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Eloesser procedure for postpneumonectomy bronchopleural fistula
The American Journal of Surgery 187 (2004) 100 –101
Clinical image
Eloesser procedure for postpneumonectomy bronchopleural fistula Jon D. Halling, M.D., Frank E. Johnson, M.D.* Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista Ave. at Grand Blvd., St. Louis, MO 63110, USA Manuscript received September 24, 2002; revised manuscript March 8, 2003
A 66-year-old man complained of recent frank hemoptysis. The remainder of his history and physical examination were unremarkable. Workup disclosed nonsmall cell bronchogenic carcinoma in the right middle lobe. He underwent right pneumonectomy with mediastinal lymph node dissection. Pathologic examination revealed a T2N0M0 (stage I) squamous cell carcinoma. All margins were uninvolved. His postoperative course was smooth, and he was discharged 8 days after surgery. The patient returned 7 weeks later with increased shortness of breath. He had noted a gurgling noise in the right side of the chest for the previous 1 to 2 weeks. He had a cough productive of brown and gray-tinged mucus but was afebrile with an unremarkable physical examination. The chest roentgenogram showed multiple air-fluid levels in his formerly opacified hemithorax. The diagnosis of bronchopleural fistula and empyema was established, and he was treated initially with antibiotics and chest tube drainage. Intraoperative thoracoscopy and bronchoscopy the next day revealed the disrupted bronchial closure. An Eloesser procedure was performed, the purulent material was evacuated from the right hemithorax, and it was packed with gauze. His recovery was uneventful. He currently feels well and has had no recurrence of cancer to date (6 years later). The bronchopleural fistula remains patent (Figs. 1, 2, and 3). In 1935, during the preantibiotic era, Leo Eloesser [1] described a procedure to treat tuberculous empyema, which was then common. A skin flap is created, sections of two ribs underlying the flap are resected, and the flap is then folded into the thorax to create a permanent opening into the chest. This operation is rarely done now in areas where advanced tuberculosis is uncommon but has found application in other patients, particularly those with postpneumonectomy bronchopleural fistula. Williams and Lewis [2] reviewed 3,150 cases of pulmonary resection to determine the incidence of bronchopleural fistula. This complication
* Corresponding author. Tel.: ⫹1-314-577-8316; fax: ⫹1-314-7711945. E-mail address: [email protected]
Fig. 1. The patient is shown 4 years postoperatively with his right arm abducted. The superiorly based flap is widely patent. The diaphragm is now epithelialized (arrow).
Fig. 2. A chest radiograph 4 years postoperatively demonstrates the contracted right hemithorax. The arrow indicates the site of rib resection and skin flap.
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.03.003
J.D. Halling and F.E. Johnson / The American Journal of Surgery 187 (2004) 100 –101
101
Fig. 3. A computed tomography scan of the thorax 4 years postoperatively at the level of the Eloesser flap shows the mediastinum is shifted to the right and there is compensatory hyperinflation of the left lung. Marked pleural thickening and calcification are evident (arrow).
developed in 1.5% of their cases after lobectomy and in 4.6% of their cases after pneumonectomy. Clinical signs include pyrexia, hemoptysis, cough, and expectoration of brown fluid. If the patient lies with the normal side dependent, convulsive coughing typically occurs owing to the flow of infected fluid from the involved hemithorax through the fistula into the contralateral lung. Prevention is important [2,3]. Preoperative radiation, devascularization of the bronchial stump, prolonged highpressure ventilation, immunosuppression, and infection (particularly tuberculosis) have all been implicated as causative factors. This complication occasionally arises when an endotracheal tube is forced through a freshly closed bronchus. Errors in the technique of closure are also mentioned prominently in most analyses. Reinforcing the bronchial stump with a vascularized tissue flap has been advocated as a preventive measure. Bronchopleural fistula is associated with a high mortality
rate. Once the patient has recovered from the acute illness and long-term pleural drainage has been provided, typically with an Eloesser procedure, various tissue flaps can successfully obliterate the intrathoracic cavity and close the fistula. These employ bulky local-regional pedicled muscle tissue, omentum or free flaps [4].
References [1] Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096 –7. [2] Williams NS, Lewis CT. Bronchopleural fistula: a review of 86 cases. Br J Surg 1976;63:520 –2. [3] Cerfolio RJ. The incidence, etiology and prevention of postresectional bronchopleural fistula. Semin Thorac Cardio Surg 2001;13:3–7. [4] Molnar JA, Pennington DG. Management of postpneumonectomy bronchopleural-cutaneous fistula with a single free flap. Ann Plast Surg 2002;48:88 –91.
Clinical image
Eloesser procedure for postpneumonectomy bronchopleural fistula Jon D. Halling, M.D., Frank E. Johnson, M.D.* Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista Ave. at Grand Blvd., St. Louis, MO 63110, USA Manuscript received September 24, 2002; revised manuscript March 8, 2003
A 66-year-old man complained of recent frank hemoptysis. The remainder of his history and physical examination were unremarkable. Workup disclosed nonsmall cell bronchogenic carcinoma in the right middle lobe. He underwent right pneumonectomy with mediastinal lymph node dissection. Pathologic examination revealed a T2N0M0 (stage I) squamous cell carcinoma. All margins were uninvolved. His postoperative course was smooth, and he was discharged 8 days after surgery. The patient returned 7 weeks later with increased shortness of breath. He had noted a gurgling noise in the right side of the chest for the previous 1 to 2 weeks. He had a cough productive of brown and gray-tinged mucus but was afebrile with an unremarkable physical examination. The chest roentgenogram showed multiple air-fluid levels in his formerly opacified hemithorax. The diagnosis of bronchopleural fistula and empyema was established, and he was treated initially with antibiotics and chest tube drainage. Intraoperative thoracoscopy and bronchoscopy the next day revealed the disrupted bronchial closure. An Eloesser procedure was performed, the purulent material was evacuated from the right hemithorax, and it was packed with gauze. His recovery was uneventful. He currently feels well and has had no recurrence of cancer to date (6 years later). The bronchopleural fistula remains patent (Figs. 1, 2, and 3). In 1935, during the preantibiotic era, Leo Eloesser [1] described a procedure to treat tuberculous empyema, which was then common. A skin flap is created, sections of two ribs underlying the flap are resected, and the flap is then folded into the thorax to create a permanent opening into the chest. This operation is rarely done now in areas where advanced tuberculosis is uncommon but has found application in other patients, particularly those with postpneumonectomy bronchopleural fistula. Williams and Lewis [2] reviewed 3,150 cases of pulmonary resection to determine the incidence of bronchopleural fistula. This complication
* Corresponding author. Tel.: ⫹1-314-577-8316; fax: ⫹1-314-7711945. E-mail address: [email protected]
Fig. 1. The patient is shown 4 years postoperatively with his right arm abducted. The superiorly based flap is widely patent. The diaphragm is now epithelialized (arrow).
Fig. 2. A chest radiograph 4 years postoperatively demonstrates the contracted right hemithorax. The arrow indicates the site of rib resection and skin flap.
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.03.003
J.D. Halling and F.E. Johnson / The American Journal of Surgery 187 (2004) 100 –101
101
Fig. 3. A computed tomography scan of the thorax 4 years postoperatively at the level of the Eloesser flap shows the mediastinum is shifted to the right and there is compensatory hyperinflation of the left lung. Marked pleural thickening and calcification are evident (arrow).
developed in 1.5% of their cases after lobectomy and in 4.6% of their cases after pneumonectomy. Clinical signs include pyrexia, hemoptysis, cough, and expectoration of brown fluid. If the patient lies with the normal side dependent, convulsive coughing typically occurs owing to the flow of infected fluid from the involved hemithorax through the fistula into the contralateral lung. Prevention is important [2,3]. Preoperative radiation, devascularization of the bronchial stump, prolonged highpressure ventilation, immunosuppression, and infection (particularly tuberculosis) have all been implicated as causative factors. This complication occasionally arises when an endotracheal tube is forced through a freshly closed bronchus. Errors in the technique of closure are also mentioned prominently in most analyses. Reinforcing the bronchial stump with a vascularized tissue flap has been advocated as a preventive measure. Bronchopleural fistula is associated with a high mortality
rate. Once the patient has recovered from the acute illness and long-term pleural drainage has been provided, typically with an Eloesser procedure, various tissue flaps can successfully obliterate the intrathoracic cavity and close the fistula. These employ bulky local-regional pedicled muscle tissue, omentum or free flaps [4].
References [1] Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096 –7. [2] Williams NS, Lewis CT. Bronchopleural fistula: a review of 86 cases. Br J Surg 1976;63:520 –2. [3] Cerfolio RJ. The incidence, etiology and prevention of postresectional bronchopleural fistula. Semin Thorac Cardio Surg 2001;13:3–7. [4] Molnar JA, Pennington DG. Management of postpneumonectomy bronchopleural-cutaneous fistula with a single free flap. Ann Plast Surg 2002;48:88 –91.