Surgical Management of Late Postpneumonectomy Bronchopleural Fistula: The Transsternal, Transpericardial Route

Abstract

Background: Late postpneumonectomy bronchopleural fistula (LBPF) is a serious complication. Surgical repair of the bronchial stump through a lateral thoracotomy is a dangerous attempt due to mediastinal fibrothorax and the risk of pulmonary artery stump damage. Objectives: The goal of this study was to estimate the effectiveness of the transsternal, transpericardial approach for bronchial stump repair in case of LBPF. Methods: From 1996 to 2002, 1,294 lung resections for non-small cell lung cancer were performed at our department. Out of 412 pneumonectomies, 16 patients (3.8%) presented with LBPF after right pneumonectomy for non-small cell lung cancer. Thirteen of these patients were subjected to transsternal, transpericardial bronchial stump repair. They were followed postoperatively, and morbidity and mortality rates were recorded. Results: The interval between pneumonectomy and fistula diagnosis lasted from 12 to 85 months. The estimated sizes of the fistulae ranged from 5 to 21 mm, and the length of the bronchial stump was >1 cm only in 2 patients (15.3%).Due to persistent empyema, open-window thoracostomy was performed for definite treatment immediately after the operation for bronchial stump reamputation in 6 cases (46.1%). One patient (7.6%) died 3 months postoperatively due to bronchopleural fistula recurrence. This was also the only case of fistula recurrence. Conclusion: LBPF usually needs definite management to save the patient’s life. The transsternal, transpericardial approach is a safe and effective method.

Accelerated treatment of postpneumonectomy empyema: A binational long-term study

“…[8][9][10][11] The mortality and especially the morbidity are reported to be high. [1][2][3][4] Various treatments have been proposed, and their practicality depends on the stage of the empyema, the presence of a bronchial stump insufficiency, and the overall condition of the patient. We report on 75 patients with early and late PPE that are treated according to the rules of surgical treatment of an infected space, which includes debridement and cleaning of the infected area and final obliteration of the cavity by filling in an antibiotic solution.…”

“…T reatment of postpneumonectomy empyema (PPE) remains a serious problem, with a reported mortality of up to 10% to 20% and a failure rate with persistently open window thoracostomy of 20% or more, even in recent reports. [1][2][3][4] Recommended procedures include a wide spectrum from single-stage lavage performed by means of video-assisted thoracoscopy for early empyemas to repeated cleaning of the cavity through a temporary or persistently open window thoracostomy and various modifications for different empyema stages. Furthermore, transposition of muscles into the chest or thoracoplastic procedures to obliterate the thoracic cavity are applied.…”

“…5 During the last 2 decades, the concept of the open chest window first described by Clagett and Geraci 6 was modified, especially by Pairolero and colleagues from the Mayo clinic in Rochester, Minnesotta. 1,3,4,7,8 However, the course of treatment is usually long, and during this time, patients have to deal with an open chest window in their body. Furthermore, the open chest window remains life-long in up to one third of their patients.…”

Epidemiology, etiology and prevention of postpneumonectomy pleural empyema

“…Despite various therapeutic options developed during the last five decades, postpneumonectomy pleural empyema (PPE) is still associated with 10%-20% mortality rate, reaching up to 50% in case of broncho-pleural fistula (BPF), with high morbidity and prolonged hospitalization. [2][3][4][5] The aim of this review is to summarize the epidemiology, etiology and prophylaxis data in PPE. The treatment is discussed elsewhere.…”

Transsternal occlusion of the main bronchus stump in bronchopleural fistula and non-specific pleural empyema

“…Несостоятельность шва бронха после пневмонэктомии -одно из самых тяжелых осложнений в торакальной хирургии, летальность в этом случае достигает 20-30%. Частота несостоятельности культи главного бронха после пневмонэктомии зависит от многих факторов: этиологии первичного заболевания, соматического статуса пациента и компенсации сопутствующих заболеваний, варианта формирования шва, длины культи бронха и в специализированных отделениях торакальной хирургии составляет от 2,5 до 13,3% [1][2][3][4].…”