Ann Thorac Surg 2007;83:703-704
© 2007 The Society of Thoracic Surgeons
How To Do It
Transverse Bronchoplasty of the Membranous Wall After Resection of an Endobronchial Hamartoma
Periklis Tomos, MDa,
Theodoros Karaiskos, MDa,*,
Elias Lahanas, MDa,
Dionysios Paulopoulos, MDa,
Dimitrios Papahristou, MDa,
Antonios Stauroulias, MDb,
Antonios Papachristodoulou, MDa
a 2nd Department of Surgery, University of Athens, Athens, Greece
b Department of Lung Diseases, "Laiko" Hospital of Athens, University of Athens, Athens, Greece
Accepted for publication March 21, 2006.
* Address correspondence to Dr Karaiskos, "G. Papanikolaou" General Hospital of Thessaloniki, Cardiothoracic Surgery, Exohi, Thessaloniki, 57010 Greece. (Email: theokar{at}panafonet.gr).
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Abstract
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Lung hamartomas are rare benign tumors of the bronchi. Their management consists of bronchoscopic excision or removal through a thoracotomy and bronchotomy whenever there is a large tumor totally obstructing the bronchial lumen. As a lung-sparing procedure is usually the aim, various bronchoplastic techniques have been described, providing a functional lumen of the repaired bronchus. We describe a simple technique that can be safely undertaken to preserve a satisfactory diameter of the bronchus or trachea and prevent a stenosis at the site of repair.
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Introduction
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Lung hamartomas comprise the most common benign lung tumors with an incidence between 0.025 and 0.32 [1, 2]. The majority of these benign tumors have a parenchymal location. Endobronchial location is very rare consisting of 1.4% in a large series [3].
The management of endobronchial hamartomas is individualized according to the characteristics of each patient and each hamartoma. Rigid bronchoscopy and laser is a good therapeutic option whenever possible [4]. Large hamartomas that completely obstruct the bronchial lumen prevent their endoscopic removal. In such cases surgical resection with bronchoplasty is being undertaken to avoid lobectomy. The purpose of this article is to describe a simplified bronchoplasty technique, after bronchotomy and removal of the obstructing lesion.
We present a 76-year-old emphysematous patient, admitted in our department with complete obstruction of the left main bronchus, and repeated respiratory infections of the corresponding lung. Two repeated fiberoptic bronchoscopies revealed a totally obstructing tumor the left main bronchus, just a little above the level of the left upper lobar bronchus takeoff. The tissue samples of the tumor taken through the bronchoscope were not indicative enough to conclude a definite diagnosis. Because of the totally obstructed bronchus from the tumor and the uncertain diagnosis, surgical management was decided.
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Technique
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After administering the anesthesia, a double lumen endotracheal tube was positioned, and its correct position was verified with a pediatric fiberoptic bronchoscopy. The patient was then placed on his right side, and after draping, a left posterolateral thoracotomy was performed. The pleural cavity was entered through the fourth intercostal space and the left main and left upper lobar bronchi were dissected free from the adjacent structures. A 1.5-cm longitudinal incision was performed on the membranous part of the main bronchus ending at the level of the takeoff of the left upper lobar bronchus (Fig 1). The endobronchial tumor, which was revealed just under the incision, was resected at its base, and a small part was sent for frozen section.
After the identification of the lesion, as a hamartoma, a limited bronchoplasty procedure was decided and consisted by transversely approximating the edges of the longitudinal membranous incision using interrupted 4-0 Vicryl (Ethicon Inc, Johnson & Johnson Company, New Brunswick, NJ) (Fig 2).
A pedicled parietal pleural flap was constructed and sutured over the membranous repair (Fig 3). The bronchoplasty was checked for air leaks. Two chest drains were inserted and the chest was closed. A fiberoptic bronchoscopy was performed to check the bronchial repair and diameter of the lumen at the bronchoplasty site from inside. The patient was extubated soon after and was transferred in stable condition to our intensive care unit for 24-hour monitoring. On postoperative day 4, the bronchoplasty was checked once more with fiberoptic bronchoscopy, and good healing was verified. The patient was discharged on postoperative day 5. A computed tomographic chest scan and bronchoscopy was performed at postoperative week 8. There was good healing and no sign of stenosis at the site of repair.
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Comment
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The main goal of a bronchoplastic procedure is the preservation of viable lung tissue to ensure a better functional result. Every patient having a benign endobronchial lesion accessible and resectable through a bronchotomy is a candidate for a bronchoplasty repair. Of course patients with prohibitive respiratory reserve for lung resection and those expected to have a difficult recovery period are two groups that mostly benefit from a bronchoplasty. In our case there was a combination of these indications that were undertaken for the bronchoplastic procedure, as it concerned a 76-year-old man with a limited respiratory reserve and a benign lesion, which was revealed from the frozen section during the operation.
Our present experience with this technique has shown that the longitudinal incision on the membranous wall must not exceed in length the width of the membranous wall of the bronchus or trachea at the level of the incision. This is an important tip for obtaining an airtight bronchoplasty with no tension of the sutures. A larger incision would cause tearing of the membranous wall fibers as they run parallel to the suture line. For the previously described reason, fiberoptic bronchoscopy at the time of bronchotomy is of great help for exact localization of the lesion site, and by this way avoids the extension of a primary bronchotomy incision. Our technique has been applied to small benign endobronchial tumor that are pedicled or with a small endoluminal base, amenable to excision through this limited membranous wall incision. Benign bronchial lesions with a broader base usually require a wider bronchial resection (eg, sleeve resection) and an end-to-end anastomosis.
Another important point of our technique is that there is no need for extended mobilization of the bronchus, except of the membranous wall dissection at the site of the planned incision. We used interrupted absorbable sutures with Vicryl (Ethicon Inc) 4-0 for the bronchotomy repair. Suture line reinforcement with a pedicled flap of the surgeon’s preference always offers an extra security for the anastomosis, promotes healing, and should be undertaken in all groups of patients, especially in the older patients with limited respiratory reserve who would not be able to withstand a second operation in case of problematic healing complicated with a bronchopleural fistula.
Endobronchial hamartoma is a rare benign tumor. A lung tissue-sparing operation should always be attempted whenever an operation is undertaken. After excision of the tumor, repair of the bronchus should always aim at providing a functional, nearly normal diameter of the bronchus. Our bronchoplasty technique is a safe procedure that ensures an adequate bronchial lumen at the site of repair.
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References
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- McDonald JR, Harrington SW, Clagett OT. Hamartoma (often called chondroma) of the lung J Thorac Surg 1945;14:128-143.
- Murray J, Kielkowski D, Leiman G. The prevalence and age distribution of peripheral pulmonary hamartoma in adult males: an autopsy based study S Afr Med J 1991;79:247-249.[Medline]
- Gjevre JA, Myers JL, Prakash UB. Pulmonary hamartomas Mayo Clin Proc 1996;71:14-20.[Medline]
- Cosi'o BJ, Villena V, Echave-Sustaeta J, et al. Endobronchial hamartoma Chest 2002;122:202-205.[Medline]
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Abstract
Introduction
