- Email: [email protected]
Diaphragm flap for routine prophylactic reinforcement of bronchial stump after pneumonectomy
CORRESPONDENCE
Improved Long-Term Survival Seen After Lung Volume Reduction Surgery Compared to Continued Medical Therapy for Emphysema To the Editor: We read with interest the prospective, randomized trial by Geddes and associates [1]. We agree with the conclusions: lung volume reduction surgery (LVRS) can improve first second expired volume (FEV1), walking distance, and quality of life in selected emphysema patients who have exhausted nonsurgical alternatives. While the measured benefit from LVRS was less than that reported from many centers, outcomes were likely influenced by the authors’ inclusion of patients with diffuse emphysema and poor exercise capabilities. Geddes and associates reported objective and subjective improvement for LVRS recipients and relentless functional decline for patients managed medically. Conclusions regarding the effect of LVRS on long-term mortality were not possible due to short follow-up and a cross-over design. Two years ago, we reported in The Annals of Thoracic Surgery our treatment outcome for two groups of emphysema patients [2]. The groups were initially equivalent: Medicare patients selected to receive LVRS. Surgery was performed in 66 patients, but 21 patients were unable to proceed to surgery when the Health Care Financing Administration (HCFA) suspended payment for LVRS. Our report showed the two groups of patients to be functionally comparable at outset. We compared 2-year outcomes and concluded that the improved clinical outcome in the surgical group was attributable to the effects of lung volume reduction surgery. Our results mirrored those of the Geddes article: medically treated patients declined despite optimal medical therapy and LVRS patients improved but experienced a late decline toward preoperative baseline. In our report, actuarial survival of the medical group did not differ from that of the surgical group. Subsequent follow-up, complete as of July 2000, is relevant to the Geddes paper. At 4 years after initial evaluation, the actuarial survival (Fig 1) of our LVRS patients was 72% and the actuarial survival of the medically treated “control group” was 41% ( p ⫽ 0.02 by Log rank). Median survival of the surgically treated patients has not been reached, with median follow-up of 4.9 years, while median survival of the medical patients was 3.4 years. The Geddes prospective, randomized trial adds additional scientific validity to previous reports of enhanced function and quality of life after LVRS. Our update of the follow-up of two
Fig 1. Survival of Medicare patients selected for lung volume reduction surgery at Washington University School of Medicine between 1993 and 1996. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
matched groups of patients indicates that functional improvement produced by LVRS is associated with a significant reduction in long-term mortality as well. Bryan F. Meyers, MD Roger D. Yusen, MD Stephen S. Lefrak, MD Joel D. Cooper, MD 3108 Queeny Tower Washington University School of Medicine One Barnes-Jewish Hospital Plaza St. Louis, MO 63110 e-mail: [email protected].
References 1. Geddes D, Davies M, Koyama H, et al. Effect of lung-volumereduction surgery in patients with severe emphysema. N Engl J Med 2000;343:239– 45. 2. Meyers BF, Yusen RD, Lefrak SS, et al. Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg 1998;66:331– 6.
Diaphragm Flap for Routine Prophylactic Reinforcement of Bronchial Stump After Pneumonectomy To the Editor: Our recent literature review disclosed an article by Mineo and Ambrogi [1] on therapeutic use of a diaphragm flap for treatment of postpneumonectomy bronchopleural fistula. We had independently utilized a similar technique for prevention of postpneumonectomy bronchopleural fistula. We believe that prophylactic application of this technique deserves consideration as one alternative for reinforcing the bronchial stump after pneumonectomy. Many surgeons believe that prophylactic reinforcement of the bronchial stump following pneumonectomy confers added security against bronchial stump leak and associated complications. Pleura, intercostal muscle, pericardium, azygous vein, and pericardial fat pads are employed for stump reinforcement. In fact, a more robust flap—thicker, larger, better vascularized, more versatile—is easily available in the operative field: the diaphragm itself. Surgeons do not consider the diaphragm disposable, having been trained to preserve the phrenic nerve and diaphragm because of their importance to respiration. However, the ipsilateral diaphragm is generally inconsequential following pneumonectomy. Some surgeons deliberately crush the phrenic nerve, allowing the diaphragm to rise up to minimize the postpneumonectomy space. In our technique, a rectangular, medially based flap of diaphragm is taken by two parallel, radially directed incisions extending outward from the central mediastinum (Fig 1). The parallel incisions are carried out to the costal margin. A large, bulky, well-vascularized flap results which can reach throughout the thorax. The flap is hinged at its medial base and advanced to the previously closed bronchial stump. The thoracic surface of the diaphragm pedicle faces inward toward the mediastinum. The pedicle is attached to the mediastinal tissues around the bronchial stump by interrupted sutures, creating a roof over the stump. The resulting defect in the diaphragm is closed with a running suture begun at each end of the harvest site and carried toward the middle. This suture accomplishes hemostasis of the vascular diaphragm as well as closing the defect. The entire Ann Thorac Surg 2001;71:2081– 8 • 0003-4975/01/$20.00 PII S0003-4975(00)02552-2
2082
CORRESPONDENCE
Ann Thorac Surg 2001;71:2081– 8
to close established bronchopleural fistulas presenting late after operation, as empyema or space infection, as in the article by Mineo and Ambrogi [1]. Yet, despite the severity of bronchopleural fistula, surgeons do not commonly employ the diaphragm prophylactically to reinforce the bronchial stump after pneumonectomy. We recommend this technique specifically for routine prophylactic application for the prevention of the serious complication of postpneumonectomy bronchial stump breakdown and its accompanying sequellae. It is possible that routine application of this technique may decrease the incidence of this dreaded problem. Umer Sayeed-Shah, MD Jaime Strachan, MD John A. Elefteriades, MD Section of Cardiothoracic Surgery Yale University School of Medicine 121 FMB, 333 Cedar St New Haven, CT 06510 e-mail: [email protected].
References 1. Mineo TC, Ambrogi V. Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps. Ann Thorac Surg 1995;60:714–5. 2. Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109: 989–96. 3. Petrovsky BV. The use of diaphragm grafts for plastic operations in thoracic surgery. J Thorac Cardiovasc Surg 1961;41: 348–55.
Reply To the Editor:
Fig 1. Technique of prophylactic diaphragm flap reinforcement for prevention of bronchopleural fistula following pneumonectomy. (A) Mobilization of medially based transmural diaphragm flap. (B) Closure of diaphragm. (C) Close-up of flap over bronchus. process is simple, efficient, and definitive. We have used this technique routinely after pneumonectomy, following an initial application in a patient previously heavily radiated for unrelated lymphoma. In each case, this technique has proven feasible, easy to implement, and effective in preventing bronchial stump leak. Postpneumonectomy bronchopleural fistula occurs in 2.1% to 10% of cases. Patients who have had radiation therapy for downstaging of stage III tumors are especially vulnerable. Bronchopleural fistula is disabling at best and lethal at worst. As the mortality of bronchopleural fistula is significant (16% to 71%), prevention is the best therapy [2]. Petrovsky [3] used the diaphragm as a flap during the 1950s, especially for esophageal defects. The diaphragm has been used
We appreciate the interest expressed by Drs Sayeed-Shah, Strachan, and Elefteriades, in our article on the early treatment of bronchopleural fistula using a pedicled diaphragmatic flap [1]. As we described, use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is safe and practical [2]. Since 1987, we have performed a total of 27 procedures in which the diaphragm was employed for protective or reconstructive purposes for early bronchopleural fistula (n ⫽ 6); prophylaxis of pneumonectomy stumps (n ⫽ 10) and bronchial anastomoses (n ⫽ 2); pericardial defect (n ⫽ 4); and early spontaneous (n ⫽ 2) and iatrogenic (n ⫽ 3) esophageal lesions. No perioperative mortality was recorded. Complications were mainly related to the poor preoperative condition of the patients. For those patients who survived more than 1 year (n ⫽ 13), no diaphragmatic hernias occurred. Bronchopleural fistulas, esophageal fistulas, and pericardial defects healed in all instances. The diaphragmatic flap was also effective in preventing bronchopleural fistula; only one patient developed a late fistula due to cancer relapse at the bronchial stump. Contrary to Drs Sayeed-Shah, Strachan, and Elefteriades, we do not perform a stump protection flap on a routine basis, but use it in patients who have neoadjuvant therapy, vascular disease, or diabetes. We do not contest their strategy; the diaphragmatic flap is ready available after a pneumonectomy and it is the ideal material for preventing bronchopleural fistula, which is a dreadful, life-threatening complication. To conclude, we are pleased about the renewed interest elicited by our article. Indeed, this flap is an ace up the sleeve,
Improved Long-Term Survival Seen After Lung Volume Reduction Surgery Compared to Continued Medical Therapy for Emphysema To the Editor: We read with interest the prospective, randomized trial by Geddes and associates [1]. We agree with the conclusions: lung volume reduction surgery (LVRS) can improve first second expired volume (FEV1), walking distance, and quality of life in selected emphysema patients who have exhausted nonsurgical alternatives. While the measured benefit from LVRS was less than that reported from many centers, outcomes were likely influenced by the authors’ inclusion of patients with diffuse emphysema and poor exercise capabilities. Geddes and associates reported objective and subjective improvement for LVRS recipients and relentless functional decline for patients managed medically. Conclusions regarding the effect of LVRS on long-term mortality were not possible due to short follow-up and a cross-over design. Two years ago, we reported in The Annals of Thoracic Surgery our treatment outcome for two groups of emphysema patients [2]. The groups were initially equivalent: Medicare patients selected to receive LVRS. Surgery was performed in 66 patients, but 21 patients were unable to proceed to surgery when the Health Care Financing Administration (HCFA) suspended payment for LVRS. Our report showed the two groups of patients to be functionally comparable at outset. We compared 2-year outcomes and concluded that the improved clinical outcome in the surgical group was attributable to the effects of lung volume reduction surgery. Our results mirrored those of the Geddes article: medically treated patients declined despite optimal medical therapy and LVRS patients improved but experienced a late decline toward preoperative baseline. In our report, actuarial survival of the medical group did not differ from that of the surgical group. Subsequent follow-up, complete as of July 2000, is relevant to the Geddes paper. At 4 years after initial evaluation, the actuarial survival (Fig 1) of our LVRS patients was 72% and the actuarial survival of the medically treated “control group” was 41% ( p ⫽ 0.02 by Log rank). Median survival of the surgically treated patients has not been reached, with median follow-up of 4.9 years, while median survival of the medical patients was 3.4 years. The Geddes prospective, randomized trial adds additional scientific validity to previous reports of enhanced function and quality of life after LVRS. Our update of the follow-up of two
Fig 1. Survival of Medicare patients selected for lung volume reduction surgery at Washington University School of Medicine between 1993 and 1996. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
matched groups of patients indicates that functional improvement produced by LVRS is associated with a significant reduction in long-term mortality as well. Bryan F. Meyers, MD Roger D. Yusen, MD Stephen S. Lefrak, MD Joel D. Cooper, MD 3108 Queeny Tower Washington University School of Medicine One Barnes-Jewish Hospital Plaza St. Louis, MO 63110 e-mail: [email protected].
References 1. Geddes D, Davies M, Koyama H, et al. Effect of lung-volumereduction surgery in patients with severe emphysema. N Engl J Med 2000;343:239– 45. 2. Meyers BF, Yusen RD, Lefrak SS, et al. Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg 1998;66:331– 6.
Diaphragm Flap for Routine Prophylactic Reinforcement of Bronchial Stump After Pneumonectomy To the Editor: Our recent literature review disclosed an article by Mineo and Ambrogi [1] on therapeutic use of a diaphragm flap for treatment of postpneumonectomy bronchopleural fistula. We had independently utilized a similar technique for prevention of postpneumonectomy bronchopleural fistula. We believe that prophylactic application of this technique deserves consideration as one alternative for reinforcing the bronchial stump after pneumonectomy. Many surgeons believe that prophylactic reinforcement of the bronchial stump following pneumonectomy confers added security against bronchial stump leak and associated complications. Pleura, intercostal muscle, pericardium, azygous vein, and pericardial fat pads are employed for stump reinforcement. In fact, a more robust flap—thicker, larger, better vascularized, more versatile—is easily available in the operative field: the diaphragm itself. Surgeons do not consider the diaphragm disposable, having been trained to preserve the phrenic nerve and diaphragm because of their importance to respiration. However, the ipsilateral diaphragm is generally inconsequential following pneumonectomy. Some surgeons deliberately crush the phrenic nerve, allowing the diaphragm to rise up to minimize the postpneumonectomy space. In our technique, a rectangular, medially based flap of diaphragm is taken by two parallel, radially directed incisions extending outward from the central mediastinum (Fig 1). The parallel incisions are carried out to the costal margin. A large, bulky, well-vascularized flap results which can reach throughout the thorax. The flap is hinged at its medial base and advanced to the previously closed bronchial stump. The thoracic surface of the diaphragm pedicle faces inward toward the mediastinum. The pedicle is attached to the mediastinal tissues around the bronchial stump by interrupted sutures, creating a roof over the stump. The resulting defect in the diaphragm is closed with a running suture begun at each end of the harvest site and carried toward the middle. This suture accomplishes hemostasis of the vascular diaphragm as well as closing the defect. The entire Ann Thorac Surg 2001;71:2081– 8 • 0003-4975/01/$20.00 PII S0003-4975(00)02552-2
2082
CORRESPONDENCE
Ann Thorac Surg 2001;71:2081– 8
to close established bronchopleural fistulas presenting late after operation, as empyema or space infection, as in the article by Mineo and Ambrogi [1]. Yet, despite the severity of bronchopleural fistula, surgeons do not commonly employ the diaphragm prophylactically to reinforce the bronchial stump after pneumonectomy. We recommend this technique specifically for routine prophylactic application for the prevention of the serious complication of postpneumonectomy bronchial stump breakdown and its accompanying sequellae. It is possible that routine application of this technique may decrease the incidence of this dreaded problem. Umer Sayeed-Shah, MD Jaime Strachan, MD John A. Elefteriades, MD Section of Cardiothoracic Surgery Yale University School of Medicine 121 FMB, 333 Cedar St New Haven, CT 06510 e-mail: [email protected].
References 1. Mineo TC, Ambrogi V. Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps. Ann Thorac Surg 1995;60:714–5. 2. Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109: 989–96. 3. Petrovsky BV. The use of diaphragm grafts for plastic operations in thoracic surgery. J Thorac Cardiovasc Surg 1961;41: 348–55.
Reply To the Editor:
Fig 1. Technique of prophylactic diaphragm flap reinforcement for prevention of bronchopleural fistula following pneumonectomy. (A) Mobilization of medially based transmural diaphragm flap. (B) Closure of diaphragm. (C) Close-up of flap over bronchus. process is simple, efficient, and definitive. We have used this technique routinely after pneumonectomy, following an initial application in a patient previously heavily radiated for unrelated lymphoma. In each case, this technique has proven feasible, easy to implement, and effective in preventing bronchial stump leak. Postpneumonectomy bronchopleural fistula occurs in 2.1% to 10% of cases. Patients who have had radiation therapy for downstaging of stage III tumors are especially vulnerable. Bronchopleural fistula is disabling at best and lethal at worst. As the mortality of bronchopleural fistula is significant (16% to 71%), prevention is the best therapy [2]. Petrovsky [3] used the diaphragm as a flap during the 1950s, especially for esophageal defects. The diaphragm has been used
We appreciate the interest expressed by Drs Sayeed-Shah, Strachan, and Elefteriades, in our article on the early treatment of bronchopleural fistula using a pedicled diaphragmatic flap [1]. As we described, use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is safe and practical [2]. Since 1987, we have performed a total of 27 procedures in which the diaphragm was employed for protective or reconstructive purposes for early bronchopleural fistula (n ⫽ 6); prophylaxis of pneumonectomy stumps (n ⫽ 10) and bronchial anastomoses (n ⫽ 2); pericardial defect (n ⫽ 4); and early spontaneous (n ⫽ 2) and iatrogenic (n ⫽ 3) esophageal lesions. No perioperative mortality was recorded. Complications were mainly related to the poor preoperative condition of the patients. For those patients who survived more than 1 year (n ⫽ 13), no diaphragmatic hernias occurred. Bronchopleural fistulas, esophageal fistulas, and pericardial defects healed in all instances. The diaphragmatic flap was also effective in preventing bronchopleural fistula; only one patient developed a late fistula due to cancer relapse at the bronchial stump. Contrary to Drs Sayeed-Shah, Strachan, and Elefteriades, we do not perform a stump protection flap on a routine basis, but use it in patients who have neoadjuvant therapy, vascular disease, or diabetes. We do not contest their strategy; the diaphragmatic flap is ready available after a pneumonectomy and it is the ideal material for preventing bronchopleural fistula, which is a dreadful, life-threatening complication. To conclude, we are pleased about the renewed interest elicited by our article. Indeed, this flap is an ace up the sleeve,