(Chest. 2000;117:884-886.)
© 2000
American College of Chest Physicians
Video-Assisted Contralateral Treatment for Bronchial Stump Diastasis After Left Pneumonectomy*
Yoshio Tsunezuka, MD, PhD;
Hideo Sato, MD, PhD and
Takamitsu Kodama, MD
*
From the Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan.
Correspondence to: Yoshio Tsunezuka, MD, PhD, Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, 153-Nu, Minamishinbomachi, Kanazawa, 920-8530, Japan;
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Abstract
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Postoperative bronchial stump failure is a life-threatening
complication, and several surgical approaches and procedures have been
developed to close the stump. In this report, we describe a case of
left mainstem bronchial stump diastasis after pneumonectomy for lung
cancer, in which the bronchial stump was re-closed using a
contralateral approach with video-assisted thoracic surgery, with good
success. The left main bronchus was closed with an automatic stapler
device, but the stump reopened and left pyothorax developed
postoperatively. Emergent intratracheal intubation and ventilation was
required due to rapid progression of right pyothorax. Under strict
nutritional management by IV hyperalimentation, administration of
antibiotics to which the organisms were sensitive, and drainage, the
patient recovered from pneumonia. However, thoracic air leak increased
daily, and reoperation for bronchial diastasis was performed. Using
this approach, the left main bronchus near the carina was easily
exposed extrapleurally, with only the azygos vein being incised.
Video-assisted contralateral treatment was effective in avoiding
sternal osteomyelitis due to a transpericardial approach via median
sternotomy in the case of mainstem bronchial stump failure, only after
left pneumonectomy.
Key Words: bronchial stump diastasis • contralateral treatment • lung cancer • video-assisted thoracic surgery
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Introduction
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Postoperative
bronchial stump failure is a life-threatening complication and remains
a major therapeutic challenge. In a case of postpneumonectomy stump
failure with empyema, contralateral pneumonitis may involve the entire
remaining lung because there is a large connection between the
interbronchus and the infectious intrathoracic space.1
If
stump failure is severe, direct reclosure of the stump is essential.
Herein we report a case managed by an unusual new surgical
procedure—video-assisted contralateral treatment for successful
closure of postpneumonectomy left main bronchial stump failure.
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Case Report
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A 59-year-old man underwent left pneumonectomy via standard
posterolateral thoracotomy, with systematic nodal dissection for
squamous cell carcinoma of the upper lobe of the left lung invading the
left main pulmonary artery and main bronchus. The left main bronchus
was closed with an automatic stapling device (TX30G-4.8; Ethicon
Endo-Surgery; Cincinnati, OH). After stapling, the closed bronchus was
tested for air leaks at 20 cm H2O of airway pressure. Nine
days postoperatively, the patient developed a low-grade fever, but
cultures of thoracocentesis specimens were negative. Acute management
consisted of tube drainage of the pleural cavity. Systemic antibiotic
therapy was administered because high fever developed. The patient
complained of dyspnea, and a chest roentgenogram showed right lobar
pneumonia. Air leak was noted in the thoracic tubes. Bronchoscopy
revealed an approximately 10-mm defect in the residual left main
bronchus, and bronchial stump diastasis was diagnosed rather than
bronchopleural fistula (Fig 1)
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Based on arterial blood gas analysis (PaCO2, 41
mm Hg; PaO2, 38 mm Hg; oxygen saturation,
68%), emergent intratracheal intubation and ventilation was required.
Repeated bacterial cultures of pleural effusion and blood cultures
yielded coagulase-negative staphylococcus, Haemophilus
parainfluenzae, and Candida albicans. After 7 days
under strict nutritional management by IV hyperalimentation,
antibiotics to which the organisms were sensitive (imipenem/cilastatin,
1.0 g/d and minocycline hydrochloride, 100 mg/d), and antifungal agents
(fluconazole, 150 mg/d), the patient showed a fair recovery from
pneumonia and was able to be weaned from the respirator. Arterial blood
gas analysis was remarkably improved (PaCO2, 38
mm Hg; PaO2, 96 mm Hg; oxygen saturation, 96%
at room air).
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Figure 1.. Top: Bronchoscopic findings showing
that the postpneumonectomy stump had reopened. Bottom:
Post-reoperative bronchoscopic findings showing that the second stump
near the carina was clear and the trachea had not become stenotic.
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However, thoracic air leak increased daily, and repeat surgery for
bronchial fistula was performed 17 days after the initial surgery.
Reoperation was carried out in the left lateral position (Fig 2) .
With a posterior incision, right minithoracotomy on the triangle of
auscultation was performed. The smallest skin incision needed was 6 cm
to insert a stapling device into the intrathoracic space. A 12-mm
thoracoport was placed at the fifth intercostal space at the anterior
axillary line, and another was placed at the sixth intercostal space at
the posterior axillary line. A thoracoscope was inserted through the
posterior port as a light guide. Using a lung spatula through the
anterior port, the azygos vein was incised, the posterior field of the
vein was spread, and the vagus nerve, right bronchial arteries, and
lower part of the trachea were isolated between two tapes to prevent
injury. The left main bronchus was exposed at the posterior mediastinum
and separated from connective tissue. The left bronchial stump was
stapled using another stapler device (TLH30–4.8; Ethicon Endo-Surgery)
that allowed the operator to control the intensity of the grasping
power applied to the bronchus. By intraoperative bronchoscopy, we
ascertained that the trachea had not become stenotic due to stapling
(Fig 1) . The bronchial leak disappeared postoperatively. Recovery was
uneventful, and the temperature gradually returned to normal in the
course of 5 days. The drainage system was removed on the 14th
postoperative day after pleural cultures and arterial blood cultures
did not show any growth of pathogens, and serum C-reactive protein was
within normal limits. The patient remained functionally well for 18
months postoperatively.
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Figure 2.. Right minithoracotomy view. After incision of the
azygos vein, the left main bronchus near the carina was exposed. The
vagus nerve and bronchial arteries were isolated between two slings.
AS = automatic suture device; AV = azygos vein; BA = bronchial
artery; LMB = left main bronchus; SVC = superior vena cava;
VN = vagus nerve.
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Comment
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Bronchial stump failure is the most troublesome complication in
thoracic surgery.1
2
Once bronchial stump failure occurs,
especially after pneumonectomy, contralateral pneumonia develops due to
ipsilateral pyothorax and may frequently be a fatal event. The etiology
of bronchial stump failure is complex and related to several factors.
Numerous studies indicate that the causes of bronchial failure include
devitalization and devascularization of the bronchial stump by
excessive dissection, peribronchial infection related to nonabsorbable
suture, residual bronchial disease, poor approximation of the mucosa,
the length of the stump, and the experience and technique of the
surgeon. Automatic stapling devices are widely used for bronchial stump
closure, and, in general, the incidence of fistula is considerably
reduced by the use of such automatic suture devices.3
4
However, it is reported that the incidence of bronchopleural fistula
changes according to the type of automatic stapler
devices.5
We routinely use a 4.8-mm stapling device to
close the main bronchus after pneumonectomy. In the case being reported
here, the stump was checked by pressure proof test intraoperatively but
was reopened 9 days postoperatively. A thickened and inflamed bronchus
is a relative contraindication for using a stapler,5
but
this was not found in the present case. Bronchoscopically, bronchial
failure was judged to involve diastasis rather than fistula. The cause
of this failure remains unknown, but one speculation is that closure of
the bronchus by the staple device was too tight and may have caused
devitalization and devascularization of the bronchial stump.
A contralateral approach was first described in a case of chronic
empyema by Maassen.6
Using this approach, the left main
bronchus near the carina was easily exposed extrapleurally, with only
the azygos vein being incised. Maassen’s procedure and ours are
fundamentally the same, but his thoracotomy was a general
posterolateral procedure, while our procedure involved a
minithoracotomy with video-assisted thoracic (not thoracoscopic)
surgery. The thoracotomy was located at the triangle of auscultation to
keep the respiratory muscles intact.
Some technical skills are required for this approach. First, this
procedure must be performed concurrently with ventilation of the right
lung, as it is necessary to prevent collapse of the right lung by the
spatulas as much as possible. Second, the vagus nerve and bronchial
arteries must be carefully isolated to avoid injuring these structures.
Other procedures for direct left main bronchial closure include the
ipsilateral approach and transpericardial approach. It is dangerous to
expose the left main bronchus stump by an ipsilateral approach because
the stump is covered with fibrous adhesion and because it lies near the
descending aorta and left main pulmonary artery. Moreover, the
recurrent nerve is present in the pulmoaortic window, and the
nerve may be injured during exposure of the left main bronchus stump.
The transpericardial approach is a generally recommend
technique.7
An outstanding problem of this median approach
is the production of sternal osteomyelitis.8
Using a
median approach, sternal incision is performed, and connective tissue
of the anterior mediastinum is separated to expose the left bronchial
stump between the superior vena cava and the ascending aorta. If
subcarinal and hilar lymph nodes are dissected during systematic nodal
dissection during lung cancer surgery, the left mediastinal pleura are
disrupted through the left pleural cavity. Therefore, intrathoracic
bacteria may extend to the anterior mediastinum and sternum.
Indications for the contralateral approach are limited. Respiratory
function must be adequate for contralateral thoracotomy, and this
approach must be avoided when pyothorax is active. If a stapling device
will be used during this approach, bronchoscopic examination is
necessary to measure the stump length because the length must be
greater than the thickness of the device. However, to avoid sternum
osteomyelitis due to a transpericardial approach via median sternotomy,
this approach is worth considering in some patients with bronchial
stump failure after left pneumonectomy for lung cancer and systematic
nodal dissection.
Received for publication June 9, 1999.
Accepted for publication September 28, 1999.
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References
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Zoetmulder, FA, Rutgers, EJ, Baas, P (1995) Bronchopleural fistula after pneumonectomy: repair and prevention with a de-epithelialized latissimus dorsi myocutaneous island flap. J Thorac Cardiovasc Surg 110,1139-1141[Free Full Text]
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Weissberg, D, Kaufman, M (1992) Suture closure versus stapling of bronchial stump in 304 lung cancer operations. Scand J Thorac Surg 26,125-127
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Vester, SR, Faber, LP, Kittle, CF, et al (1991) Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 52,1253-1257[Abstract]
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Fansa, H, Handstein, S (1998) Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap. Scand Cardiovasc J 32,33-39[CrossRef][Medline]
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Abstract
Introduction
