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Ann Thorac Surg 1996;62:976-978
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Surgical Management of Bronchiectasis

Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The prevalence of bronchiectasis has decreased significantly over recent decades. We reviewed the morbidity, mortality, and outcome of surgical treatment for pulmonary bronchiectasis in the modern era of antibiotic therapy.

Methods. From January 1976 through January 1993, 134 patients (55 male and 79 female patients) underwent pulmonary resection for bronchiectasis. The mean age was 48.4 years (range, 4 to 89 years). The indication for operation was failure of medical therapy in 85 patients (63.4%), hemoptysis in 26 (19.4%), lung abscess in 12 (9.0%), and a nondiagnostic mass in 11 (8.2%). Mean duration of symptoms was 6 years (range, 1 to 60 years) and included a productive cough in 104 patients, fetid sputum in 91, recurrent infections in 81, and hemoptysis in 56. Thirteen patients (9.7%) had no prior symptoms and presented with either hemoptysis, lung abscess, or unresolved pneumonia. The disease was bilateral in 26 patients (19.4%) and mainly confined to the lower lobe in 75 (56.0%). The mean number of segments involved was 4.4 (range, one to 14 segments). Surgical treatment included lobectomy in 86 patients (64.2%), pneumonectomy in 21 (15.7%), wedge resection or segmentectomy in 18 (13.4%), and a combination of these approaches in 9 (6.7%). Disease was considered completely resected in 108 patients (80.6%).

Results. The operative mortality rate was 2.2% and the morbidity rate was 24.6%. The mean follow-up in 103 patients was 6 years (range, 1 to 16 years). Overall, 61 patients (59.2%) were asymptomatic after operation. Symptoms were improved in 30 patients (29.1%) and unchanged in 12 (11.7%). Complete resection resulted in a significantly better result than incomplete resection (p < 0.05).

Conclusions. Pulmonary resection for bronchiectasis can be done with low mortality and morbidity. When possible, complete resection should be performed.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 979.

Bronchiectasis, which was once prevalent and disabling, has now become rare in industrialized countries because of the nearly complete elimination of measles, pertussis, and tuberculosis [1]. Improved antibiotic regimens in recent decades also have contributed to this reduction [2]. Consequently, few reports have dealt with the current surgical management of bronchiectasis in recent years. We reviewed our recent experience with pulmonary resection for this condition to evaluate the results of contemporary surgical management.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Methods
Between January 1976 and January 1993, 3,421 patients were seen at the Mayo Clinic with a clinical diagnosis of bronchiectasis. One hundred thirty-four (3.9%) of those patients underwent pulmonary resection for bronchiectasis. The records of these 134 patients were analyzed for age, sex, symptoms, type of resection, operative morbidity and mortality, and functional results. The pulmonary resection was considered complete if the patient was believed to be free of bronchiectasis after thoracotomy. Bronchiectasis was considered to be bilateral if there was evidence of contralateral involvement on either chest roentgenography, computed tomography, or contrast bronchography. Failure of medical treatment was defined as frequent exacerbations interfering with work (or school) or requiring multiple hospitalizations. All specimens had pathologic confirmation of bronchiectasis.

Operative mortality included patients who died within 30 days after thoracotomy or those who died later but during the same hospitalization. Functional results were compared using a ² test. A p value of less than 0.05 was considered significant.

Clinical Findings
The mean age of the 134 patients at the time of thoracotomy was 48.0 years (range, 4 to 89 years). There were 79 female and 55 male patients. Eighteen patients (13.4%) were less than 20 years old. One hundred ten patients (82.1%) had chronic symptoms present for a mean of 6.0 years (range, 1 to 60 years) that included productive cough in 104 patients (94.5%), fetid sputum in 91 (82.7%), recurrent infections in 81 (73.6%), and hemoptysis in 56 (50.9%). Thirteen patients (9.7%) had no prior symptoms but presented with hemoptysis in 7 (massive in 3), lung abscess in 4, and unresolved pneumonia in 2. The remaining 11 patients (8.2%) presented with an asymptomatic lung mass discovered on chest roentgenograph.

Eighty-five patients (63.4%) had received prior medical therapy for a mean of 10.4 years (range, 1 to 60 years). Fifty patients (58.8%) had been treated previously with only one antibiotic, 26 (30.6%) had been taking two, and 9 (10.6%) had been taking three or more. Nine of these 85 patients (6.7%) had undergone prior operations for bronchiectasis: 7 had lobectomy, 1 had bilobectomy, and 1 had lobectomy and lingulectomy.

Preoperative diagnostic studies included posteroanterior and lateral chest roentgenographs in all patients. Bronchoscopy was performed in 124 patients (92.5%), contrast bronchography in 66 (49.3%), and chest computed tomography in 44 (32.8%). The disease was unilateral in 108 patients (80.6%) and bilateral in 26 (19.4%). The mean number of segments involved was 4.4 (range, one to 14 segments). Four or fewer segments were involved in 85 patients (63.4%). Bronchiectasis involvement was predominantly in the basilar segments in 46 patients (34.3%), superior segment in 29 (21.6%), lingula in 16 (11.9%), middle lobe in 16 (11.9%), and upper lobe segments in 27 (7.5%). The probable cause of bronchiectasis was postobstructive pneumonitis in 34 patients (25.4%), childhood infections in 23 (17.2%), pneumonia in 22 (16.4%), an immunodeficient state in 5 (3.7%), immotile cilia syndome in 4 (3%), and pulmonary sequestration in 2 (1.5%). A cause for bronchiectasis was not identified in 44 patients (32.8%).

The indication for pulmonary resection was failure of medical therapy in 85 patients (63.4%), recurrent or massive hemoptysis in 26 (19.4%), lung abscess in 12 (9.0%), and an indeterminate mass in 11 (8.2%). Thoracotomy was performed in all patients. Complete resection of all bronchiectasis was done in 108 patients (81%). One hundred seven of 108 patients (99.1%) with unilateral involvement had complete resections. In contrast, 25 of 26 patients (96.2%) with bilateral involvement had incomplete resections. Eighty-six patients (64.2%) had a lobectomy, 21 (15.7%) had a pneumonectomy, 18 (13.4%) had a wedge resection or segmentectomy, and 9 (6.7%) had a combination of these approaches. Seven of the pneumonectomy patients had completion pneumonectomies. Thirteen of the patients who had pneumonectomy had the operation on the left side, and 8 on the right. A lower lobectomy was performed in 49 patients, middle lobectomy in 16, and an upper lobectomy in 15. Five additional patients had bilobectomies. One patient underwent staged thoracotomies (bilateral lobectomies).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Complications occurred in 33 patients (24.6%) and included atelectasis requiring bronchoscopy in 9, a prolonged air leak (greater than 10 days) in 6, empyema in 5, pneumonia in 5, postoperative hemorrhage requiring reexploration in 4, arrhythmias in 3, postpneumonectomy pulmonary edema in 3, respiratory failure in 3, and bronchopleural fistula in 1. Three patients died (2.2%), all after completion pneumonectomy. The cause of death was respiratory failure in 2 patients and intraoperative bleeding in 1. Follow-up was complete in 103 patients, with a mean of 6.0 years (range, 1 to 16 years). Overall, 61 patients (59.2%) were asymptomatic after pulmonary resection. Symptoms were improved and antibiotic requirements were decreased in 30 patients (29.1%). Twelve patients (11.7%) had no improvement. In the group that had a complete resection, 89 patients were available for follow-up. Fifty-eight (65.2%) were asymptomatic, 23 (25.8%) were improved, and 8 (9.0%) were unimproved. In the group that had an incomplete resection, 14 were available for follow-up. Three (21.4%) were asymptomatic, 7 (50.0%) were improved, and 4 (28.6%) were unimproved. Complete resection resulted in a significantly better result than incomplete resection (p < 0.05).

Seventy-four of 85 patients who had failed previous medical management were available for follow-up. Forty patients (54.1%) were asymptomatic after pulmonary resection, 26 (35.1%) were improved, and 8 (10.8%) were unimproved. Eighteen of the 26 patients who were operated on for hemoptysis were available for follow-up. Eleven patients (61.1%) were asymptomatic, 3 (16.7%) were improved, and 4 (22.2%) were unimproved.

In the pneumonectomy group, 15 patients were available for follow-up. Thirteen (86.7%) were either asymptomatic or improved, and they all had complete resection. Two patients (13.3%) had incomplete resection, and they were unimproved after operation.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Bronchiectasis is a chronic necrotizing infection of the bronchi and bronchioles leading to irreversible abnormal dilatation of the airways. This should not be confused with pseudobronchiectasis, which is a transient (up to 6 months) cylindric dilatation of the bronchi accompanying lung infection in children. Pathologic findings in bronchiectasis [3–5] can be classified as cylindric, varicose, or cystic (saccular) and cover a spectrum from mild (cylindric) to the most severe form of this disease (cystic). Associated with these bronchial changes are varying degrees of scarring and fibrosis of the lung parenchyma.

The incidence of bronchiectasis is unknown, but had been reported to be as high as one per million children per year in the late 1950s [2]. Bronchiectasis is usually caused by pulmonary infection or bronchial obstruction. About half of the patients can trace the onset of symptoms to a childhood infection. Cystic fibrosis is currently the most common cause of bronchiectasis in the white population of North America and Europe [5]. Symptoms primarily are chronic cough and expectoration of foul-smelling, purulent sputum. Once chronic, respiratory infections tend to be frequent. Pseudomonas aeruginosa and Haemophilus influenzae are the most common organisms isolated from sputum [6]. Complications of this condition include hemoptysis, pulmonary abscess, brain abscess, amyloidosis, and respiratory failure. Cor pulmonale accounts for 37% of deaths [7].

Chest roentgenographic findings that are suggestive but nondiagnostic of bronchiectasis include stranding, cystic lesions, volume loss with crowding of vessels, and areas of infiltrates and atelectasis. High-resolution computed tomography has now largely supplanted bronchography for the definite diagnosis [8].

The initial treatment of patients with symptomatic bronchiectasis is primarily medical, with the goal being to reduce airway obstruction and to eliminate bacteria from the lower respiratory tract. Therapy should include rotating antimicrobial therapy, postural physiotherapy, inhaled bronchodilators, and corticosteroids [9]. Broad-spectrum antibiotics should be instituted for acute respiratory infection and exacerbations of chronic infection.

The role of pulmonary resection has evolved from early curative resection for all patients [10–12] to a more palliative approach limited to either those patients who have medically resistant disease or those who have complications [13–15]. Our operative patient population in the present study was highly selected and represented only 3.4% of all patients with the diagnosis of bronchiectasis seen during this time period.

The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients who have failed medical treatment [16] and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess. Appropriate selection of patients is critical for optimal results. Early pulmonary resection while the disease is still localized is preferred [17]. Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation [18]. Most of our patients had limited disease, and complete resection was possible in 81%. None had cystic fibrosis.

All patients should have a preoperative bronchoscopy study to rule out a stricture, neoplasm, or foreign body. Pulmonary function studies are rarely vital in the candidate with localized disease, but they should be obtained when a more extensive or repeat resection is considered. Acute suppurative bronchitis should be treated aggressively preoperatively with appropriate antibiotics. The operation is conducted with a double-lumen endotracheal tube to decrease soiling by blood and infected secretions. Completion pneumonectomy is a high-risk procedure when performed for benign disease [19]. When indicated, precautions such as optimal exposure, intrapericardial isolation of blood vessels, and bronchial reinforcement should be used routinely [20].

More than 80% of our patients had total relief or substantial improvement of their preoperative symptoms. These results are comparable to those reported by others [16, 17, 21, 22]. Our overall operative mortality rate of 2.2% also compares favorably with that reported previously [11, 16, 17, 21–25]. Morbidity, however, was substantial, with at least one complication developing in 33 patients (24.6%).

In conclusion, surgical treatment for bronchiectasis should be limited to patients with localized disease unless life-threatening symptoms are present. Complete resection should be performed whenever possible to achieve maximum benefit. In properly selected patients, pulmonary resection can be done with acceptable morbidity and low mortality rates.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Address reprint requests to Dr Deschamps, Section of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Claude Deschamps Victor F. Trastek Mark S. Allen Peter C. Pairolero Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Agasthian, T. Articles by Pairolero, P. C. Search for Related Content PubMed PubMed Citation Articles by Agasthian, T. Articles by Pairolero, P. C. Related Collections Related Article