Ann Thorac Surg 2009;88:2008-2010. doi:10.1016/j.athoracsur.2009.05.009
© 2009 The Society of Thoracic Surgeons
Case Reports
Double-Barrel Reconstruction for Complex Bronchial Disruption Due to Blunt Thoracic Trauma
Masaya Tamura, MD*,
Makoto Oda, MD,
Isao Matsumoto, MD,
Hideki Fujimori, MD,
Yosuke Shimizu, MD,
Go Watanabe, MD
Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
Accepted for publication May 4, 2009.
* Address correspondence to Dr Tamura, Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medicine, Takaramachi 13-1, Kanazawa, Ishikawa, 920-8640, Japan (Email: mtamura{at}med.kanazawa-u.ac.jp).
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Abstract
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We herein present a case of a 20-year-old man who presented with complex rupture of bronchus after blunt chest trauma. The involvement of both the main bronchus and right upper bronchus separately is unusual. Emergency double-barrel bronchial reconstruction was performed with complete preservation of the right lung. Such a serious bronchial injury with a positive outcome has not been reported so far. The features of this uncommon entity are discussed.
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Introduction
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Tracheobronchial rupture by blunt thoracic trauma is relatively rare, and especially with the involvement of both the main bronchus and upper bronchus simultaneously, which is quite rare. We believe that this is the first case of double-barrel reconstruction for complex bronchial disrupture due to blunt thoracic trauma. In terms of the rare bronchial laceration, the double-barrel reconstruction is discussed.
A 20-year-old man was involved in a car accident. When transferred to our hospital he had progressive respiratory distress and severe subcutaneous emphysema of the neck and chest. Moreover, severe flail chest injury was revealed. A chest tube for the right thorax was immediately inserted, because there was absolutely no audible lung sound. A chest roentgenogram showed no expansion of the right lung, and an inserted chest tube revealed persistent massive air leak. A computed tomographic scan of the thorax demonstrated atelectasis of whole right lung (Fig 1) and multiple fractures of the rib. A bedside emergent flexible bronchoscopy was performed, and the diagnosis of a right main bronchial rupture was made. An emergent operation was performed 3 hours after his arrival at our hospital; the right main bronchus and the right upper lobar bronchus were completely disrupted. The truncus intermedius was also lacerated, and its stump was severely damaged (Fig 2A). At first, the disrupted ends were dissected and completely debrided. Afterward, the upper lobar bronchus and truncus intermedius were anastomosed like a double-barrel (Fig 2B); the double-barrel reconstruction was anastomosed to the main bronchus (Fig 2C). Wrapping of the anastomosis was performed by using the pedunculated pericardial fat tissue. Eight days after the operation, failure to wean the patient from the ventilator because of the persistent flail chest resulted in fixation of the ribs, which was made using an AO plate. Thereafter the patient was discharged on postoperative day 24. A bronchoscopy showed a complete healing and no evidence of a stricture at the bronchial anastomosis.
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Fig 1. Computed tomographic chest scan of the thorax displayed bilateral pneumothorax and atelectasis of the whole right lung.
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Fig 2. Operative findings: (A) The right main bronchus and the right upper lobar (RUL) bronchus were completely disrupted, and (B) the upper lobar bronchus and truncus intermedius was anastomosed like double-barrel. (C) Double-barrel reconstruction anastomosed to the main bronchus. (RLL = right lower lobe; RML = right middle lobe.)
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Comment
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The incidence of bronchial rupture after blunt chest trauma is 0.03% to 2.5%, even in those with severe trauma in comparison with other intrathoracic injuries [1, 2]. Seventy-five percent of the patients died before arriving at a hospital, and 30% of patients died even if they arrived at the hospital [3].
Most cases for bronchial rupture occur within 2.5 cm from the carina [3, 4]. Besson and Saegesser [4] reported that the lesion is the main bronchus in 80% of the cases, the trachea in 15%, and the right upper truncus in 1%. Although some investigators have found equal frequency of right-sided and left-sided injuries [3, 5], others have also noticed an increased frequency of right main stem injuries [6]. The higher incidence of right bronchial injuries may be from the shorter length of the main bronchus compared with the left. The heavier right lung on the shorter right main bronchus may also play an important role in the amount of traction force experienced in deceleration injuries. Most bronchial injuries can be accounted for by three mechanisms: (1) first, compression of the chest between the sternum and vertebral column; (2) a sudden deceleration of the pendulous lung, producing a shearing force at the fixed trachea; and (3) forced expiration from a position of full inspiration against a fixed glottis. We had performed complete dissection of the edge of the truncus intermedius because this case showed a severely damaged edge. Surgical debridement of the area of injury should be performed to create healthy edges that can be repaired successfully.
We reviewed the reported cases of tracheobronchial disruption due to blunt thoracic trauma and bronchoplasty without lung resection that were performed. Most cases manifested a disrupture of the trachea or main bronchus. We could find only three cases that presented multiple parts of a ruptured trachea and main bronchus. This is the first reported case that presented a complete disruption of both the main bronchus and the upper bronchus. Primary repair results in preservation of lung function and good long-term results in more than 90% of patients [7]; however, this may not be possible depending on the position or extent of the tear. Generally, more severe lung parenchyma damage is recognized in the cases of lobar bronchus disruption comparing those of the main bronchus [8]. Lobectomy or pneumonectomy is sometimes necessary. Actually, we had considered to execute upper lobe lobectomy or middle and lower lobe lobectomy or pneumonectomy. Although the presented case showed severe damage of the truncus intermedius, it was fortunate that only mild damage of the lung parenchyma could be seen. We could complete double-barrel reconstruction of the bronchus after the trimming of the bronchial edge. Double-barrel reconstruction is sometimes adopted for cases of carina resections for tracheal tumors. This technique is seldom applied for the reconstruction of upper bronchus and truncus intermedius.
We believe that even in main bronchus or distal bronchial ruptures, primary anastomosis has to be considered in all suitable patients. Resection of the lung should be saved for complicated cases. Our case emphasizes the possibility of double-barrel reconstruction for the multiple parts of the bronchus due to blunt chest trauma.
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References
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- Besson A, Saegesser F. Trauma of the trachea and major bronchi Chest Trauma 1982;2:9.
- Symbus PN, Justicz AG, Ricketts RR, et al. Rupture of the airways from blunt trauma: treatment of complex injuries Ann Thorac Surg 1992;54:177-183.[Abstract/Free Full Text]
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Abstract
Introduction
