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Technique of bronchial closure after pneumonectomy
J
THORAC CARDIOVASC SURG 1989;98:220-3
Technique of bronchial closure after pneumonectomy Three hundred thirty-two patients had a pneumonectomy at Wythenshawe Hospital, Manchester, England, between 1974 and 1984. In all patients, the bronchus was closed with a posterior flap from the pliable membranees bronchus, leaving no stump, and with the suture line proximal to the carina. In a mean follow-up of 54 months, none of the patients had bronchopleural fistula, and 10 patients had empyema in the pneumonectomy space (3 %). A fistula could not be found in any of these patients. The suture material used in closing the bronchus in all these cases was 2-0 chromic catgut, which underlines the fact that bronchial healing is not affected by the type of suture material as long as no tension exists at the suture line.
Mazin A. I. Sarsam, MD,· and Henri Moussali, MD, FRCS, Manchester, England
Rom
1974 to 1984 a total of 332 patients had a pneumonectomy performed by one surgeon (H.M.) or his chief assistant. The technique of bronchial closure used in all these cases was the nontension posterior membranous flap, leaving no stump, as described by Jack' from Baguly Hospital, Manchester, England, in 1965. With a mean follow-up of 54 months, bronchopleural fistula, that is, a communication between the bronchial tree and the pneumonectomy space as a result of breakdown of the bronchial suture line, did not develop in any of the patients. Patients and methods Of the 332 patients, 252 were male and 80 were female. The youngest patient was a 17 year old with bronchiectasis. The youngest patient with lung cancer (squamous cell) was a 26-year-old man. The oldest patient in the series was a 79-year-old man with squamous cell carcinoma. The mean age for the whole series was 59.8 years. A right pneumonectomy was performed in 152 patients and a left pneumonectomy in 180 patients. The type of disease necessitating a pneumonectomy is shown in Table 1. Anesthetic considerations. With the exception of nine patients, all had a double-lumen tube. In our institution, either a right-sided or a left-sided Robertshaw double-lumen tube or a Carlens tube (left-sided only) is used. The advantages
Fromthe Division of Cardiovascular Surgery, Wythenshawe Hospital, Manchester, England. Received for publication June 7, 1988. Accepted for publication Nov. 14, 1988. Address reprint requests to either author at appropriate address. ·Present address: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
220
include an objective assessment of the patient's oxygenation and hemodynamic status on one lung anesthesia and isolation of the normal lung from blood and secretions. A period of hyperventilation is used (I) if a double-lumen tube cannot be used or (2) if on opening the bronchus one sees that there will be interference with closure (from the hook if a Carlens tube has been used or because the tube position is such that the bronchial cuff will interfere). Both tracheal and bronchial cuffs are deflated and the double-lumen tube is withdrawn into the trachea so that the tip is positioned about 3 cm above the carina. The bronchial cuff is reinflated and the tube will then act as a single-lumen tube. The withdrawal of the tube is guided by the surgeon under direct vision through the bronchial opening. Bronchial closure proceeds as described below. When oxygenation becomes inadequate, the bronchial opening is occluded with a swab and ventilation is momentarily resumed. This may be repeated until bronchial closure is completed. Surgical technique. The object of the closure is to taper the trachea into the remaining bronchus, leaving no stump and with no tension on the suture line. This is done by creating a flap from the pliable posterior membranous bronchus. It is important, however, that the cartilaginous part be cut flush at its origin from the carina. In a right pneumonectomy, the right main bronchus with the carcina and the lower 3 ern of the trachea are dissected free; the azygos vein is retracted upward and need not be divided. It is helpful at this stage to clamp the bronchus distally and remove the specimen, as this facilitates access. Two stay sutures are inserted, one into the carina and the other into the trachea about 3 em above the origin of the right main bronchus (Fig. I). A longitudinal incision is made at the junction of the cartilaginous and the membranous bronchus, starting at point I on Fig. 2 and extending for 2 em into the trachea (point 2) and for about I cm into the right main bronchus (point 3) before curving into the carina (point 4). At the upper end of the incision, a triangle of the right side of the lower tracheal rings is removed and a few sutures are inserted. The cartilaginous part of the right main bronchus is
Volume 98 Number 2
Bronchial closure after pneumonectomy
August 1989
Right Bronchus
Fig. 1. Right pneumonectomy: exposure. (By permission of Mayo Foundation; redrawn from Jack.')
Fig. 2. A. B. C. and D. Preparation of trachea and bronchus: surgical technique (see text for explanation of
numbers). (By permission of Mayo Foundation; redrawn from Jack.')
22 1
The Journal of Thoracic and Cardiovascular Surgery
222 Sarsam and Moussali
Left
Bronchus
Trachea
Fig. 3. Left pneumonectomy: exposure. (By permission of Mayo Foundation; redrawn from Jack.')
Table I. Causes Causes Carcinoma of the bronchus Squamous cell carcinoma Adenocarcinoma Oat cell Bronchiectasis Tuberculosis Lymphoma Malignant carcinoid Sarcoma Mesothelioma Pulmonary fibrosis
No. of patients 312
245 46 18 6
3 3 2
2 2 2
amputated flush at its origin from the carina, and the posterior flap is swung forward and sutured to the right tracheal wall. As Jack noted, the closure is, in effect, a tracheal closure. The suture line will be noted to fall into the mediastinum. The suture line is tested by manual inflation of the lung to a pressure of 35 to 40 em H 20 . Additional sutures are inserted if required. The sutures are all cut and the pericardium is approximated to the periesophageal tissue, which thereby completely isolates the closure from the pneumonectomy space.
In a left pneumonectomy the lower trachea is less accessible because of the aortic arch. The lower 3 cm of the trachea with carina is exposed. Stay sutures are inserted and the posterior flap is fashioned in a way similar to that on the right side (Fig. 3). It is important that a few sutures be inserted at the superior edge before the cartilaginous part of the bronchus is completely divided, because the upper part of the tracheal closure will retract underneath the arch. The sutures are left uncut. The suture line is tested. Rarely is an additional suture required. The sutures are cut and the pericardium is approximated to the periesophageal tissue. Closure. The chest is closed with a single chest tube that is clamped and released intermittently for 30 seconds every hour. The tube is normally removed 24 hours postoperatively. In the rare instance of some air bubbles escaping after unclamping of the tube beyond the 24-hour period, the tube is left in for another 2 to 3 days. This is in contrast to bronchopleural fistula in which the leak is persistent and the chest tube cannot be clamped. In patients who require positive-pressure ventilation, the tube is left in as a safety measure until after the patient is no longer supported by ventilator. The suture material used for bronchial closure in all these cases was 2-0 catgut.
Results Seventeen patients died within 30 days (mortality rate 5.1%). The causes of death were bronchopneumonia and respiratory failure in six, myocardial infarction in four,
Volume 98 Number 2 August 1989
pulmonary embolus in five, and cerebrovascular accidents in two patients. Empyema developed in the pneumonectomy space in 10 patients (3%); a fistula could not be demonstrated in any of them. There were nine men and one woman. Nine patients had resection for carcinoma and one for bronchiectasis. The diagnosis was made within 6 weeks of operation in seven patients, within 12 weeks in two more, and empyema developed at 36 months postoperatively in one patient. The organisms responsible were Staphylococcus aureus in five, Escherichia coli and other coliform in three, and nontyphoidal Salmonella in one; no organism could be isolated in one patient. All 10 patients were treated with drainage and appropriate antibiotics. Two died within 3 months as a result of sepsis. The remaining eight had thoracoplasty. Three died at 14, 23, and 24 months after their original operation as a result of metastatic recurrence. The remaining five are alive and well. Intensive physiotherapy has eliminated the bony deformity usually associated with the thoracoplasty procedure.
Discussion The prevalence of bronchopleural fistula after pneumonectomies varies from as low as 3% to 7% to as high as 15%.2-6 Although several factors are often cited as causes, that is, endobronchitis, malignant tissue at the resection margin, and preoperative irradiation,' it is our belief that bronchial closure constitutes the main factor. Nontension bronchial closure was first described by Brewer and associates' in 1953. In that report and a more recent one, much emphasis was put on covering the bronchial stump with a pedicle of fat. 8 In 1965,Jack' described his technique of using the posterior membranous flap, with the closure being completely proximal to the carina-a tracheal closure. In his series there were 450 pneumonectomies with only one case of bronchopleural fistula. Postpneumonectomy empyema developed in 10 patients (3%), and a fistula could not be demonstrated in any of them. We doubt if any technique will eliminate empyema. Our patients were treated with drainage followed by thoracoplasty (8 of 10 patients). We did not attempt to use the Clagett procedure? as our results with its prototype, the Eloesser flap,'? were less than satisfactory-continued purulent drainage and the need for dressing changes, depression and social isolation, bleeding, amyloidosis and the development of squamous cell carcinoma in the skin flap-s-despite reports that these procedures work better in postpneumonectomy empyema not associated with bronchopleural fistula.":" Thoracoplasty was done as a one-stage procedure in all but one ill patient, in whom a two-stage procedure was
Bronchial closure after pneumonectomy
223
performed. Intensive physiotherapy is absolutely essential for pulmonary toilet and for the elimination of the bony deformities associated with this procedure. The type of suture material used in all our cases was chronic catgut, and as long as no tension exists at the suture line, this is adequate. If, however, the posterior flap is not adequately sized so that some tension exists at the suture line, it is advisable to use a nonabsorbable material. A current and popular technique for closing the bronchus is the use of staplers. This offers the advantage of speed, and in a comparative analysis with the conventional technique the prevalence of fistula was reduced from 6% to 4.3%.14 However, staplers remain expensive, the bronchial lumen cannot be examined, and they have not eliminated the problem of bronchopleural fistula. REFERENCES 1. Jack GO. Bronchial closure. Thorax 1965;20:8-12. 2. Boyd AD, Spencer Fe. Bronchopleural fistulas. How often should they occur? Ann Thorac Surg 1972;13: 195-6. 3. Ravitch MM. Letter to the editor. Ann Thorac Surg 1972;13:288-9. 4. Hankins JR, Miller JE, Attar S, Satterfield JR, Mclaughlin JS. Bronchopleural fistula: thirteen-year experience with 77 cases. J THORAC CARDIOVASC SURG 1978;76:755-60. 5. Baldwin JC, Mark JBD. Treatment of bronchopleural fistula after pneumonectomy. J THORAC CARDIOVASC SURG 1985;90:813-6. 6. Virkkula L. Treatment of the bronchopleural fistula. [Editorial]. Ann Thorac Surg 1978;25:489-90. 7. Brewer LA III, King EL, Lilly LJ, Bai AF. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J THORAC SURG 1953;26:507-32. 8. Iverson LIG, Young IN, Ecker RR, et al. Closure of bronchopleural fistulas by an omental pedicle flap. Am J Surg 1986;152:40-2. 9. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J THORAC CARDIOVASC SURG 1963;45:141-5. 10. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096-7. II. Adler RH, Plaut ME. Post-pneumonectomy empyema. Surgery 1972;71:210-4. 12. Goldstraw P. Treatment of postpneumonectomy empyema: the case for fenestration. Thorax 1979;34:740-5. 13. Weissberg D. Empyema and bronchopleural fistula: experience with open window thoracostomy. Chest 1982; 82:447-50. 14. Takaro T. Use of staplers in pulmonary surgery. Surg Clin North Am 1984;64:461-8.
THORAC CARDIOVASC SURG 1989;98:220-3
Technique of bronchial closure after pneumonectomy Three hundred thirty-two patients had a pneumonectomy at Wythenshawe Hospital, Manchester, England, between 1974 and 1984. In all patients, the bronchus was closed with a posterior flap from the pliable membranees bronchus, leaving no stump, and with the suture line proximal to the carina. In a mean follow-up of 54 months, none of the patients had bronchopleural fistula, and 10 patients had empyema in the pneumonectomy space (3 %). A fistula could not be found in any of these patients. The suture material used in closing the bronchus in all these cases was 2-0 chromic catgut, which underlines the fact that bronchial healing is not affected by the type of suture material as long as no tension exists at the suture line.
Mazin A. I. Sarsam, MD,· and Henri Moussali, MD, FRCS, Manchester, England
Rom
1974 to 1984 a total of 332 patients had a pneumonectomy performed by one surgeon (H.M.) or his chief assistant. The technique of bronchial closure used in all these cases was the nontension posterior membranous flap, leaving no stump, as described by Jack' from Baguly Hospital, Manchester, England, in 1965. With a mean follow-up of 54 months, bronchopleural fistula, that is, a communication between the bronchial tree and the pneumonectomy space as a result of breakdown of the bronchial suture line, did not develop in any of the patients. Patients and methods Of the 332 patients, 252 were male and 80 were female. The youngest patient was a 17 year old with bronchiectasis. The youngest patient with lung cancer (squamous cell) was a 26-year-old man. The oldest patient in the series was a 79-year-old man with squamous cell carcinoma. The mean age for the whole series was 59.8 years. A right pneumonectomy was performed in 152 patients and a left pneumonectomy in 180 patients. The type of disease necessitating a pneumonectomy is shown in Table 1. Anesthetic considerations. With the exception of nine patients, all had a double-lumen tube. In our institution, either a right-sided or a left-sided Robertshaw double-lumen tube or a Carlens tube (left-sided only) is used. The advantages
Fromthe Division of Cardiovascular Surgery, Wythenshawe Hospital, Manchester, England. Received for publication June 7, 1988. Accepted for publication Nov. 14, 1988. Address reprint requests to either author at appropriate address. ·Present address: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
220
include an objective assessment of the patient's oxygenation and hemodynamic status on one lung anesthesia and isolation of the normal lung from blood and secretions. A period of hyperventilation is used (I) if a double-lumen tube cannot be used or (2) if on opening the bronchus one sees that there will be interference with closure (from the hook if a Carlens tube has been used or because the tube position is such that the bronchial cuff will interfere). Both tracheal and bronchial cuffs are deflated and the double-lumen tube is withdrawn into the trachea so that the tip is positioned about 3 cm above the carina. The bronchial cuff is reinflated and the tube will then act as a single-lumen tube. The withdrawal of the tube is guided by the surgeon under direct vision through the bronchial opening. Bronchial closure proceeds as described below. When oxygenation becomes inadequate, the bronchial opening is occluded with a swab and ventilation is momentarily resumed. This may be repeated until bronchial closure is completed. Surgical technique. The object of the closure is to taper the trachea into the remaining bronchus, leaving no stump and with no tension on the suture line. This is done by creating a flap from the pliable posterior membranous bronchus. It is important, however, that the cartilaginous part be cut flush at its origin from the carina. In a right pneumonectomy, the right main bronchus with the carcina and the lower 3 ern of the trachea are dissected free; the azygos vein is retracted upward and need not be divided. It is helpful at this stage to clamp the bronchus distally and remove the specimen, as this facilitates access. Two stay sutures are inserted, one into the carina and the other into the trachea about 3 em above the origin of the right main bronchus (Fig. I). A longitudinal incision is made at the junction of the cartilaginous and the membranous bronchus, starting at point I on Fig. 2 and extending for 2 em into the trachea (point 2) and for about I cm into the right main bronchus (point 3) before curving into the carina (point 4). At the upper end of the incision, a triangle of the right side of the lower tracheal rings is removed and a few sutures are inserted. The cartilaginous part of the right main bronchus is
Volume 98 Number 2
Bronchial closure after pneumonectomy
August 1989
Right Bronchus
Fig. 1. Right pneumonectomy: exposure. (By permission of Mayo Foundation; redrawn from Jack.')
Fig. 2. A. B. C. and D. Preparation of trachea and bronchus: surgical technique (see text for explanation of
numbers). (By permission of Mayo Foundation; redrawn from Jack.')
22 1
The Journal of Thoracic and Cardiovascular Surgery
222 Sarsam and Moussali
Left
Bronchus
Trachea
Fig. 3. Left pneumonectomy: exposure. (By permission of Mayo Foundation; redrawn from Jack.')
Table I. Causes Causes Carcinoma of the bronchus Squamous cell carcinoma Adenocarcinoma Oat cell Bronchiectasis Tuberculosis Lymphoma Malignant carcinoid Sarcoma Mesothelioma Pulmonary fibrosis
No. of patients 312
245 46 18 6
3 3 2
2 2 2
amputated flush at its origin from the carina, and the posterior flap is swung forward and sutured to the right tracheal wall. As Jack noted, the closure is, in effect, a tracheal closure. The suture line will be noted to fall into the mediastinum. The suture line is tested by manual inflation of the lung to a pressure of 35 to 40 em H 20 . Additional sutures are inserted if required. The sutures are all cut and the pericardium is approximated to the periesophageal tissue, which thereby completely isolates the closure from the pneumonectomy space.
In a left pneumonectomy the lower trachea is less accessible because of the aortic arch. The lower 3 cm of the trachea with carina is exposed. Stay sutures are inserted and the posterior flap is fashioned in a way similar to that on the right side (Fig. 3). It is important that a few sutures be inserted at the superior edge before the cartilaginous part of the bronchus is completely divided, because the upper part of the tracheal closure will retract underneath the arch. The sutures are left uncut. The suture line is tested. Rarely is an additional suture required. The sutures are cut and the pericardium is approximated to the periesophageal tissue. Closure. The chest is closed with a single chest tube that is clamped and released intermittently for 30 seconds every hour. The tube is normally removed 24 hours postoperatively. In the rare instance of some air bubbles escaping after unclamping of the tube beyond the 24-hour period, the tube is left in for another 2 to 3 days. This is in contrast to bronchopleural fistula in which the leak is persistent and the chest tube cannot be clamped. In patients who require positive-pressure ventilation, the tube is left in as a safety measure until after the patient is no longer supported by ventilator. The suture material used for bronchial closure in all these cases was 2-0 catgut.
Results Seventeen patients died within 30 days (mortality rate 5.1%). The causes of death were bronchopneumonia and respiratory failure in six, myocardial infarction in four,
Volume 98 Number 2 August 1989
pulmonary embolus in five, and cerebrovascular accidents in two patients. Empyema developed in the pneumonectomy space in 10 patients (3%); a fistula could not be demonstrated in any of them. There were nine men and one woman. Nine patients had resection for carcinoma and one for bronchiectasis. The diagnosis was made within 6 weeks of operation in seven patients, within 12 weeks in two more, and empyema developed at 36 months postoperatively in one patient. The organisms responsible were Staphylococcus aureus in five, Escherichia coli and other coliform in three, and nontyphoidal Salmonella in one; no organism could be isolated in one patient. All 10 patients were treated with drainage and appropriate antibiotics. Two died within 3 months as a result of sepsis. The remaining eight had thoracoplasty. Three died at 14, 23, and 24 months after their original operation as a result of metastatic recurrence. The remaining five are alive and well. Intensive physiotherapy has eliminated the bony deformity usually associated with the thoracoplasty procedure.
Discussion The prevalence of bronchopleural fistula after pneumonectomies varies from as low as 3% to 7% to as high as 15%.2-6 Although several factors are often cited as causes, that is, endobronchitis, malignant tissue at the resection margin, and preoperative irradiation,' it is our belief that bronchial closure constitutes the main factor. Nontension bronchial closure was first described by Brewer and associates' in 1953. In that report and a more recent one, much emphasis was put on covering the bronchial stump with a pedicle of fat. 8 In 1965,Jack' described his technique of using the posterior membranous flap, with the closure being completely proximal to the carina-a tracheal closure. In his series there were 450 pneumonectomies with only one case of bronchopleural fistula. Postpneumonectomy empyema developed in 10 patients (3%), and a fistula could not be demonstrated in any of them. We doubt if any technique will eliminate empyema. Our patients were treated with drainage followed by thoracoplasty (8 of 10 patients). We did not attempt to use the Clagett procedure? as our results with its prototype, the Eloesser flap,'? were less than satisfactory-continued purulent drainage and the need for dressing changes, depression and social isolation, bleeding, amyloidosis and the development of squamous cell carcinoma in the skin flap-s-despite reports that these procedures work better in postpneumonectomy empyema not associated with bronchopleural fistula.":" Thoracoplasty was done as a one-stage procedure in all but one ill patient, in whom a two-stage procedure was
Bronchial closure after pneumonectomy
223
performed. Intensive physiotherapy is absolutely essential for pulmonary toilet and for the elimination of the bony deformities associated with this procedure. The type of suture material used in all our cases was chronic catgut, and as long as no tension exists at the suture line, this is adequate. If, however, the posterior flap is not adequately sized so that some tension exists at the suture line, it is advisable to use a nonabsorbable material. A current and popular technique for closing the bronchus is the use of staplers. This offers the advantage of speed, and in a comparative analysis with the conventional technique the prevalence of fistula was reduced from 6% to 4.3%.14 However, staplers remain expensive, the bronchial lumen cannot be examined, and they have not eliminated the problem of bronchopleural fistula. REFERENCES 1. Jack GO. Bronchial closure. Thorax 1965;20:8-12. 2. Boyd AD, Spencer Fe. Bronchopleural fistulas. How often should they occur? Ann Thorac Surg 1972;13: 195-6. 3. Ravitch MM. Letter to the editor. Ann Thorac Surg 1972;13:288-9. 4. Hankins JR, Miller JE, Attar S, Satterfield JR, Mclaughlin JS. Bronchopleural fistula: thirteen-year experience with 77 cases. J THORAC CARDIOVASC SURG 1978;76:755-60. 5. Baldwin JC, Mark JBD. Treatment of bronchopleural fistula after pneumonectomy. J THORAC CARDIOVASC SURG 1985;90:813-6. 6. Virkkula L. Treatment of the bronchopleural fistula. [Editorial]. Ann Thorac Surg 1978;25:489-90. 7. Brewer LA III, King EL, Lilly LJ, Bai AF. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J THORAC SURG 1953;26:507-32. 8. Iverson LIG, Young IN, Ecker RR, et al. Closure of bronchopleural fistulas by an omental pedicle flap. Am J Surg 1986;152:40-2. 9. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J THORAC CARDIOVASC SURG 1963;45:141-5. 10. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096-7. II. Adler RH, Plaut ME. Post-pneumonectomy empyema. Surgery 1972;71:210-4. 12. Goldstraw P. Treatment of postpneumonectomy empyema: the case for fenestration. Thorax 1979;34:740-5. 13. Weissberg D. Empyema and bronchopleural fistula: experience with open window thoracostomy. Chest 1982; 82:447-50. 14. Takaro T. Use of staplers in pulmonary surgery. Surg Clin North Am 1984;64:461-8.