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Ann Thorac Surg 1996;61:1462-1463
© 1996 The Society of Thoracic Surgeons
DR HAROLD C. URSCHEL, JR, (Dallas, TX): I compliment Dr Cerfolio on an excellent presentation that brings to our attention an important aspect of bronchoplasty. I had not planned to discuss this, but Dr Deschamps gave me the manuscript, and I will emphasize two points that are in it.
Sir Clement Price Thomas published the first account of bronchoplasty resection. Actually, Gerbauer performed the first bronchoplasty for benign disease and I think Dr Robert Shaw did the first for malignant disease. Sir Clement Price Thomas was in the United States, saw them do it, went home, did one, and reported it earlier. The first one for cancer was done in Dallas, to the best of my knowledge. That group reported its results in 1955, and we did it again in 1970.
The important thing is that the morbidity and mortality for pneumonectomy are high. Therefore, lung tissue should be spared whenever possible. Bronchoplasty is very difficult, particularly in the left mainstem bronchus. I think this presentation by Dr Cerfolio is very well done.
I did not have a chance to review our data, but I think we have done more than 300 bronchoplasties. Dr. Cerfolio, how many bronchoplasties does this series of 22 represent, not total pulmonary resections but bronchoplasty procedures? We have roughly 40 for just mainstem bronchi.
Broncholiths located near the carina can become adherent to both the right and left mainstem bronchi. They can be devastating problems causing bleeding and infection and require careful management.
The most interesting group was in this report. Doctor Harrell, a pulmonologist in San Diego, does a lot of laser and stent work for bronchoplasty. Seven or 8 years ago, he referred to us a patient who was pregnant and had a totally obstructed left mainstem bronchus. Because of the distal infection, he had to use a laser to open the obstructing mucoepidermoid carcinoma. He then placed a stent to hold it open. This cleaned out the patient's lungs, and she delivered the baby. We resected that lesion at an interval stage with only bronchosplasty. The patient is alive and doing well.
Since that time, we have had approximately 10 patients who have had some sort of acute obstruction with distal infection. One effective form of treatment of these patients is to open up the bronchus, place a stent, and then drain the lung. At a later time, perform the resection, whether it be for a carcinoid or any other type of tumor.
DR CERFOLIO: Thank you for your comments, Dr Urschel. You raise several points. I do not have the exact number of bronchoplasties performed over this 30-year interval. However, similar to your data, this series is a mere fraction of the patients who underwent bronchoplasty. We had a very strict definition and equally strict entry criteria for this study. Only patients who had complete circumferential resection were included in this series.
Only 2 of the 22 patients had impacted broncholiths. A bronchoplasty procedure was initially tried, and because the broncholith and the tissue around it were so inflamed, a circumferential resection had to be performed.
The other topic concerned draining a septic lung. We agree that in select patients, either a stent or laser can be used successfully to drain a lung that has been atelectatic, septic, or both. If indicated, resection of the bronchus can then be performed subsequently.
DR JOSEPH I. MILLER, JR, (Atlanta, GA): I congratulate Dr Cerfolio and associates on an exceedingly well done report and thank them for the opportunity to briefly review it before presentation. I, too, emphasize the extremely rare incidence of this. As pointed out, the incidence in this study was 22 cases in about 17,200 resections, or 0.1%, in a 30-year period at the Mayo Clinic.
I have a couple of questions. First, in this group of patients, 15 had bronchial adenomas, only two of which were squamous cell carcinomas; so 13 of the 15 patients with tumor had bronchial adenomas. In this subgroup, was the reason for circumferential resection the extent of involvement on the circumferential wall? A lot of bronchial adenomas arise on the posterior wall and could be excised by bronchotomy with reconstruction and reinforcement.
Second, my colleagues and I see a large number of patients with a mainstem bronchial adenoma, and frequently they are not surgical candidates. They are elderly. I submit that yttrium-aluminum garnet laser therapy combined with endobronchial brachytherapy leads to almost total control of the adenomas when the patients are not candidates for surgical intervention. We have had at least 5 needing major resection, and they could not tolerate even a thoracotomy physiologically. Laser therapy plus brachytherapy was used.
My final comment concerns your stricture group. I realize this study covers a 30-year period and that stents were not readily available until 1993. However, in the stricture group, maybe rather than resection, dilation and stenting might prove helpful.
DR CERFOLIO: Thank you, Dr Miller, I appreciate your comments. You had three points. The first one concerns 13 of the 15 patients who had primary endobronchial tumors, excluding the 2 patients with squamous cell carcinoma. This series does not represent all patients who had endobronchial malignancies in the mainstem bronchus. Bronchotomy was initially attempted in some instances, but full circumferential resection was necessary to remove all tumor and achieve negative margins.
The second point concerns yttrium-aluminum garnet laser treatment and brachytherapy in patients who are either too old or too sick to undergo resection. We agree that in selected patients, this is a viable option.
The last point concerns patients with strictures. We think that in a young person with a posttraumatic stricture, the best chance for long-term function without having to return for stent removal or replacement is to proceed with stricture resection and primary anastomosis. We favor this option in patients who are good surgical candidates. However, in selected patients, stenting can be an option.
DR MARK J. KRASNA (Baltimore, MD): I have a brief technical comment. With our experience now with lung transplantation, my associates and I have found that a telescoping anastomosis with a figure-of-8 suture is very good when we are resecting the main bronchus distally or at the bronchus intermedius. I think that when a true main bronchus resection that is flush with the carina, as you described, is done, one usually does not have the option to telescope. Therefore, we generally use an intercostal muscle flap and simply wrap it circumferentially.
DR CERFOLIO: We agree. None of the patients in this series had the telescoping method, and as described, we favor wrapping the bronchial anastomosis with vascularized tissue in select patients.
Related Article
Ann. Thorac. Surg. 1996 61: 1458-1462.
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