputum production.

Bacteriological data
The infectious status was noted both before and after operation. The bacteriological and fungal analyses were obtained either from sputum or by endoscopic aspiration. The preoperative samples contained 8 Pseudomonas aeruginosa, 2 Aspergillus fumigatus, 1 Mycobacterium avium, and 7 community germs including 3 Staphylococcus aureus. The antibiotic therapy was also evaluated both before and after operation by noting the number of antibiotic treatments for infection linked to bronchiectasis either during hospitalization or at home.

Imagery data
A high-resolution computerized tomographic (HRCT) scan was performed before the operation in all patients. All the HRCT scan results were reconfirmed by a radiologist specialized in thoracic imagery. The 19 segments were studied for each patient according to the following segmentary division: 9 on the left (3 in the upper division of the left upper lobe, 2 in the lingula, 4 in the lower lobe); and 10 on the right (3 in the upper lobe, 2 in the middle lobe, 5 in the lower lobe). The mean number of preoperative pathologic segments was 10.2 (range, 6 to 14) (Table 1). Each bronchiectatic segment was indexed according to Reid’s classification [9]: type 1, cylindrical; type 2, fusiform; and type 3, cystic (saccular). Cystic dilatations were the most frequent abnormalities and were present in 15 patients. Fusiform bronchiectasis occurred in 12 patients and was cylindrical in 11. Postoperative HRCT scans were available for 10 patients.

Functional data
Spirometric data with vital capacity and forced expiratory volume in the first second were available for 11 patients. The preoperative and postoperative spirometric data were compared. The preoperative assessment was done well after any acute complication and the postoperative assessment was carried out between the sixth and twelfth month.

Operation
Among the 16 patients, 22 surgical resections were performed. Eleven patients underwent a single thoracotomy, 4 had two thoracotomies for bilateral disease, and 1 patient had a third stage operative procedure. No patient underwent simultaneous bilateral resection. The right middle lobe was removed from 11 patients, the left lower lobe from 7, the right lower lobe from 5, the lingula from 3, and segmentectomies of the upper right lobe were performed on 2 patients (Table 1). The mean number of resected segments was 5.2 (range, 2 to 10). In all patients, the number of resected segments was less than the number of segments considered pathologic from the HRCT scan. The mean number of pathologic segments not removed was 4.8 per patient (range, 2 to 11) (Figs 1 and 2). Data on postoperative morbidity, mortality, and duration of chest drainage, which provide a good indication of immediate postoperative complications, were also collected.

View larger version (53K): [in this window] [in a new window]   Fig 1. Comparison of pathologic (n = 163, average = 10.2; solid bars) and resected segments (n = 91, average = 5.7; shaded bars) for each patient. For all patients, some involved segments were not removed (n = 72, average = 4.5)

View larger version (156K): [in this window] [in a new window]   Fig 2. Computed tomographic scan showing bilateral disease with cystic bronchiectasis in the middle lobe and cystic and cylindrical bronchiectasis in the left and right lower lobes. This patient underwent a middle lobectomy with favorable clinical outcome.

	Results

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The evolution of the symptoms was satisfactory as reported in Table 2. Six patients had hemoptysis before the operation and none afterward. Sputum production, which was disabling in 3 patients, decreased dramatically for all of them. Dyspnea score was also improved in 9 patients and unchanged in 7. Among the 4 patients who had a high preoperative dyspnea score, 3 improved with operation. The recurring infections also decreased in frequency in 8 of the patients, disappeared completely in 5 patients, and remained unchanged in 3 patients. The use of antibiotics, either in oral form or by intravenous administration during hospitalization, decreased dramatically in 8 patients. Moreover, 5 of them no longer used antibiotics after operation. The follow-up in these patients was 2 to 6 years.

We also focused on the bacteriological and fungal analyses. After operation, the infectious analyses remained unchanged in 12 patients and became sterile in 4 initially infected patients.

Comparisons of the values of vital capacity and forced expiratory volume in the first second before and after operation were available for 11 patients and were 2,486 mL (standard deviation ±897 mL) and 1,570 mL (standard deviation ±639 mL), respectively, before operation and 2,568 mL (standard deviation ±973 mL) and 1,690 mL (standard deviation ±688 mL) after operation (Table 2). Our population is too small to allow statistical analysis but no worsening in spirometric data was noted after operation. Furthermore, HRCT scans performed 1 year after operation in 10 patients did not show any progression of the not-removed lesions.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Since the 1950s operation for bronchiectasis has taken a significant place in departments of thoracic surgery. The indications are well accepted and operation is performed in localized but poorly tolerated bronchiectasis. From the end of the 1970s onward, some thoracic surgeons have suggested that bilateral bronchiectasis is not a contraindication to resection [2, 5, 10, 11]. Nevertheless, the patients reported in the literature remained quite rare. The therapeutic options in nonfocal bronchiectasis are limited. Most of the time patients are treated with antibiotics and physiotherapy. Recently, progress has been made with the use of new antibiotics and inhalation of tobramycin solution in cases of Pseudomonas aeruginosa colonization [12]. These therapies allow a good quality of life and symptomatic improvement for several years, but the usual evolution is a progression toward chronic respiratory failure with a poor prognosis and selection of resistant strains [13, 14]. Transplantation remains indicated for homogenous disease and for patients with advanced disease with seriously compromised pulmonary function and chronic respiratory failure [15]. The 3-year survival rate is 75% for patients undergoing double-lung transplantation [16]. Some investigators have proposed a radical operation for bilateral bronchiectasis [17, 18] but others report a higher mortality with pneumonectomy [19]. Considering the limited and palliative effect of medical treatment and the risk of transplantation or radical operation, it seems that a limited operation should be offered to some patients with diffuse bronchiectasis.

We studied the feasibility of such a procedure. This operation is considered risky, and hemorrhagic or infectious complications are often expected because of the bronchial arterial circulation and the septic context. In our study, mortality was null and morbidity was low (two infectious complications without empyema and one persistent air leak) and this was comparable or even lower than those reported in other series concerning localized bronchiectasis [3, 6, 20–22]. We compared these results with those from the patients who underwent operation for localized disease in the same period in our institution. Among 160 patients, 113 lobectomies, 12 pneumonectomies, 23 wedge resection, and 12 combined procedures were performed. Morbidity was 22% (n = 35) and mortality was 1% (n = 2), showing similar results with nonlocalized disease. The duration of chest drainage and the postoperative length of stay confirmed these data. Thus, the fear of major complications should not be a limiting factor in the decision to opt for operation provided that preoperative and postoperative management in the intensive care unit can be done with antibiotics and drainage.

Our study shows the benefit of operation in nonlocalized bronchiectasis. Disappearance or regression of the preoperative symptoms occurred in 75% of the patients. Improvement of disabling symptoms, reduction in hospital stay, and reduction of antibiotic consumption should result an improved quality of life. Even if these data had not been analyzed independently, subjective impressions reported by the patients or by their general practitioners confirm this improvement. Of course, the rate of complete cure was lower than in localized bronchiectasis, which is about 35% to 50% [7, 11]. In our own institution, operation for localized bronchiectasis had a 59% complete cure, 29% improvement, and 12% stable disease. The spirometric improvement was very moderate, as reported in the literature [3]. It is, however, interesting to note the absence of deterioration as a result of the operation, although the number of patients and the duration of the follow-up were too small for conclusions to be drawn. No researcher has described the influence of operation on bacteriological colonization in diffuse bronchiectasis, except for patients with cystic fibrosis. Nevertheless, it remains a fundamental element of treatment. In this study, sputum sterilization was obtained in only 4 patients. Pseudomonas aeruginosa, Aspergillus fumigatus, Haemophilus influenzae, and Staphylococcus aureus were initially isolated in these 4 patients with a follow-up of 2 to 6 years. In most patients, the germs initially isolated persisted after operation. It is necessary to differentiate the obvious infections from usual colonization. Reduction of the use of antibiotics is a good indication of the decrease in severe infection, as reported in our study. In most patients operation did not lead to the eradication of the germ but it allowed the elimination of the active territories involved in the contamination of surrounding parenchyma.

According to this study and review of the literature, we bring some arguments to help in the selection of patients who should be considered for operation. First, respiratory function and performance status must be compatible with the anesthetic risk. Second, the resection should be done quite early in the evolution of the disease because of the risk of contamination of healthy bronchi by an "active" territory and because of the low morbidity when the pulmonary function is good [23]. In addition, in our study, three bacteriological recoveries occurred in patients with six to eight pathologic segments. Third, operation is recommended for patients exhibiting disabling bronchiectasis with hemoptysis or a recurring infection that becomes resistant to medical treatment. Fourth, the etiology of bronchiectasis should not be considered in the decision for operation. Some studies showed the benefit of operation in primary ciliary dyskinesia [24] and in hypogammaglobulinemia [25]. In our study, patients with Kartagener’s syndrome or after whooping cough dilatations also benefited from operation. Lastly, the ideal candidate has a nonhomogenous disease. Some territories are more severely involved and constitute real targets. Most of the time, cystic destruction or advanced fusiform bronchial dilatations are found in such areas. As these territories are no longer functional, they can be considered as infection tanks that can contaminate adjacent territories. Certain physiopathologic arguments support this theory. The removal of an active infectious territory may protect the healthy bronchi from infectious contamination. Inflammation usually initiates the destructive process that results in bronchiectasis by toxin release and reduction of the mucociliary clearance [26]. Removal of diseased segments can break the vicious circle as described by Cole and colleagues [27], and stop the progression of the disease. To define this target population as efficiently as possible, the preoperative assessment requires an HRCT scan [28]. Another argument for a limited operation can be provided by the fact that the pulmonary perfusion is retained in the area of cylindrical changes and therefore, as proposed by Ashour [29], this type is not a primary indication for surgical management that should be reserved for more damaged territories.

In conclusion, this study suggests that severe bronchiectasis with bilateral involvement that becomes resistant to the usual medical treatment and physiotherapy can be improved with operation. In the properly selected patients, pulmonary resection can be done with acceptable morbidity and mortality rates and can lead to lasting symptomatic improvements. The aim of this limited surgical procedure is to obtain a functional gain and to slow down or stop the progression of the disease. The best indication for operation is nonhomogeneous disease with functionless territories that will constitute the target for the resection.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors thank Maité Turmon for her help in reviewing the manuscript and Dr W. Heurtaux for his contribution.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marcel Dahan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mazières, J. Articles by Léophonte, P. Search for Related Content PubMed PubMed Citation Articles by Mazières, J. Articles by Léophonte, P. Related Collections Lung - other