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Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University, Shanghai, China
Accepted for publication March 22, 2010.
* Address correspondence to Dr Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University, Shanghai, China 200433 (Email: jgnwp{at}yahoo.com.cn).
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods: We retrospectively reviewed the medical records of 790 consecutive patients who underwent surgery for bronchiectasis in our department between January 1989 and December 2008. Localized bronchiectasis was diagnosed by high-resolution computed tomography. The persistence of symptoms after failure of nonsurgical treatment was an indication for surgery. Cystic fibrosis patients were excluded from this study.
Results: The study sample included 790 patients (466 male, 324 female) who underwent 810 operations for bronchiectasis. Mean age at time of surgery was 41.6 years (range, 6 to 79 years). Several surgical procedures were used: lobectomy (497; 62.9%), segment resection (37; 4.7%), pneumonectomy (90; 11.3%), bilobectomy (56; 7.1%), and lobectomy and segmentectomy (110; 14.0%). There were no intraoperative deaths. Nine (1.1%) patients died in the postoperative period. Univariate analysis showed that advanced age (p = 0.04) and renal failure (p = 0.001) were associated with postoperative mortality, and multivariate analysis revealed that preoperative renal failure was associated with mortality (p = 0.025). The mean follow-up time was 4.2 years (range, 10 months to 10 years). After surgery, 478 (60.5%) patients were asymptomatic, 111 (14.1%) had improved, and 117 (14.8%) showed no improvement or worsened condition.
Conclusions: Localized bronchiectasis is usually the indication for surgical resection, which is a safe procedure with acceptable operative morbidity, mortality, and outcomes.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Once considered to be of decreased relevance in the developed world of the late 20th century, bronchiectasis is diagnosed with increasing frequency in North America and worldwide [4]. Certain demographic groups have been recognized to have increased risk for the development of bronchiectasis, including individuals with high rates of pulmonary infection in childhood or poor access to health care. Many such individuals reside in the rural areas of China [5, 6].
Bronchiectasis causes severe pulmonary infections and loss of lung function, results in chronic morbidity, and may contribute to premature mortality [7, 8]. A few reports considering the surgical management of bronchiectasis have been recently published. This study conducted a review of operations for bronchiectasis conducted during the last two decades (1989 to 2008) at a single hospital in China. Our goal was to determine postoperative mortality and morbidity rates, long-term results, and risk factors for poor outcomes.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Data were obtained from the hospital's database and medical records, referring physicians, and patients or their families. The study variables included age, sex, preoperative comorbidities, pulmonary function, operative findings, surgical procedure, duration of postoperative ventilation, operative mortality, postoperative morbidity, and follow-up results. The preoperative comorbidities encountered in this study were renal failure (defined as creatinine clearance < 60 mL/min), obesity (body mass index > 27 kg/m2), hypertension (systolic pressure > 140 mm Hg, diastolic pressure > 90 mm Hg or established medical treatment), and coronary artery disease (preoperative coronary revascularization or diagnosed and treated myocardial ischemia).
The patient selection criteria included the following: localized bronchiectasis diagnosed by high-resolution computed tomography, symptoms such as chronic productive cough, repeated or significant hemoptysis, lung abscess, empyema, recurrent pulmonary infection, and failure of nonsurgical treatment. Nonsurgical treatments included antibiotic therapy, postural drainage with vibratory massage, and bronchodilator and corticosteroid treatments. Failure of nonsurgical treatment was defined as frequent exacerbations that interfered with normal professional or social life or required multiple hospitalizations. Hemorrhagic loci were bronchoscopically identified in patients with repeated or significant hemoptysis. Although cystic fibrosis is a common cause of inherited bronchiectasis, it is often related to diffuse bronchiectasis cases that are seldom suitable for operation. For this reason, cystic fibrosis patients were not included in this study.
Preoperative Evaluation
Functional status was evaluated by physical examination, chest roentgenography, spirometry, arterial blood gases, quantitative ventilation measurements, and perfusion scans. Patients at high risk for heart disease were screened by echocardiography, thallium stress testing, and, in some cases, selective coronary arteriography. Preoperative evaluation included fiberoptic bronchoscopy when a large amount of sputum was present in the respiratory tract or the mucous membranes were inflamed.
Preoperative comorbidities were noted in 166 (21%) patients. These comorbidities consisted of chronic obstructive pulmonary disease (n = 79; 10%), hypertension (n = 67; 8.5%), coronary artery disease (n = 18; 2.3%), renal failure (n = 14; 1.8%), dyslipidemia (n = 16; 2%), diabetes mellitus (n = 21; 2.7%), and morbid obesity (n = 9; 1.1%). The median percentage of predicted forced expiratory volume in 1 second was 65.3% (range, 45% to 96%).
Patients stayed in the hospital for at least 2 weeks of preoperative preparation. Most patients spent this time in the respiratory department of our hospital. The patients were given antibiotics on the basis of sputum or bronchial aspirate culture tests. If the culture was negative and the patient had no contraindications or allergies, cephalosporin and aminoglycoside were prescribed. Atomization and postural drainage with vibratory massage were also used to prepare the airway.
Surgical Procedures
Each surgery was performed after single-lung ventilation was established through a double-lumen endotracheal tube. A posterolateral thoracotomy was performed on 745 patients, and 45 patients were treated by video-assisted thoracoscopic surgery. Excessive bronchial dissection was avoided. A flap was routinely used to cover the bronchial stump and to separate it from the pulmonary artery, thus preventing bronchovascular fistula. The bronchial stump was kept short, and bronchial closure was performed with interrupted sutures in 657 (83.2%) patients and 2.5-cm staples (Ethicon TA 30, Somerville, NJ) in 133 (16.8%) patients. The pedicled flap used to cover the bronchial suture line was taken from the serratus anterior muscle, adjacent pleura, or mediastinum.
Two tubes were inserted to ensure drainage for at least 48 hours; one tube was used for patients undergoing pneumonectomy. Damaged lung tissue presented the potential hazard of thorax contamination during pneumolysis; in cases in which thoracic contamination was detected, the tubes were left in place for a longer period and removed only when plural effusion tests and bacterial cultures gave normal results. Thoracentesis was also performed when radiographs showed significant pleural effusion after removal of the tubes.
Complete resection was defined as an anatomic resection of all affected segments preoperatively identified by high-resolution computed tomography or bronchography. At the end of the procedure, the bronchial suture was bronchoscopically checked, and secretions were removed from the airways. Most patients were extubated in the operating room. When postoperative mechanical ventilation was necessary, a standard endotracheal tube was substituted for the double-lumen tube.
Postoperative Treatment and Follow-Up
Postoperative pain was treated with epidural or patient-controlled analgesia. Antibiotics were administered for 5 days after surgery, or longer if the patient had inflammatory symptoms. Percussive chest physiotherapy was performed three to four times daily by respiratory therapists. The fluids of some elderly patients, especially those who had undergone pneumonectomy, were restricted to 1500 mL/day, and diuretic therapy was administered to maintain a negative fluid balance. Patients were encouraged to ambulate for several hours each day (beginning with postoperative day 1) with the aid of physical and occupational therapists. Postoperative death was defined as death within 30 days after surgery or before hospital discharge. Follow-up was conducted by telephone or written correspondence.
Data Analysis
The following preoperative, intraoperative, and postoperative variables were retrospectively recorded: general demographic data, comorbidity, pulmonary function, previous chest physiotherapy, type of surgical procedure, postoperative complications, and postoperative mortality within 30 days. The relationships between potential predictors and postoperative pulmonary complications were assessed by univariate and multivariate analyses. The univariate analysis examined categorical variables using Pearson's 
2 or Fisher's exact test, and compared continuous variables with Student's unpaired t tests. Continuous variable data are presented as mean and standard deviation, and categorical variable data are presented as percentages. Differences were considered significant when probability values were less than 0.05.
The risk of poor surgical outcome was evaluated with forward and backward stepwise logistic regression analyses to estimate odds ratios (OR) and their 95% confidence intervals (CI).
Variables identified as significant in the univariate analysis were included in the multivariate analysis. The final model included factors that remained significant with a probability value of less than 0.10. Goodness of fit was assessed with the Hosmer-Lemeshow 2 test. Statistical analyses were performed with SPSS 10.0 for Windows software.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The distribution of surgical procedures is shown in Table 1. Most patients underwent a lobectomy (497; 62.9%), followed by lobectomy and segmentectomy (110; 14%), pneumonectomy (90; 11.3%), bilobectomy (56; 7.1%), and segment resection (37; 4.7%). The mean operative time was 160.5 minutes (range, 55 to 320 minutes), and the mean intraoperative blood loss was 427.4 mL (range, 20 to 2,500 mL). Intraoperative and postoperative blood transfusions were required in 16 (2%) patients (median, 4 units; range, 1 to 12 units). Pleural adhesion was encountered in 616 (78.0%) patients. Complete resection was achieved in 703 (89.0%) patients. No intraoperative deaths occurred.
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The mean duration of postoperative hospital stay was 9.8 days (range, 6 to 120 days). Postoperative complications occurred in 128 (16.2%) patients. Empyema developed in 5 (0.6%) patients; 1 was managed with chest tube insertion and pleural lavage, 1 with open debridement, and 3 with a Clagett procedure. Bronchopleural fistula (BPF) developed in the 3 (2%) patients who underwent a Clagett procedure. Nine (1.1%) patients with postoperative hemothorax required subsequent operations. Chylothorax occurred in 1 patient, who required surgical ligation of the thoracic duct. Postoperative lung torsion occurred in 1 patient who had undergone a left upper lobectomy and wedge resection of the inferior lobe for bronchiectasis with video-assisted thoracoscopic surgery. A completion pneumonectomy was required for this patient. The remaining patients experienced minor complications (Table 3) for which they received nonsurgical treatment. Univariate analyses showed that only preoperative percent predicted forced expiratory volume in 1 second less than 50% was associated with postoperative complications (p < 0.03). Multivariate analysis found no factors that were significantly associated with postoperative complications.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Infections are the most common cause of acquired bronchiectasis. Although widespread vaccination in developed regions has decreased the incidence of childhood infections such as measles and pertussis, these infections continue to be a causal factor for bronchiectasis in less-developed regions such as rural China.
The primary clinical symptom of bronchiectasis is a recurrent or permanent cough with ample sputum production [9], an observation supported by the results of our study. The sputum is frequently purulent and is often accompanied by hemoptysis in advanced stages of the disease. In China, patients with bronchiectasis and hemoptysis usually receive surgical treatment. Limited bleeding may occur from the inflamed and vulnerable airway mucosa. Severe and life-threatening bleeding may result from erosions of the hypertrophic bronchial arteries or lesions in abnormal anastomoses between the pulmonary and bronchial arterial circulations. Symptoms may be mild (eg, unproductive cough) or even absent if the disease is restricted to the upper lobes. Patients may also present with symptoms of the underlying disease that has led to the development of bronchiectasis.
The widespread use of high-resolution computed tomography scanning has increased the number of bronchiectasis diagnoses [10]. High-resolution computed tomography is a sensitive method for the detection of bronchiectasis and assessment of the distribution of bronchiectatic alterations [11–14], with only 2% false-negative and 1% false-positive rates [15]. This method has largely replaced bronchography with endobronchial instillation of iodinated contrast medium, and has been used in our hospital since 1999. Bronchography was used to evaluate only a small number of patients in our sample in the early years of this study.
The primary therapeutic goal for bronchiectasis patients must obviously be the treatment of any reversible underlying disease. Adequate antibiotic therapy, bronchodilators, and physiotherapy must therefore accompany any form of bronchiectasis treatment.
Careful preoperative preparations are of the utmost importance to reduce operation-related morbidity and mortality. In this study, patients were preoperatively monitored until they produced less than 20 mL/day of sputum with little purulence. Operation was not conducted until bronchofibroscopy showed no engorgement or edema in the tunica mucosa bronchiorum. All patients in this study underwent at least 2 weeks of preoperative monitoring and preparation.
Although antibiotics and postural drainage are broadly used to manage bronchiectasis, resection of the involved lung is the only treatment modality that can offer a potential cure [16]. The role of surgery for the treatment of bronchiectasis has changed with the development of more effective antibiotics and conservative treatment options; with careful patient selection, however, surgery offers substantial benefits. Surgical treatment is primarily indicated for patients with localized bronchiectasis [17, 18].
Complete resection is considered the best surgical option because it most effectively prevents infectious complications and recurrence, conditions that have been reported with other surgical treatments and were observed in this study [1, 18]. Although the greatest possible amount of healthy parenchyma must be spared, radical resection of the affected areas most effectively improves patient outcomes. Bilateral resection was not performed on patients in this study because of the numerous contraindications for this procedure. Pneumonectomy may become necessary in rare cases of unilateral presentation with one healthy lung. Ninety patients in our study sample received a pneumonectomy for bronchiectasis that produced satisfactory results, especially for patients with a destroyed lung. Some authors have argued that pneumonectomy may be preferable to residual disease presence [17–19].
Bronchiectasis is associated with a high risk of postoperative BPF, especially when the bronchial mucosa is inflamed. It is important to avoid BPF whenever possible, especially in regions such as rural China where poor medical care persists. In our experience, BPF can most effectively be avoided when the patient exhibits a limited amount of sputum and preoperative bronchofibroscopy shows no engorgement or edema in the tunica mucosa. Another measure to reduce the occurrence of BPF is coverage of the stump during operation. Postoperatively, bronchofibroscopy was used to aspirate the sputum when atelectasis occurred. Thoracentesis is also recommended when radiography shows significant pleural effusion after tube removal. Each of the above preventive steps is important for the effective avoidance of BPF. Very few patients in our study, which used the above measures, experienced postoperative BPF.
Advanced age and renal failure were associated with postoperative death in our patients, indicating the need for more conservative treatment of patients in these categories. Postoperative treatment of these patients should include fluid restriction, diuretic therapy, and early onset of ambulation.
Tuberculous bronchiectasis was associated with poor outcomes in this study. Inasmuch as this condition was often accompanied by massive hemoptysis, only the most experienced surgeons could satisfactorily treat it. Most cases of tuberculous bronchiectasis among our hospital were often treated with antibiotics.
In summary, localized bronchiectasis is usually an indication for surgical resection, a safe procedure with acceptable operative morbidity, mortality, and outcomes. Bronchiectasis patients require careful evaluation to ensure that residual lung function will be adequate after surgery. We believe that complete resection is the best treatment option because it avoids infectious complications and recurrence of the disease.
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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