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Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach
Closure of Chronic Postpneumonectomy Bronchopleural Fistula Using the Transsternal Transpericardial Approach Robert J. Ginsberg, MD, F. Griffith Pearson, MD, Joel D. Cooper, MD, Ernest Spratt, MD, Jean Deslauriers, MD, Melvyn Goldberg, MD, Robert D. Henderson, MD, and Donald Jones, MD Divisions of Thoracic Surgery, University of Toronto, Toronto, Ontario, and Hopital Laval, Sainte-Foy, Quebec, Canada
Thirteen patients with postpneumonectomy bronchopleural fistula occurring 4 months to 10 years after the initial operation have been treated with a transsternal transpericardial approach after the associated empyema had been treated by either tube thoracostomy or openwindow thoracostomy. In 10 patients, there were contraindications to using an ipsilateral transthoracic approach. In 10 of the 13 patients, the procedure was
successful. Three fistulas recurred; two were quite small, one of them closing spontaneously within 6 months. There were no deaths or clinically significant morbidity related to the transsternal approach. We have found this technique to be most applicable in those patients in whom other procedures have failed to resolve the problem. The technique is relatively simple and safe. (Ann Thorac Surg 1989;47:231-5)
ith modern surgical techniques, a bronchopleural fistula after pneumonectomy should be rare, but these fistulas still complicate up to 5% of such procedures [l]. Fistulas occurring in the early postpneumonectomy period are best treated by immediate reoperation and reclosure, augmented by a protective patch of well-vascularized tissue. Fistulas occurring later (weeks to years postoperatively) are usually managed initially by tube drainage as most patients are seen with a fistula plus an empyema. Ultimately, both the fistula and the empyema must be dealt with. Many methods have been used to close the chronic postpneumonectomy bronchial fistula. Open-window thoracostomy as described by Clagett and Geraci [2] deals with the associated empyema and can ultimately result in spontaneous closure of some of the smaller fistulas [3]. Nonsurgical maneuvers including repeated bronchoscopic cauterization of the fistula [4] or the application of fibrin glue [5] have been described as being somewhat successful. Direct surgical methods of managing this problem include repeat thoracotomy with reclosure of the bronchus using a vascularized patch (pericardium, muscle, or omentum) for reinforcement [6], large myovascular bundles to simultaneously close the fistula and cavity [7], or nearly total thoracoplasty. A contralateral right thoracotomy approach to the left main bronchus has also been successful in cases of chronic fistulas after left pneumonectomy [ 8 ] . In 1960, Padhi and Lynn [9] in Canada were among the first to document a transpericardial approach to close chronic postpneumonectomy fistula utilizing anterior tho-
racotomy with division of multiple costal cartilages. One year later, Abruzzini [lo] in Italy described the transsternal transpericardial approach. This has been employed extensively in Russia by Perelman and Ambatiello [ll] and Bogush and colleagues [12]. The technique was reintroduced in centers in North America in the 1980s [13, 141. In the past 10 years, we have had 13 patients in whom the transsternal transpericardial approach was used for closure of chronic bronchopleural fistulas following pneumonectomy.
Presented at the Twenty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Sep 2 6 2 8 , 1988. Address reprint requests to Dr Ginsberg, Mount Sinai Hospital, 600 University Ave, Suite 451, Toronto, Ont, Canada M5G 1x5.
0 1989 by The Society of Thoracic Surgeons
Material and Methods In all patients, preoperative drainage of the postpneumonectomy space had been effected by tube thoracostomy or open-window thoracostomy, or both. To facilitate intraoperative ventilation in the presence of a bronchopleural cutaneous fistula, a variety of anesthesia techniques were used, including double-lumen tubes, long single tubes inserted into the remaining bronchus, an endobronchial blocker in the stump of the pneumonectomy, packing the open stump through the thoracostomy window, and high-frequency jet ventilation. We use a full median sternotomy (Fig 1). After the mobilization and retraction of the superior vena cava and the aorta (Fig 2), the lower trachea above the pericardial reflection is mobilized; care is taken to avoid injury to the left recurrent nerve. The anterior pericardium is opened, and the pulmonary artery is either mobilized and retracted inferiorly or reamputated to effect better exposure. The posterior pericardium is then opened behind the pulmonary artery, thereby totally exposing the carina (Fig 3). A substantial shift of the mediastinum as a result of the pneumonectomy can make this exposure somewhat difficult, especially on the left. 0003-4975/89/$3.50
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Fig 3 . A wide incision of the posterior pericardium totally exposes both bronchi and the lower trachea. Fig 1. A full sternotomy incision has been made. The anterior pericardiuin has been opened, exposing the great vessels. (PA = pulinonary artery; SVC = superior vena cava.)
The affected bronchial stump is then dissected at the carina, isolated, and divided. This reamputated stump is closed using interrupted sutures or staples. The suture line is reinforced with vascularized pericardium. The distal stump is totally excised if possible (Fig 4). Alternatively, after the distal stump mucosa has been destroyed by cauterization (either at bronchoscopy before the procedure or at the surgical operation), the proximal end of this remaining stump is closed and left in situ.
Fig 2 . Retraction of the superior uena caua and aorta to each side exposes the right pulnlonary artery (RPA) and the posterior pericardiutn ouerl.ying the cizrina.
Results We reviewed the records of 13 patients (8 men, 5 women) who had chronic postpneumonectorny fistulas closed utilizing this technique during the years 1978 to 1987. Age ranged from 38 to 73 Years. In 9 Patient$;,PneumonectomY
Fig 4. A chronic right fistula treated by division and reclosure of the proximal and distal sturnps. Preferably, the distal stump should be excised, but this is not alulays possible.
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was performed for carcinoma. The other 4 patients had irreversible inflammatory disease, including tuberculosis, bronchiectasis, bronchocentric granulomatosis, and necrotizing pneumonia. There were five left and eight right fistulas. The patients were seen 4 months to 10 years after development of the fistula. In 10 patients, there were associated problems that did not allow a simple ipsilateral thoracotomy approach. The problems included previous attempted single or multiple closures by ipsilateral thoracotomy (3 patients), previous thoracoplasties with or without associated myovascular flaps that had failed (3 patients), persisting infection in a thick-walled postpneumonectomy space (3 patients), and associated tracheal stricture (1 patient). In 3 other patients, the transsternal approach was elected as the first closure attempt. There was no postoperative mortality or clinically significant morbidity. In two instances, reamputation of the ipsilateral pulmonary artery stump allowed further exposure of the residual bronchial stump. In all patients except 1, the bronchial stump was redivided close to the carina and then sutured or stapled. In the 1 exception, the mobilized stump was stapled in continuity without transsection. In 9 patients, the reclosed bronchus was covered by a vascularized patch (pericardium or thymus, or both). In 1 patient with an associated low tracheal cuff stricture after intubation, a concomitant tracheal resection was performed, and pedicled omentum was used to cover the anastomosis. A variety of techniques were used to handle the 12 residual distal stumps, including total excision (2 patients), cautery of the mucosa and proximal closure (6 patients), and cautery of the mucosa without proximal closure (4 patients). In all patients, the empyema space was not closed initially but was handled by continued drainage through the thoracostomy window or tube. In 10 patients, the bronchial closure healed primarily and has remained intact 18 months to 7.5 years later. Three patients have died in late follow-up. There were three instances of failure of this technique. In the single patient in whom stapling was done without division of the bronchus, the fistula totally reopened within 1 week after closure as a result of failure of the staple line. The two other failures resulted in tiny recurrent fistulas, both in patients in whom multiple previous operations led to the closure of a difficult stump without closure of the distal remnant. One of these fistulas subsequently closed spontaneously within 6 months.
Comment The technique of transsternal closure of bronchopleural fistulas has been well described by Abruzzini [lo] and Perelman and Ambatiello [ll].In most cases, the associated empyema cavity will have been drained by tube or open-window thoracostomy before closure of the fistula. The selection of anesthesia technique depends on the situation at hand. We found a variety of techniques useful, including double-lumen tubes, a bronchial blocker to occlude the stump, a long endotracheal tube to ventilate the contralateral (usually left) mainstem bronchus,
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and high-frequency jet ventilation. In one instance, the fistula was occluded by packing through the thoracostomy window. Although the right mainstem bronchus can be exposed extrapericardially with a transsternal approach, we have found that the best exposure is obtained by opening the anterior pericardium, retracting or reamputating the ipsilateral main pulmonary artery, and then opening up the posterior pericardium to expose the total carinal area. Once the affected bronchial stump has been isolated near the carina, division and reclosure by suture or staple is imperative. We and others [14] have experienced failures caused by stapling in continuity without division. This should be avoided. Once the proximal stump has been closed, we believe it important to attempt to reinforce the closure with adjacent vascularized pericardium, mobilized thymus, or omentum, which is easily obtained on a vascular pedicle from the upper abdomen through an extension of the median sternotomy. The omentum can be extremely valuable, especially in very difficult dissections or whenever the blood supply to the closure appears tenuous (eg, after irradiation). If possible, the distal remnant stump should be totally excised to avoid mucus secretion in the empyema cavity. If this is not technically feasible, the mucosa should be obliterated either at the time of operation by cauterization or just before operation by electrocoagulation or laser cauterization through a bronchoscope. The proximal end of this stump should be closed whenever possible. Ultimately, the residual empyema cavity can be sterilized by the method of Clagett and Geraci [2] or closed by large myovascular flaps or thoracoplasty. Although there are many approaches to facilitate closure of a chronic postpneumonectomy bronchopleural fistula, we have found the transsternal transpericardial approach relatively simple and effective. The single disadvantage of this method is that the residual empyema space is not dealt with at the same time, unlike myovascular transpositions or thoracoplasty. This technique is most useful when there are contraindications to performing an ipsilateral transthoracic approach. In some instances, with extreme shifts of the mediastinum, especially to the left after a left pneumonectomy, the anterior thoracotomy approach described by Padhi and Lynn [9], in which multiple costal cartilages are divided or excised, has theoretical advantages, allowing a more direct approach to the pericardium and left mainstem bronchus. The technique of transsternal transpericardial resection of chronic postpneumonectomy bronchopleural fistulas should be placed in the armamentarium of all thoracic surgeons, and is most advantageous when a direct approach through the ipsilateral thoracotomy space is contraindicated or when previous attempts at closure have failed.
References 1. Hakim M, Milstein BB. Role of automatic staplers in the etiology of bronchopleural fistula. Thorax 1985;40:27-31. 2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963;45:141-5.
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3. Shamji FM, Ginsberg RJ, Cooper JD, et al. Open window thoracostomy in the management of post-pneumonectomy empyema with or without bronchopleural fistula. J Thorac Cardiovasc Surg 1983;86:818-22. 4. Hier-Madsen K, Schulz ES, Miller-Pedersen V, Halkier E. Management of bronchopleural fistula following pneumonectomy. Scand J Thorac Cardiovasc Surg 1984;18:2634. 5. Torre M, Chiesa G, Ravini M, Vercelloni M, Belloni PA. Endoscopic gluing of bronchopleural fistula. Ann Thorac Surg 1987;43:295-7. 6. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. 7 . Pairolero PC, Arnold PG, Pihler JM. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg 1983;86:809-17. 8. Perelman MI, Rymko LP, Ambatiello GP. Bronchopleural fistula: surgery after pneumonectomy. In: Grillo H, Escha-
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9. 10. 11. 12. 13. 14.
passe H, eds. International trends in thoracic surgery, Vol 2. Philadelphia: WB Saunders, 1987:407-l:!. Padhi RK, Lynn RB. The managenierk of bronchopleural fistulae. J Thorac Cardiovasc Surg 1960;39:385-93. Abruzzini P. Tratamento chirugico delle fistulae del broncho principale consecutive pneumonectomia tubercolosi. Chir Torac 1961;14:165-71. Perelman MI, Ambatiello GP. Transpleuraler, transsternaler und kontralateralar sugang bei Operationen wegen, Bronchialfistel nach Pneumonektomie. Chir Vaskul 1970;18:4!%57. Bogush LK, Travin AA, Semenendo JL. Transpericardial Operationen und den Hauptbronchian u nd Langengefussen. Stuttgart: Hoppokrates-Verlag, 1971. Anderson RP, Li W. Transpericardial closure of main bronchus fistula after pneumonectomy. Am J Surg 1983;145:63G 2. Baldwin JC, Marks JBD. Treatment of bronchopleural fistula after pneumonectomy. J Thorac Cardiovasc Surg 1985;90: 81%7.
DISCUSSION DR PETER L. PAIROLERO (Rochester, MN): I thank Dr Ginsberg and his colleagues for calling to our attention yet another method to manage chronic bronchopleural fistula, which can occur after pneumonectomy. Although a rare complication, bronchopleural fistula in this situation can at times be life-threatening. It is important to note, however, that this is not a single complication but actually two, namely, bronchopleural fistula and postpneumonectomy empyema. Consequently, for these two complications to be successfully treated, not only must the fistula be closed but the pneumonectomy pleural space must also be ultimately obliterated and the chest wall eventually closed. Thus, closure of the fistula by any means is only partial treatment of this problem, and our colleagues from Toronto are among the first to point this out. Because the thrust of their presentation is an alternative method of closure of the fistula, I will make no further comments regarding management of the associated empyema other than to mention that open-window thoracostomy with frequent mechanical debridement by wet-to-dry dressing changes followed by secondary chest wall closure as described by Clagett some 25 years ago remains highly effective. Transsternal closure of a bronchopleural fistula is not applicable to all patients. As Ginsberg and his colleagues clearly pointed out, bronchopleural fistula occurring in the immediate postoperative period is best treated not by the transsternal route, but by immediate reoperation through the original lateral thoracotomy with subsequent reclosure of the bronchial stump followed by reinforcement with well-vascularized tissue. In our practice, this has been intrathoracic transposition of extrathoracic skeletal muscles, such as the serratus anterior muscle. What about patients in whom a fistula occurs weeks to years after pneumonectomy? Certainly, they are more difficult to manage. All too frequently, treatment in these patients is limited to management of the associated postpneumonectomy empyema, initially by pleural drainage, usually eventually open pleural drainage, and later by thoracoplasty, muscle transposition, or other pleural space-reducing maneuvers. This was the setting in 10 of the patients of Dr Ginsberg and associates. Certainly, direct dissection of the hilar structures through a lateral approach in a patient who has had multiple pleural space operations is at best tedious and at worst life-threatening because of massive hemorrhage, and I agree that persistent fistula in this clinical situation can be better inanaged with a transsternal approach. Are there contraindications to transsternal closure? I have
several questions for Dr Ginsberg. What atout the patient who has had a prior cardiac operation? Can the transsternal route still provide adequate exposure safely? Also, how long does the stump have to be for this approach to be effective? What about the patient who has no stump whatsoever but rather has an open lateral carinal wall? Can the transsternal a p >roach still be used? Finally, what did happen to the empyema cavity in your patients? Did any patient eventually have the chest wall closed? Again I congratulate the Toronto group for their alternative method of management of a very difficult problem. DR P. KNAEPEN (Nieuwegein, the Netherlands): Dr Ginsberg and colleagues are to be congratulated for the. outstanding results obtained in the treatment of this life-threi tening complication after pneumonectomy. At the St. Antonius Hospital, Nieuwegein, we have been performing this type of operation for almosl 20 years, and it has become our procedure of choice in patients with large bronchopleural fistula. I suppose Dr Ginsberg would agree that we should restrict this major operation to this particular group of patients. Our overall results are less satisfactory than those of his group. Univariate analysis showed that :he most important predictor of hospital mortality was recurrence of the bronchopleural fistula. In 25 patients without recurrence of fistula, hospital mortality was 12%. However, once a bronchopleural fistula recurred, and this was the case in 7 patients, mortality was extremely high57%. The best way to prevent recurrences and the associated mortality is aggressive treatment of the empilema. In our initial experience with 17 patients, repeat thoracentesis or tube drainage was used, and the recurrence rate was very high-35%. Since 1982, when open-window thoracostomy ha:; been routinely performed before the closure procedure (15 patients), the recurrence rate has dropped dramatically to 7%, and :io has hospital mortality. On the basis of this experience, we believe that transpericardial closure of bronchopleural fistula per se is riot the final answer, but that open-window thoracostomy should be an integral part of the total treatment. How many times, Dr Ginsberg, have you used tube drainage alone, and was there any relation to the recurrences? Finally, although we fully support your recommendations to
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avoid failures, we do not agree with your method of leaving the thoracostomy window open. It is a terrible burden for the patient, both physically and psychologically. Dr Ginsberg, could you explain to us why you do not close the window after successful closure of the bronchopleural fistula?
DR JAMES P. GEIGER (San Francisco, CA): 1 compliment the authors on their success with this procedure, but I wonder about the management of their failures. 1 also express some dismay at the length of the bronchial stump. The opportunity to learn thoracoplasty and myoplasty techniques is rarely available to trainees today. This explains why some patients are advised that there is no suitable treatment. During 20 years of duty at Army referral centers, and subsequently in private practice, I have seen a variety of problems and associated fistulas. These include active tuberculosis, war wounds, postirradiation pneumonectomy, necrotizing pneumonia, and draining empyema after pneumonectomy and prior thoracoplasty for tuberculosis. I have utilized a technique described by Dr John Grow of Denver (Diseases of Chest, Vol 12, 1946). This technique has been looc%successful in my large number of inherited cases. The principles include drainage and local control of sepsis, special attention to nutrition, and restoration of positive nitrogen balance. Preserve all the muscle, excise all the rigid parietal scar, and suture a viable muscle pedicle flap over the fistula, followed by layer closure. Psychological support has been important in most patients. DR GINSBERG: 1 thank all the discussants for their comments. In answer to Dr Pairolero’s questions, we have not had any patients who have undergone previous cardiac operations. This could create a very difficult situation, especially if the intrapericardial area is scarred. I wonder whether the anterolateral pa-
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rasternal thoracotomy might be valuable in this instance, but it is one situation that we’ve not encountered. Dr Pairolero and all the other speakers did emphasize the necessity of adequate drainage of the empyema cavity as a very important and integral part of this management. Dr Pairolero also asked about the minimum length of stump that we could close and what would happen if there was a lateral tracheal defect left after multiple previous operations. 1 think the transsternal approach would be the best approach for that very difficult problem. You can do a lateral patch. Omentum or some other patch reinforced by omentum would be very valuable when total closure of the stump cannot be done or there is a lateral opening in the trachea. I think this would be an indication for the transsternal approach. What happened to the cavities that we did not treat primarily? Three patients died of carcinoma within 2 years and had no cavity treatment, and 3 patients were treated by either thoracoplasty alone, myoplasty plus thoracoplasty, or myoplasty alone. The other patients accepted the thoracostomy window and did not want another operation, and they are alive and well with the thoracostomy window. Dr Knaepen mentioned that this was the procedure of choice for a long stump. I think this is the procedure of choice when the other attempts at closure have failed. Certainly if there is a long stump, one can dissect the bronchial stump and remove it, but this can be difficult. The high mortality he reported was, I‘m sure, related to the fact that the empyema cavities were not adequately drained before elective closure of the bronchopleural fistula. We all agree that there has to be adequate drainage of the space. In only 3 of our patients was tube thoracostomy drainage used, and that was when the patient had had previous thoracoplasty with a very tiny space. Only a tube could be inserted; a window could not be created. I thank Dr Geiger for reminding us of the value of myovascular bundles in the management of this disorder.
Thirteen patients with postpneumonectomy bronchopleural fistula occurring 4 months to 10 years after the initial operation have been treated with a transsternal transpericardial approach after the associated empyema had been treated by either tube thoracostomy or openwindow thoracostomy. In 10 patients, there were contraindications to using an ipsilateral transthoracic approach. In 10 of the 13 patients, the procedure was
successful. Three fistulas recurred; two were quite small, one of them closing spontaneously within 6 months. There were no deaths or clinically significant morbidity related to the transsternal approach. We have found this technique to be most applicable in those patients in whom other procedures have failed to resolve the problem. The technique is relatively simple and safe. (Ann Thorac Surg 1989;47:231-5)
ith modern surgical techniques, a bronchopleural fistula after pneumonectomy should be rare, but these fistulas still complicate up to 5% of such procedures [l]. Fistulas occurring in the early postpneumonectomy period are best treated by immediate reoperation and reclosure, augmented by a protective patch of well-vascularized tissue. Fistulas occurring later (weeks to years postoperatively) are usually managed initially by tube drainage as most patients are seen with a fistula plus an empyema. Ultimately, both the fistula and the empyema must be dealt with. Many methods have been used to close the chronic postpneumonectomy bronchial fistula. Open-window thoracostomy as described by Clagett and Geraci [2] deals with the associated empyema and can ultimately result in spontaneous closure of some of the smaller fistulas [3]. Nonsurgical maneuvers including repeated bronchoscopic cauterization of the fistula [4] or the application of fibrin glue [5] have been described as being somewhat successful. Direct surgical methods of managing this problem include repeat thoracotomy with reclosure of the bronchus using a vascularized patch (pericardium, muscle, or omentum) for reinforcement [6], large myovascular bundles to simultaneously close the fistula and cavity [7], or nearly total thoracoplasty. A contralateral right thoracotomy approach to the left main bronchus has also been successful in cases of chronic fistulas after left pneumonectomy [ 8 ] . In 1960, Padhi and Lynn [9] in Canada were among the first to document a transpericardial approach to close chronic postpneumonectomy fistula utilizing anterior tho-
racotomy with division of multiple costal cartilages. One year later, Abruzzini [lo] in Italy described the transsternal transpericardial approach. This has been employed extensively in Russia by Perelman and Ambatiello [ll] and Bogush and colleagues [12]. The technique was reintroduced in centers in North America in the 1980s [13, 141. In the past 10 years, we have had 13 patients in whom the transsternal transpericardial approach was used for closure of chronic bronchopleural fistulas following pneumonectomy.
Presented at the Twenty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Sep 2 6 2 8 , 1988. Address reprint requests to Dr Ginsberg, Mount Sinai Hospital, 600 University Ave, Suite 451, Toronto, Ont, Canada M5G 1x5.
0 1989 by The Society of Thoracic Surgeons
Material and Methods In all patients, preoperative drainage of the postpneumonectomy space had been effected by tube thoracostomy or open-window thoracostomy, or both. To facilitate intraoperative ventilation in the presence of a bronchopleural cutaneous fistula, a variety of anesthesia techniques were used, including double-lumen tubes, long single tubes inserted into the remaining bronchus, an endobronchial blocker in the stump of the pneumonectomy, packing the open stump through the thoracostomy window, and high-frequency jet ventilation. We use a full median sternotomy (Fig 1). After the mobilization and retraction of the superior vena cava and the aorta (Fig 2), the lower trachea above the pericardial reflection is mobilized; care is taken to avoid injury to the left recurrent nerve. The anterior pericardium is opened, and the pulmonary artery is either mobilized and retracted inferiorly or reamputated to effect better exposure. The posterior pericardium is then opened behind the pulmonary artery, thereby totally exposing the carina (Fig 3). A substantial shift of the mediastinum as a result of the pneumonectomy can make this exposure somewhat difficult, especially on the left. 0003-4975/89/$3.50
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Fig 3 . A wide incision of the posterior pericardium totally exposes both bronchi and the lower trachea. Fig 1. A full sternotomy incision has been made. The anterior pericardiuin has been opened, exposing the great vessels. (PA = pulinonary artery; SVC = superior vena cava.)
The affected bronchial stump is then dissected at the carina, isolated, and divided. This reamputated stump is closed using interrupted sutures or staples. The suture line is reinforced with vascularized pericardium. The distal stump is totally excised if possible (Fig 4). Alternatively, after the distal stump mucosa has been destroyed by cauterization (either at bronchoscopy before the procedure or at the surgical operation), the proximal end of this remaining stump is closed and left in situ.
Fig 2 . Retraction of the superior uena caua and aorta to each side exposes the right pulnlonary artery (RPA) and the posterior pericardiutn ouerl.ying the cizrina.
Results We reviewed the records of 13 patients (8 men, 5 women) who had chronic postpneumonectorny fistulas closed utilizing this technique during the years 1978 to 1987. Age ranged from 38 to 73 Years. In 9 Patient$;,PneumonectomY
Fig 4. A chronic right fistula treated by division and reclosure of the proximal and distal sturnps. Preferably, the distal stump should be excised, but this is not alulays possible.
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was performed for carcinoma. The other 4 patients had irreversible inflammatory disease, including tuberculosis, bronchiectasis, bronchocentric granulomatosis, and necrotizing pneumonia. There were five left and eight right fistulas. The patients were seen 4 months to 10 years after development of the fistula. In 10 patients, there were associated problems that did not allow a simple ipsilateral thoracotomy approach. The problems included previous attempted single or multiple closures by ipsilateral thoracotomy (3 patients), previous thoracoplasties with or without associated myovascular flaps that had failed (3 patients), persisting infection in a thick-walled postpneumonectomy space (3 patients), and associated tracheal stricture (1 patient). In 3 other patients, the transsternal approach was elected as the first closure attempt. There was no postoperative mortality or clinically significant morbidity. In two instances, reamputation of the ipsilateral pulmonary artery stump allowed further exposure of the residual bronchial stump. In all patients except 1, the bronchial stump was redivided close to the carina and then sutured or stapled. In the 1 exception, the mobilized stump was stapled in continuity without transsection. In 9 patients, the reclosed bronchus was covered by a vascularized patch (pericardium or thymus, or both). In 1 patient with an associated low tracheal cuff stricture after intubation, a concomitant tracheal resection was performed, and pedicled omentum was used to cover the anastomosis. A variety of techniques were used to handle the 12 residual distal stumps, including total excision (2 patients), cautery of the mucosa and proximal closure (6 patients), and cautery of the mucosa without proximal closure (4 patients). In all patients, the empyema space was not closed initially but was handled by continued drainage through the thoracostomy window or tube. In 10 patients, the bronchial closure healed primarily and has remained intact 18 months to 7.5 years later. Three patients have died in late follow-up. There were three instances of failure of this technique. In the single patient in whom stapling was done without division of the bronchus, the fistula totally reopened within 1 week after closure as a result of failure of the staple line. The two other failures resulted in tiny recurrent fistulas, both in patients in whom multiple previous operations led to the closure of a difficult stump without closure of the distal remnant. One of these fistulas subsequently closed spontaneously within 6 months.
Comment The technique of transsternal closure of bronchopleural fistulas has been well described by Abruzzini [lo] and Perelman and Ambatiello [ll].In most cases, the associated empyema cavity will have been drained by tube or open-window thoracostomy before closure of the fistula. The selection of anesthesia technique depends on the situation at hand. We found a variety of techniques useful, including double-lumen tubes, a bronchial blocker to occlude the stump, a long endotracheal tube to ventilate the contralateral (usually left) mainstem bronchus,
233
and high-frequency jet ventilation. In one instance, the fistula was occluded by packing through the thoracostomy window. Although the right mainstem bronchus can be exposed extrapericardially with a transsternal approach, we have found that the best exposure is obtained by opening the anterior pericardium, retracting or reamputating the ipsilateral main pulmonary artery, and then opening up the posterior pericardium to expose the total carinal area. Once the affected bronchial stump has been isolated near the carina, division and reclosure by suture or staple is imperative. We and others [14] have experienced failures caused by stapling in continuity without division. This should be avoided. Once the proximal stump has been closed, we believe it important to attempt to reinforce the closure with adjacent vascularized pericardium, mobilized thymus, or omentum, which is easily obtained on a vascular pedicle from the upper abdomen through an extension of the median sternotomy. The omentum can be extremely valuable, especially in very difficult dissections or whenever the blood supply to the closure appears tenuous (eg, after irradiation). If possible, the distal remnant stump should be totally excised to avoid mucus secretion in the empyema cavity. If this is not technically feasible, the mucosa should be obliterated either at the time of operation by cauterization or just before operation by electrocoagulation or laser cauterization through a bronchoscope. The proximal end of this stump should be closed whenever possible. Ultimately, the residual empyema cavity can be sterilized by the method of Clagett and Geraci [2] or closed by large myovascular flaps or thoracoplasty. Although there are many approaches to facilitate closure of a chronic postpneumonectomy bronchopleural fistula, we have found the transsternal transpericardial approach relatively simple and effective. The single disadvantage of this method is that the residual empyema space is not dealt with at the same time, unlike myovascular transpositions or thoracoplasty. This technique is most useful when there are contraindications to performing an ipsilateral transthoracic approach. In some instances, with extreme shifts of the mediastinum, especially to the left after a left pneumonectomy, the anterior thoracotomy approach described by Padhi and Lynn [9], in which multiple costal cartilages are divided or excised, has theoretical advantages, allowing a more direct approach to the pericardium and left mainstem bronchus. The technique of transsternal transpericardial resection of chronic postpneumonectomy bronchopleural fistulas should be placed in the armamentarium of all thoracic surgeons, and is most advantageous when a direct approach through the ipsilateral thoracotomy space is contraindicated or when previous attempts at closure have failed.
References 1. Hakim M, Milstein BB. Role of automatic staplers in the etiology of bronchopleural fistula. Thorax 1985;40:27-31. 2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963;45:141-5.
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3. Shamji FM, Ginsberg RJ, Cooper JD, et al. Open window thoracostomy in the management of post-pneumonectomy empyema with or without bronchopleural fistula. J Thorac Cardiovasc Surg 1983;86:818-22. 4. Hier-Madsen K, Schulz ES, Miller-Pedersen V, Halkier E. Management of bronchopleural fistula following pneumonectomy. Scand J Thorac Cardiovasc Surg 1984;18:2634. 5. Torre M, Chiesa G, Ravini M, Vercelloni M, Belloni PA. Endoscopic gluing of bronchopleural fistula. Ann Thorac Surg 1987;43:295-7. 6. Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491-9. 7 . Pairolero PC, Arnold PG, Pihler JM. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg 1983;86:809-17. 8. Perelman MI, Rymko LP, Ambatiello GP. Bronchopleural fistula: surgery after pneumonectomy. In: Grillo H, Escha-
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9. 10. 11. 12. 13. 14.
passe H, eds. International trends in thoracic surgery, Vol 2. Philadelphia: WB Saunders, 1987:407-l:!. Padhi RK, Lynn RB. The managenierk of bronchopleural fistulae. J Thorac Cardiovasc Surg 1960;39:385-93. Abruzzini P. Tratamento chirugico delle fistulae del broncho principale consecutive pneumonectomia tubercolosi. Chir Torac 1961;14:165-71. Perelman MI, Ambatiello GP. Transpleuraler, transsternaler und kontralateralar sugang bei Operationen wegen, Bronchialfistel nach Pneumonektomie. Chir Vaskul 1970;18:4!%57. Bogush LK, Travin AA, Semenendo JL. Transpericardial Operationen und den Hauptbronchian u nd Langengefussen. Stuttgart: Hoppokrates-Verlag, 1971. Anderson RP, Li W. Transpericardial closure of main bronchus fistula after pneumonectomy. Am J Surg 1983;145:63G 2. Baldwin JC, Marks JBD. Treatment of bronchopleural fistula after pneumonectomy. J Thorac Cardiovasc Surg 1985;90: 81%7.
DISCUSSION DR PETER L. PAIROLERO (Rochester, MN): I thank Dr Ginsberg and his colleagues for calling to our attention yet another method to manage chronic bronchopleural fistula, which can occur after pneumonectomy. Although a rare complication, bronchopleural fistula in this situation can at times be life-threatening. It is important to note, however, that this is not a single complication but actually two, namely, bronchopleural fistula and postpneumonectomy empyema. Consequently, for these two complications to be successfully treated, not only must the fistula be closed but the pneumonectomy pleural space must also be ultimately obliterated and the chest wall eventually closed. Thus, closure of the fistula by any means is only partial treatment of this problem, and our colleagues from Toronto are among the first to point this out. Because the thrust of their presentation is an alternative method of closure of the fistula, I will make no further comments regarding management of the associated empyema other than to mention that open-window thoracostomy with frequent mechanical debridement by wet-to-dry dressing changes followed by secondary chest wall closure as described by Clagett some 25 years ago remains highly effective. Transsternal closure of a bronchopleural fistula is not applicable to all patients. As Ginsberg and his colleagues clearly pointed out, bronchopleural fistula occurring in the immediate postoperative period is best treated not by the transsternal route, but by immediate reoperation through the original lateral thoracotomy with subsequent reclosure of the bronchial stump followed by reinforcement with well-vascularized tissue. In our practice, this has been intrathoracic transposition of extrathoracic skeletal muscles, such as the serratus anterior muscle. What about patients in whom a fistula occurs weeks to years after pneumonectomy? Certainly, they are more difficult to manage. All too frequently, treatment in these patients is limited to management of the associated postpneumonectomy empyema, initially by pleural drainage, usually eventually open pleural drainage, and later by thoracoplasty, muscle transposition, or other pleural space-reducing maneuvers. This was the setting in 10 of the patients of Dr Ginsberg and associates. Certainly, direct dissection of the hilar structures through a lateral approach in a patient who has had multiple pleural space operations is at best tedious and at worst life-threatening because of massive hemorrhage, and I agree that persistent fistula in this clinical situation can be better inanaged with a transsternal approach. Are there contraindications to transsternal closure? I have
several questions for Dr Ginsberg. What atout the patient who has had a prior cardiac operation? Can the transsternal route still provide adequate exposure safely? Also, how long does the stump have to be for this approach to be effective? What about the patient who has no stump whatsoever but rather has an open lateral carinal wall? Can the transsternal a p >roach still be used? Finally, what did happen to the empyema cavity in your patients? Did any patient eventually have the chest wall closed? Again I congratulate the Toronto group for their alternative method of management of a very difficult problem. DR P. KNAEPEN (Nieuwegein, the Netherlands): Dr Ginsberg and colleagues are to be congratulated for the. outstanding results obtained in the treatment of this life-threi tening complication after pneumonectomy. At the St. Antonius Hospital, Nieuwegein, we have been performing this type of operation for almosl 20 years, and it has become our procedure of choice in patients with large bronchopleural fistula. I suppose Dr Ginsberg would agree that we should restrict this major operation to this particular group of patients. Our overall results are less satisfactory than those of his group. Univariate analysis showed that :he most important predictor of hospital mortality was recurrence of the bronchopleural fistula. In 25 patients without recurrence of fistula, hospital mortality was 12%. However, once a bronchopleural fistula recurred, and this was the case in 7 patients, mortality was extremely high57%. The best way to prevent recurrences and the associated mortality is aggressive treatment of the empilema. In our initial experience with 17 patients, repeat thoracentesis or tube drainage was used, and the recurrence rate was very high-35%. Since 1982, when open-window thoracostomy ha:; been routinely performed before the closure procedure (15 patients), the recurrence rate has dropped dramatically to 7%, and :io has hospital mortality. On the basis of this experience, we believe that transpericardial closure of bronchopleural fistula per se is riot the final answer, but that open-window thoracostomy should be an integral part of the total treatment. How many times, Dr Ginsberg, have you used tube drainage alone, and was there any relation to the recurrences? Finally, although we fully support your recommendations to
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avoid failures, we do not agree with your method of leaving the thoracostomy window open. It is a terrible burden for the patient, both physically and psychologically. Dr Ginsberg, could you explain to us why you do not close the window after successful closure of the bronchopleural fistula?
DR JAMES P. GEIGER (San Francisco, CA): 1 compliment the authors on their success with this procedure, but I wonder about the management of their failures. 1 also express some dismay at the length of the bronchial stump. The opportunity to learn thoracoplasty and myoplasty techniques is rarely available to trainees today. This explains why some patients are advised that there is no suitable treatment. During 20 years of duty at Army referral centers, and subsequently in private practice, I have seen a variety of problems and associated fistulas. These include active tuberculosis, war wounds, postirradiation pneumonectomy, necrotizing pneumonia, and draining empyema after pneumonectomy and prior thoracoplasty for tuberculosis. I have utilized a technique described by Dr John Grow of Denver (Diseases of Chest, Vol 12, 1946). This technique has been looc%successful in my large number of inherited cases. The principles include drainage and local control of sepsis, special attention to nutrition, and restoration of positive nitrogen balance. Preserve all the muscle, excise all the rigid parietal scar, and suture a viable muscle pedicle flap over the fistula, followed by layer closure. Psychological support has been important in most patients. DR GINSBERG: 1 thank all the discussants for their comments. In answer to Dr Pairolero’s questions, we have not had any patients who have undergone previous cardiac operations. This could create a very difficult situation, especially if the intrapericardial area is scarred. I wonder whether the anterolateral pa-
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rasternal thoracotomy might be valuable in this instance, but it is one situation that we’ve not encountered. Dr Pairolero and all the other speakers did emphasize the necessity of adequate drainage of the empyema cavity as a very important and integral part of this management. Dr Pairolero also asked about the minimum length of stump that we could close and what would happen if there was a lateral tracheal defect left after multiple previous operations. 1 think the transsternal approach would be the best approach for that very difficult problem. You can do a lateral patch. Omentum or some other patch reinforced by omentum would be very valuable when total closure of the stump cannot be done or there is a lateral opening in the trachea. I think this would be an indication for the transsternal approach. What happened to the cavities that we did not treat primarily? Three patients died of carcinoma within 2 years and had no cavity treatment, and 3 patients were treated by either thoracoplasty alone, myoplasty plus thoracoplasty, or myoplasty alone. The other patients accepted the thoracostomy window and did not want another operation, and they are alive and well with the thoracostomy window. Dr Knaepen mentioned that this was the procedure of choice for a long stump. I think this is the procedure of choice when the other attempts at closure have failed. Certainly if there is a long stump, one can dissect the bronchial stump and remove it, but this can be difficult. The high mortality he reported was, I‘m sure, related to the fact that the empyema cavities were not adequately drained before elective closure of the bronchopleural fistula. We all agree that there has to be adequate drainage of the space. In only 3 of our patients was tube thoracostomy drainage used, and that was when the patient had had previous thoracoplasty with a very tiny space. Only a tube could be inserted; a window could not be created. I thank Dr Geiger for reminding us of the value of myovascular bundles in the management of this disorder.