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a Department of Surgery, Cardiothoracic Division, Indiana University School of Medicine, Indianapolis, Indiana
b Department of Medicine, Biostatistics Division, Indiana University School of Medicine, Indianapolis, Indiana
Accepted for publication December 11, 2007.
* Address correspondence to Dr Kesler, Indiana University, Department of Surgery, Cardiothoracic Division, Barnhill Dr EM No. 212, Indianapolis, IN 46202 (Email: kkesler{at}iupui.edu).
Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7–10, 2007.
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Abstract |
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Methods: Since 2003, 51 consecutive patients who required right pneumonectomy at our institution underwent carinaplasty airway closure. Malignancy was the indication for pneumonectomy in all but 2 patients. Eighteen patients received preoperative radiation therapy, including 5 patients who received 6000 cGy or more. Postoperatively, 17 patients required mechanical ventilation for an average of 13 days (range, 3 to 42 days).
Results: Six operative deaths occurred, four (8.6%) of which were in the 46 patients who did not receive preoperative bleomycin. All deaths were secondary to respiratory failure. None of these patients demonstrated bronchopleural fistula despite mechanical ventilation for up to 30 days. In 2 patients, a small (
2 mm) bronchopleural fistula developed at 3 and 4 months after operation, respectively. Both patients presented with minor symptoms and spontaneously healed within 1 month after open drainage.
Conclusions: These data suggest that the carinaplasty airway closure may reduce the morbidity and mortality of bronchopleural fistula after right pneumonectomy. We speculate mechanisms include elimination of the bronchial stump diverticulum in combination with more submucosal blood supply at the suture line compared with the standard bronchial closures. We currently consider carinaplasty airway closure the technique of choice at our institution and plan continued evaluation.
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Introduction |
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One of the most dreaded complications of pneumonectomy and right pneumonectomy in particular, which also contributes to the higher surgical risks, is a bronchopleural fistula (BPF), with a reported incidence as high as 20% and subsequent mortality rates up to 50% [1–3]. The factors resulting in the propensity for right mainstem airway closures to dehisce compared with the left mainstem airway are multiple and include the lack of natural mediastinal soft tissue coverage, a watershed bronchial blood supply from the leftward descending thoracic aorta that may be further compromised after mediastinal lymphadenectomy or preoperative radiotherapy, or both, and a larger orifice creating more distraction force on the cartilaginous/membranous wall interface [1, 2, 4]. Among other surgical strategies, shortening or completely eliminating the bronchial stump diverticulum have previously been proposed as technical factors that may reduce the risk of BPF [5, 6].
Finally, postoperative mechanical ventilation has been reported to be a significant risk factor for postoperative BPF after pneumonectomy, and avoidance of postoperative mechanical ventilation has therefore been advocated [5, 7]. Temporary mechanical ventilatory support may, however be beneficial in the immediate postoperative period to minimize postpneumonectomy edema, allow patient rest, or not infrequently becomes necessary after pneumonectomy, and delay may further exacerbate cardiorespiratory failure, thus reducing the likelihood of a successful outcome [8].
In early 2003, we performed a right pneumonectomy that included a wedge resection of the carina to obtain additional airway margin for an obstructing squamous cell carcinoma located in the proximal main stem bronchus. We noted potential benefits compared with standard bronchial closure, including more submucosal blood supply at the airway suture line and elimination of the bronchial stump diverticulum while maintaining continuity of the membranous and cartilaginous walls.
Since that observation, we have performed this "carinaplasty" airway closure for all patients who required right pneumonectomy at our institution. In addition, we have included a policy of generous tracheostomy placement, which among other benefits allows nonsedated cycled positive-pressure ventilation support for patient rest when necessary. In this study, we report our results to date with this approach designed to reduce the morbidity and mortality of right pneumonectomy including BPF.
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Material and Methods |
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Demographic data including age, sex, medical comorbidities, preoperative chemotherapy or radiation therapy, or both, and indications for surgery were recorded from hospital records when available. Operative reports were reviewed for type of pneumonectomy performed (standard, intrapericardial, extrapleural, or completion) and if and when postoperatively (<48 hours or 
48 hours) a tracheostomy tube was placed.
Documented was significant postoperative morbidity, including the length of mechanical ventilatory support, acute respiratory distress syndrome (ARDS) or pneumonia, defined as any opacification of the contralateral left lung by chest roentgenogram felt not to be secondary to atelectasis, and mortality, defined as death before hospital discharge or within 30 days of operation. Long-term follow-up data for operative survivors were obtained from our institutional records, records from a referring facility, and finally direct patient or family contact in order of preference. For patients who underwent operation for non-small cell lung carcinoma (NSCLC), the pathologic stage was recorded for patients who did not received neoadjuvant therapy [9]. For NSCLC patients who received preoperative chemotherapy or radiation therapy, or both, the clinical stage was recorded if any T or N pathologic downstaging occurred.
Our current surgical approach involves initial epidural catheter placement in eligible patients before anesthetic induction. Patients are intubated with a double-lumen left-sided endobronchial tube. Radial arterial and internal jugular central venous catheters are placed. After standard skin preparation, an antimicrobial incise drape (3M Heath Care, St. Paul, MN) is placed.
A posterolateral thoracotomy approach is used through the fifth intercostal space or after fifth rib resection if additional exposure is necessary. The right main pulmonary artery is ligated and divided, followed by ligation and division of the superior and inferior pulmonary veins. For patients undergoing operation for NSCLC or neoplasms with mediastinal lymph node involvement, en bloc mobilization of the subcarinal, upper and lower paratracheal lymph node stations (American Thoracic Society levels 4, 2, and 7) is performed.
Excising the azygous vein facilitates en bloc lymph node dissection and subsequent airway closure. Posteriorly, the esophagus and right vagus nerve are mobilized from the membranous carina. Two retraction sutures are placed in the anterior aspect of the esophageal wall above and below the carina to include the right vagus nerve. The right main stem airway is sharply divided with a scalpel flush from the trachea, preserving the carinal spur, and the specimen is removed from the operative field. Mediastinal lymph nodes are dissected from the main specimen and sent for separate pathologic analysis.
During a brief period of apnea, the endobronchial tube is withdrawn to a mid tracheal level. Small wedge shaped defects are removed from the cartilaginous and membranous carina, which establishes an elliptical airway wall defect for approximately one-half of the circumference (Fig 1). Brisk bronchial arterial bleeding is usually encountered around the anterior aspect of the carina. More recently, we have used small surgical clips to control these arterioles and avoided electrocautery.
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Results |
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A standard pneumonectomy was done in 27 patients, and 11 required intrapericardial pneumonectomy, 10 had extrapleural pneumonectomy, and 3 had completion pneumonectomy. All but 6 of the 45 patients had a complete mediastinal lymph node dissection at the time of operation. Thirteen recent patients had airway coverage with a pericardial fat pad in addition to the pericardial flap. One patient, who received more than 7000 cGy of radiation preoperatively, had additional airway coverage with a transposed ipsilateral latissimus dorsi muscle.
Tracheostomies were placed in 33 patients (64.7%). Of these, 30 patients underwent tracheostomy during the operation or within 48 hours postoperatively, and the other 3 patients had a tracheostomy placed more than 48 hours after the operation.
Postoperatively, 17 patients (33.3%) required positive pressure ventilation for more than 48 hours. These patients averaged 13 days (range, 3 to 42 days) on mechanical ventilation.
Considering the four risk factors for postpneumonectomy BPF of (1) preoperative radiotherapy with or without chemotherapy, (2) complete mediastinal lymph node dissection, (3) insulin-dependant diabetes mellitus or steroid use at time of operation, or both, and (4) postoperative mechanical ventilation 48 hours, the patients in this series had an average of 1.6 risk factors. Only four patients had no risk factors, 18 patients had one risk factor, and 29 patients had two or more risk factors.
Progressive respiratory failure was responsible for 6 deaths (11.7%) postoperatively. All of these patients received postoperative mechanical ventilation for an average of 13 days (range, 2 to 30 days) and at the time of death. Among them were 2 of the 5 patients with germ cell cancer who had received bleomycin chemotherapy preoperatively. Four operative deaths (8.6%) occurred in patients who did not receive bleomycin, all of whom were operated on for NSCLC. Two operative deaths (10.0%) occurred in the 20 patients who received either preoperative chemotherapy or radiation therapy. Two of 26 patients (7.7%) who did not receive induction chemotherapy or radiation therapy died postoperatively.
Nonfatal postoperative morbidity occurred in 19 patients (42.2%), including ARDS/pneumonia in 10 patients and atrial tachyarrhythmias in 9. Five patients underwent pleural space reexploration for suspected empyema without fistula within the 2 months after operation. Pleural fluid cultures were positive for Staphylococcus in 2 of these patients; however, the other 3 patients were gram-stain and culture-negative, including 1 patient who had a large postobstructive lung abscess at time of pneumonectomy. All 5 patients underwent successful pleural space débridement and closed postoperative antibiotic irrigation.
Postoperative bronchoscopy was done in 22 patients (43.1%) for aspiration of secretions or inspection of the airway suture line from 2 to 150 days after operation, including 11 patients who required more than 48 hours of mechanical ventilation.
In 2 (3.9%) patients who underwent operation for NSCLC and were discharged after initially uncomplicated hospital courses, a small (2 mm) discrete BPF developed in the cartilaginous wall suture line at 3 and 4 months. Both patients presented with symptoms of minor productive cough, low-grade fevers, and shortness of breath. Computed tomography scans revealed minimal contralateral lung aspiration. Neither patient had received additional pericardial fat airway coverage.
One of these patients had two previous pleural space reexplorations for what was believed to be an empyema, with only a small area of ulceration at the airway suture line and no evidence of a fistula by bronchoscopy or during positive-pressure ventilation at the time of the pleural space débridement. This patient had received approximately 6000 cGy of radiation before the operation and required postoperative positive-pressure ventilation for 2 postoperative days. The other patient had undergone prolonged conservative treatment of a large postobstructive lung abscess and was significantly debilitated at the time of operation but did not require postoperative ventilation past the first postoperative day. The fistulas spontaneously healed in both patients within 1 month after open-window thoracostomy drainage and daily outpatient dressing changes.
Of note, one patient who died on postoperative day 11 secondary to progressive respiratory failure demonstrated a small but deep ulcer without a fistula in the cartilaginous wall suture line by bronchoscopy. This patient had received preoperative chemoradiation with 4500 cGy for a stage IIIA (N2) NSCLC. The airway had been buttressed with both a pericardial rotation flap and a pericardial fat pad. The remaining patients who underwent postoperative bronchoscopy demonstrated good to excellent airway healing.
After a mean follow-up of 19 months (range 2 to 49 months), 30 patients were alive, of which 25 were alive and well, and 5 were alive with recurrent disease. There have been 15 late deaths after an average of 13 months (range, 4 to 46 months). Of these, 13 patients died of recurrent disease, including 10 of NSCLC disease, and 1 each died of SCLC, sarcoma, or germ cell cancer. Two patients died secondary to cardiac failure (n = 1) and complications of adjuvant chemotherapy (n = 1).
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Comment |
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Not infrequently, pneumonectomy patients who experience postoperative respiratory or cardiac failure manifest more insidious rather than more acute fulminate initial symptoms of minor tachypnea or hypoxemia on postoperative day 2 or 3. Although the factors involved are probably multiple and vary from case to case, the end result is hypoxemia from progressive alveolar edema that is difficult to reverse. Moreover, owing to the increased risk of bronchial stump dehiscence, there exists a pervasive reluctance for early reintubation and positive-pressure ventilation, which not infrequently leads to further cardiorespiratory deterioration before intervention.
Shortening the length or even complete elimination of the bronchial stump has been previously proposed as one of several surgical techniques to minimize the risk of BPF. Algar and coworkers [5], reviewing 242 consecutive pneumonectomies performed at their institution, found that shorter bronchial stump lengths and bronchial stump coverage were independent factors for reducing the incidence of BPF. Although minimizing the length of the bronchial stump can be easily accomplished, particularly with the use of surgical staplers, mainstem bronchial closures close to the carina would at least conceptually be subject to more distraction force owing to compression of the relatively rigid U-shaped cartilages of the carina.
In 1965, Jack [12] described a bronchial closure technique that completely eliminated the bronchial stump. This technique involved preservation of the membranous bronchial wall to establish a flap closure of the airway defect at the carina. In 1989, Sarsam and Moussali [6] reported 332 pneumonotomies, including 152 right pneumonectomies, using Jack’s airway closure method without a fistula. The authors theorized that these impressive results were due to lack of tension on the airway suture line but also emphasized that elimination of the bronchial diverticulum was an important contributing factor.
A large airway radius exists at the carina after standard bronchial closure that may place proportionally more wall tension particularly on the more distensible membranous wall of the bronchial suture line during postoperative mechanical ventilation. The observation that BPFs did not develop in any patients in our series who required mechanical ventilation for more than 48 hours supports the premise that elimination of the airway diverticulum at the carina may be an important factor to reduce the incidence of BPF in this patient subset.
Regardless of the mechanism, in our experience thus far, it appears that positive-pressure ventilation is not a risk factor for BPF after carinaplasty airway closure. During a 15-year time interval, 119 right pneumonectomies have been performed at our institution, which includes the more recent 51 patients who underwent carinaplasty airway closure in this report and 68 prior patients who underwent standard bronchial closure. The incidence and mortality rate of BPF after right pneumonectomy have both decreased to 3.9%, with no deaths in our carinoplasty closure patients, from an 8.8% incidence of BPF with an associated 33.3% mortality during the era of standard bronchial closure. The inherent limitations of using historical data for comparison purposes not withstanding, a reduction in the risks of this dreaded complication has been encouraging at our institution.
Despite what we believe to be a reduction in the incidence and mortality of BPF after right pneumonectomy at our institution, BPF unfortunately still occurred in 2 of our 51 patients. The apparent mechanism in both cases was a discrete area of transmural cartilage necrosis and subsequent erosion through the overlying pericardial flap. This mechanism is in direct contradistinction to BPF occurring after standard bronchial closure, which is more likely a result of other factors including a watershed bronchial circulation to the right bronchial stump diverticulum. This difference is reflected by the 2 patients who manifested a BPF in our series, with small fistulas occurring relatively late after operation compared with most BPFs after pneumonectomy, which typically present within the first postoperative month [2, 13] The small BPF size prevented significant contralateral lung soilage, and the occurrence after significant postoperative recovery had taken place minimized the severity of this complication in these two cases. Moreover, both fistulas healed rapidly with conservative measures, which is distinctly unusual because most BPFs require surgical repair that is typically formidable [14]. We speculate the spontaneous healing was due to the same factors previously cited, which may reduce the incidence of BPF to begin with. The BPF developed in patients who were later in this series, which prompted our relatively recent addition of pericardial fat pad coverage.
Other surgical strategies have previously been used in an attempt to reduce the incidence of BPF after pneumonectomy. Two large retrospective series by Vester and colleagues [15] and Deschamps and colleagues [2] independently reported a decreased incidence of BPF after stapled bronchial closure. These findings may support the theory that the U-shaped cartilages of the main stem airway create a distraction force on a standard bronchial closure, which is more easily overcome by the strength of surgical staples and staplers compared with hand suture techniques.
More recent surgical strategies to avoid BPF after pneumonectomy have focused on soft tissue coverage of the bronchial stump, particularly after radiation therapy.
Local soft tissue coverage may successfully contain a small bronchial stump dehiscence and may also provide vascular ingrowth to promote stump healing. Further study is required to determine if soft tissue buttress of standard bronchial closures or techniques that eliminate the bronchial diverticulum are more efficacious with respect to reducing the risks of BPF.
We recognized other potential benefits this type of airway closure technique may provide, some of which had been previously noted by Fahimi and coworkers [19]. In 2000, they reported a series of 4 pneumonectomy patients where the airway was closed after carinal wedge resection either to obtain additional surgical margins due to a central tumor location or because poor quality of the bronchial tissues precluded standard bronchial closure. Among the benefits Fahimi and colleagues cited were continuity of membranous and cartilaginous walls at the airway suture line compared with standard bronchial closure and preservation of the left tracheobronchial angle that maintains continuity of the airway’s submucosal blood supply. We typically have observed brisk submucosal and bronchial artery bleeding at the cut airway margins during these procedures, which usually requires bronchial artery ligation even after complete subcarinal and paratracheal lymph node dissections. This is in contrast to the watershed submucosal blood flow observed at the sites of standard main stem bronchial division and closure.
Finally, we speculate that carinaplasty may cause a baseline reduction of airway suture line distraction tension because the trachea takes a direct "hypotenuse of the triangle" course to the left main stem bronchus, with the preserved left tracheobronchial angle as a pivot point rather than approximating the membranous wall to the relatively more rigid U-shaped cartilaginous wall during standard bronchial closure. Secondary advantages of carinaplasty airway closure include elimination of pooled secretions in the bronchial stump diverticulum.
Induction chemoradiation therapy is considered to potentially have a survival benefit in NSCLC cases where ipsilateral mediastinal lymph node metastases are present; however, it may further increase the risk of postoperative death when a right pneumonectomy is required. A multi-intuitional randomized trial recently reported 11 deaths in 29 patients (37.9%) with good to excellent performance status after right pneumonectomy after induction chemoradiation therapy for stage IIIA (N2) NSCLC [20]. The exact cause of these deaths has not been reported to date.
A review of 470 NSCLC patients undergoing operation after induction chemotherapy with or without radiation therapy at Memorial Sloan-Kettering Cancer Center found a 3-month mortality rate of 24% in a subset of 46 patients who underwent right pneumonectomy [21]. Other single institution series have reported lower mortality rates after right pneumonectomy in select patients after neoadjuvant therapy however. Daly and coworkers [8] impressively reported only 1 death in 15 patients who underwent right pneumonectomy after two cycles of cisplatin-based chemotherapy and 5900 cGy radiation therapy. They emphasized that postoperative care with 48 hours of mechanical ventilation and fluid restriction were factors that prevented early fluid accumulation in the remaining lung and therefore reduced the risk of postpneumonectomy pulmonary edema in their series. A relatively brief initial period of mechanical ventilation will not only have the potential to prevent fluid shift into the remaining alveoli but also the potential to avoid early atelectasis due to hypoventilation that may occur in patients who are allowed to breathe spontaneously immediately after thoracotomy.
Owing to the high mortality rate when fulminate postoperative respiratory or cardiac failure occurs after pneumonectomy, any measures that may prevent or reverse early respiratory or cardiac failure would seem worthy of consideration. We have used a postoperative care protocol of at least initial postoperative mechanical ventilation on the evening of the operation with typical fluid restriction. In addition however, in light of what we believe to be a negligible risk of BPF after carinaplasty airway closure with positive-pressure ventilation, we have a generous tracheostomy placement/reintubation policy for cycled positive-pressure ventilation that allows patient rest when necessary while recovery occurs.
Tracheostomy has other well-known benefits that can be particularly valuable to right pneumonectomy patients, including the facilitation of secretion removal and decreasing the work of breathing by reduction of dead space ventilation. No serious complications have occurred in our patients related to temporary tracheostomy, and the tracheostomy tube can be serially downsized and decannulation accomplished without prolonging normal hospital discharge in most patients.
Our institution’s operative mortality rate after right pneumonectomy during the time period of standard bronchial closure was 13.8% for patients who did not receive bleomycin. Again, acknowledging the limitations of using historical data for comparison, we believe our current 8.6% mortality rate using this strategy represents an improvement and also favorably compares with many reported series, particularly when comorbid risk factors are considered.
There are several potential limitations inherent to this study as well as potential limitations specific to our technique. Our series is relatively small, and the exact incidence of operative death and morbidity, including BPF, using this airway closure technique will require continued investigation. Along these same lines, demonstrating any statistically significant differences in death and the risks of BPF between various surgical strategies will be challenging given the relatively small reported disparity. The 5 patients early in our series who had a documented or suspected postpneumonectomy empyema without a fistula raised a concern of this complication owing to the potential for pleural space contamination during open airway surgery. By implementing changes, including the use of an antimicrobial incise drape, disposal of potentially contaminated instruments immediately after airway closure, and antibiotic irrigation before thoracotomy closure, we appear to have eliminated this complication.
Compared with standard bronchial closure techniques, some additional technical expertise is required to perform carinaplasty airway closure, and operative time is increased. Thoracic surgeons who have performed formal carinal right pneumonectomies will find that this technique is relatively easy to perform and requires little additional time. Conversely, thoracic surgeons, particularly at high-volume centers who wish to expand their surgical armamentarium to include carinal pneumonectomies, will find carinaplasty closure to be a good transitional step in the learning curve. Finally, we believe the judicious use of a temporary tracheostomy may reduce the incidence of BPF and overall operative risks.
These data suggest that carinaplasty closure may reduce risks of BPF after right pneumonectomy. We believe that positive-pressure ventilation is a negligible to nonexistent risk factor for BPF after carinaplasty airway closure, which has significantly reduced our anxiety and reluctance for postoperative ventilation after right pneumonectomy. Our strategy of carinaplasty airway closure in right pneumonectomy patients, in addition to the generous use of tracheostomy placement or positive-pressure ventilatory support, or both, may also reduce operative deaths. We currently consider carinaplasty airway closure the technique of choice for right pneumonectomy at our institution. Continued evaluation of this technique and strategy is planned.
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Discussion |
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I would agree with everything that he said today: the concepts of sutured closure, staying away from the stapler, preserving the blood supply, and avoiding tension. I think all of those things are really important. It is the way we do it as well. We have a more standard closure with the membranous wall to the cartilaginous wall. In those cases where we have a problem, when you get a U-shaped cartilage or the calcified cartilage, we close it side to side, not totally differently from what you are talking about. Neither technique probably gets rid of that little right main stem stump as you do in this particular technique.
With the approach that we have used, from 1985 to 1996 we had a 3% BPF rate. I don’t know what it is currently. My sense is that it is lower than that currently. I think avoiding tension is the most important aspect to avoid this problem.
I do have three questions. In the video, you get a sense that mobilization of the trachea and the left main stem is not an issue, and I would like you just to comment on that. Is that always the case when you do this? Is your feeling also that a remote mediastinoscopy might create a little more tethering and make this a little more difficult to accomplish in bringing the ends of the cartilage together?
The 4% incidence of BPF, is it implied that before this that was higher in your experience and therefore justifies this approach?
And the third point, which may not have come out in the presentation as much but certainly in the paper it does, is the issue of ARDS and pneumonia, which I believe was about 20% in your series. I have always thought that the ARDS is related to barotrauma, less and less to fluid. Does the use of ventilation and tracheostomy contribute to the relatively high incidence of pneumonia and/or ARDS. I again would assume that prior to this you had a higher incidence of that.
DR KESLER: Doug, first of all, thank you for your thoughtful comments. We all recognize and appreciate you and your institution’s pioneering efforts in the field of tracheal and bronchial surgery and the principles that you have taught us over the years. We hope that we have incorporated many of these principles into this technique for airway closure after right pneumonectomy.
In response to the first question, we certainly encountered patients with various degrees of stiffness to their mediastinum, including for example, patients who had previous mediastinoscopy as you point out or, for another example, patients who were undergoing completion pneumonectomy. With this technique, the airway obviously comes together by pivoting on the preserved left tracheobronchial angle with the trachea taking someway more of a direct "hypotenuse of the triangle" course into the left main stem bronchus. Some of these airway closures did have a little more tension than others based on the amount of preexisting mediastinal stiffness, as you point, out but the tension never seemed to be excessive. We believe that simply doing a complete paratracheal and subcarinal mediastinal lymph node dissection frees enough of proximal and distal airway to make this operation happen without undue tension while preserving the leftward tracheal/bronchial blood supply.
In response to the second question, from historical data in 68 right pneumonectomies previously performed at our institution, we had a BPF rate of approximately 9%, with a third of these patients dying as a result. These statistics are not inconsistent with reports from other institutions. So not only has our incidence of BPF decreased by more than half, but our mortality of BPF has decreased to zero with this technique to date. Finally, the morbidity of the two BPFs in our series was low. Both patients who manifested BPFs presented comparatively late with small fistulas, and we were very pleasantly surprised that both BPFs healed after open drainage with outpatient dressing changes only. Can you please repeat your other question?
DR MATHISEN: The other was about ARDS and pneumonia, whether the use of ventilation and tracheostomy as liberally as you did had improved what you had experienced before, or do you think it contributes to a rate that would seem to be fairly high?
DR KESLER: We had a very low threshold to score a complication of ARDS and pneumonia in this study. We basically made this determination with any infiltrate in the contralateral lung by chest radiograph. We used this low threshold because the presence of even a very minor infiltrate was an indication to initiate treatment with broad-spectrum antibiotics. Many of these minor infiltrates resolved quickly and did not significantly prolong hospitalization.
We believe our policy of generous tracheostomy tube placement benefits these patients, and we don’t think that this policy significantly contributed to pulmonary infections. Right pneumonectomy is obviously a major insult to the cardiopulmonary systems, particularly if any additional comorbid risk factors exist. In the past, due to the increased risks of BPF with positive pressure ventilation, we have had an understandable reluctance to place pneumonectomy patients on positive-pressure support. Our data to date suggest that this airway closure technique does not present the risks of BPF with positive-pressure ventilation compared with standard bronchial closure. We further believe that unsedated and cycled positive pressure support, which allows rest during the early postoperative period, can be very beneficial to many of these patients.
We have instructed our intensive care unit staff that if any degree of tachypnea develops, particularly at night, to suction through the tracheostomy and place the patient on enough positive airway pressure that allows rest in addition to the normal evaluation of this situation if deemed necessary. Tracheostomy has other known benefits such as diminishing the work of breathing, which also can be helpful to these patients as they recover. So in the balance, we believe that our policy of generous tracheostomy tube placement has been beneficial.
DR MATHISEN: Well, thanks again for introducing us to a novel technique and also to remind us why physics is still important, and we will go back and look up a little bit about Laplace’s Law.
DR MARK J. KRASNA (Towson, MD): I wasn’t going to say anything, Ken, because I was wearing shorts and a Hawaiian shirt, but Doug let it out of the bag. I want to congratulate you again; an excellent report. Your group has been doing great work. Particularly, I want to draw attention to everybody in the room, that many of these patients were actually after high-dose radiation. As you know, our group has had a tremendous experience with good survival and low BPF rate. Dr Cerfolio is shaking his head in agreement. The same results were found in Birmingham as well as with Ben Daly’s group in Boston. So this is now at least the fourth group with less than a reported 25% mortality with right pneumonectomy.
So the two questions that beg then are, is there in fact in your mind a role for right pneumonectomy after high-dose radiation therapy. I am curious to hear your response. And then the other question specifically, we have heard Cerf talk a lot about intercostal muscle bundles. My group is now routinely using the serratus anterior for the postpneumonectomy and the intercostal for the lobectomy. Have you tried instead of putting pieces of fat to use some muscle in there instead?
DR KESLER: Thanks for these interesting questions Mark. We definitely acknowledge that yours and other groups have shown that right pneumonectomy can be done even after high-dose radiation therapy with excellent short- and long-term results. We too believe chemoradiation therapy, followed by right pneumonectomy as a planned approach, can be sufficiently safe and beneficial from a long-term survival standpoint in select patients with N2 disease, as the Intergroup phase III study recently demonstrated with the lobectomy subset. The 38% surgical mortality following right pneumonectomy after induction therapy in this study is obviously striking and offset any long-term survival this group might have derived from induction therapy. The key is obviously to achieve an acceptable surgical mortality, which patient selection also plays a significant role. Our institution, however, subscribes to a moderate preoperative radiation dose similar to the Intergroup trial. The patients in our series who received high-dose radiation therapy preoperatively were typically treated at outside facilities as a definitive strategy but ultimately referred to us for "salvage" surgery.
Obviously, many different surgical strategies with respect to bronchial stump closure designed to minimize the risks of BPF have been described with very good results. I agree that intrathoracic transposition of a large skeletal muscle to cover the bronchial stump has appeal but also has potential downsides. Additionally, if the patient is being mechanically ventilated, then even a large skeletal muscle may not contain a small dehiscence of the bronchial stump. The pericardial coverage of our technique seems to nicely seal and buttress the airway suture line. We are cautiously optimistic that the relatively simple addition of pericardial fat pad coverage will successfully manage the few small and late occurring BPFs we have seen with this technique.
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