Ann Thorac Surg 2008;85:2112-2114. doi:10.1016/j.athoracsur.2007.11.062
© 2008 The Society of Thoracic Surgeons
Case Reports
A Completion Sleeve Bilobectomy for Nonstump Postlobectomy Bronchopleural Fistula
Abdel-Mohsen Hamad, MD,
Giuseppe Marulli, MD,
Marco Schiavon, MD,
Federico Rea, MD*
Division of Thoracic Surgery, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
Accepted for publication November 26, 2007.
* Address correspondence to Dr Rea, Division of Thoracic Surgery, University of Padua, Via Giustiniani 2, Padova, 35128, Italy (Email: federico.rea{at}unipd.it).
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Abstract
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We present a novel approach for treatment of nonstump postlobectomy bronchial fistula. Our patient had right lower lobectomy for T3 N2 M0 adenocarcinoma. An increased air leak developed 8 days later, and bronchoscopy revealed the presence of a bronchial fistula. On reexploration, the bronchial stump was intact, and the membranous part of the bronchus intermedius was sloughed up to the opening of the upper lobe bronchus. A middle lobectomy with sleeve resection of the bronchus intermedius and part of the right main bronchus was performed, and the upper lobe was reanastomosed to the right main bronchus. The patient's postoperative course was uneventful, and follow-up bronchoscopy showed an intact healed anastomosis.
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Introduction
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Bronchopleural fistula (BPF) is a relatively rare but feared complication of pulmonary resection. The incidence of BPF after lobectomy was reported to be 1.1% in a series of 1083 lobectomies [1], with higher incidence after lower lobectomies [2]. A BPF that occurs within 7 days after operation is usually the result of a technical failure, but when the bronchial leak occurs later in the postoperative course, it may be caused by failure of healing. The management approach of BPF is challenging and includes both interventional bronchoscopic and surgical procedures.
A 62-year-old man underwent en bloc resection of the right lower lobe and the posterior segments of the right sixth and seventh ribs with mediastinal lymphadenectomy for right lower-lobe non-small cell lung cancer (NSCLC). Air leakage increased on postoperative day 8, and the drained pleural fluid became cloudy. A bronchoscopic examination showed a large opening of the bronchus intermedius. A roentgenogram showed he had a pneumothorax and atelectatic residual lung tissue. There was no fever or significant leucocytosis. Histopathologic diagnosis of the resected lobe was adenocarcinoma with metastasis to the 4R mediastinal lymph nodes (T3 N2 M0).
The patient underwent reoperation, and the bronchial suture line was intact. The membranous part of the bronchus intermedius was sloughed up to the origin of the upper lobe bronchus, resulting in large fistula with necrotic margin (Fig 1). We performed a middle lobectomy, with sleeve resection of the bronchus intermedius and part of the right main bronchus (Fig 2). The upper lobe bronchus was reanastomosed to the right main bronchus with running sutures. Four sutures of 4-0 polydioxanone (Ethicon Inc, Somerville, NJ) suture were used, and each extended for one-quarter of the circumference of the anastomosis. Finally, all sutures were tightened and the adjacent limbs were each tied together. Decortication of the upper lobe and cleaning of the pleural space were done.
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Fig 1. An intraoperative view shows the intact bronchial stump (C). The membranous part of the bronchus intermedius was sloughed (B) up to the upper lobe bronchus (A). A middle lobectomy (D) was started, with division of its bronchus and artery.
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The patient's postoperative course after the second operation was uneventful. There was no air leak and the chest roentgenogram showed inflation of the upper lobe. A bronchoscopic examination 1 week later showed an intact anastomosis. The chest tubes were removed, and the patient was discharged without any complication. The follow-up bronchoscopy in the second postoperative month revealed a healed, adequate anastomosis. After 6 months' follow-up, the patient is doing well.
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Comment
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With refinements of bronchial surgical techniques and better understanding of the bronchial healing process, the incidence of BPF has decreased in the past decades. However, the occurrence of BPF still represents a major problem for thoracic surgeons. The risk factors for development of BPF are variable and include both patient-specific and technical factors. Residual tumors in the resection margin, a long bronchial stump, and inadequate suture techniques are among other factors that are most important [3]. In our patient, ischemic necrosis of the bronchus intermedius could be the responsible factor for fistulization.
The importance of peribronchial tissue in wound healing is well established: extensive mediastinal lymphadenectomy and excessive peribronchial dissection have been associated with an increased incidence of fistulization. Satoh and colleagues [4] reported an association between ischemic changes in the bronchial stump with subsequent fistulization and subcarinal lymphadenectomy. The subcarinal area is traversed by feeding bronchial arteries, and dissection in this area must be performed as carefully as possible to preserve some of these nutrient vessels [4].
The management plan of BPF depends on many factors, including the physical condition of the patient, the time of onset of the fistula, presence or absence of empyema, the underlying disease, and type of the resection performed. Endoscopic treatment with application of different sealing substances has been reported for small-sized fistulas [3]. Otherwise, operative closure with coverage of the fistula with viable tissue, such as intercostal muscle, omentum, pericardium, and even diaphragm is offered.
When repair is not successful, completion pneumonectomy, which has the risk of more serious complications, is the last choice. A 37.5% mortality rate is reported for completion pneumonectomy used for an early complication of a primary operation [5], and the mortality rate after the procedure on the right side was significantly higher than that on the left side. In the Mayo Clinic experience of completion pneumonectomy, the incidence of postoperative morbidity was 69.6%, most of which were cardiopulmonary complications, mainly respiratory failure and arrhythmia [6].
Sleeve resection after a postlobectomy bronchial fistula will preserve lung tissue with subsequently less deterioration in pulmonary and cardiac functions compared with completion pneumonectomy; moreover, reexpansion of residual lung tissue will fill the pleural space and thus avoid infection problems of the postpneumonectomy space.
In our patient, the plan was to do middle lobectomy with the creation of new bronchial stump at a more proximal healthy bronchus; however, the site and size of the fistula did not permit this, and resection of the whole bronchus intermedius was mandatory.
Sleeve lobectomy is a demanding operation and is not without complications. Toker and colleagues [7] reported sleeve resection of the right main bronchus for lobectomy stump fistula, and they postulated—and we agree with them—certain criteria for this procedure, including patients with good performance status, technical feasibility, healthy remnant lung, without residual tumor, and absence of frank empyema. We, however, consider sleeve resection is safer than completion pneumonectomy in the presence of infection, and in this situation, we would wrap the anastomosis with viable tissue to help healing and separate it from the pulmonary artery to avoid bronchovascular fistula.
In conclusion, the management of BPF after lobectomy is challenging, and each patient should be considered separately in a logical stepwise fashion. We hope this procedure will be added to the armamentarium of thoracic surgeons in their treatment of postlobectomy BPFs.
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References
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- Vester SR, Faber LP, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of the bronchus Ann Thorac Surg 1991;52:1253.[Abstract]
- Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Delichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management Ann Thorac Cardiovasc Surg 2001;7:330-336.[Medline]
- Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management Chest 2005;128:3955-3965.[Medline]
- Satoh Y, Okumura S, Nakagawa K, et al. Postoperative ischemic change in bronchial stumps after primary lung cancer resection Eur J Cardiothorac Surg 2006;30:172-176.[Abstract/Free Full Text]
- Muysoms FE, de la Riviere AB, Defauw JJ, et al. Completion pneumonectomy: analysis of operative mortality and survival Ann Thorac Surg 1998;66:1165-1169.[Abstract/Free Full Text]
- Completion pneumonectomy: factors affecting operative mortality and cardiopulmonary morbidity Ann Thorac Surg 2002;74:876-884.[Abstract/Free Full Text]
- Toker A, Tanju S, Dilege S, Kalayci G. Sleeve resection of the right main bronchus for postlobectomy broncho-pleural fistula Euro J Cardiothorac Surg 2002;22:1020-1022.[Abstract/Free Full Text]
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Abstract
Introduction
