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Interact CardioVasc Thorac Surg 2008;7:609-612. doi:10.1510/icvts.2007.163972 © 2008 European Association of Cardio-Thoracic Surgery
Surgical treatment of bronchiectasis: early and long-term resultsDepartement of Thoracic Surgery, Hôtel Dieu University Hospital, Paris V University, Paris, France Received 8 August 2007; received in revised form 21 December 2007; accepted 21 December 2007
*Corresponding author. Unité de Chirurgie, Thoracique, Hôtel Dieu, 1, Place du parvis Notre-Dame, 75004 Paris, France. Tel.: +33-1-42348234; fax: +33-1-42348885.
Management of bronchiectasis remains controversial and information on long-term results of surgical treatment is poor. Clinical records of 45 patients, who underwent surgery for bronchiectasis in an 8-year period, were retrospectively reviewed. Bronchiectasis focus was isolated in 24 cases, associated with a limited homolateral or controlateral focus in 9 and 11, respectively; two patients had bilateral evident foci. Bronchiectasis was responsible for lobe destruction in 23 cases. All patients had symptoms: haemoptysis (n=7), recurrent pneumonia (n=7), persistent bronchorrea with recurrent infection (n=15), hemoptysis and recurrent infection (n=16). A total of 23 lobectomies, 11 lobectomies+segmentectomies, 2 bi-lobectomies, 9 segmentectomies and 1 pneumonectomy were carried out. There were no perioperative deaths; complications occurred in 5 patients (postoperative pneumonia in 2, prolonged air-leak, residual air-space and bronchial infection 1 each). Symptoms disappeared in 32 patients, 10 patients experienced a significant improvement. Exercise tolerance remained stable or improved in 33 and 2 cases, respectively, a slight impairment was observed in 9. Out of 32 evaluable patients 11 had an unchanged FEV1, 15 had a limited FEV1 lowering (<15%), and 9 had a more important functional loss. Surgical treatment of bronchiectasis obtains satisfactory long-term results, with acceptable morbidity rates.
Key Words: Bronchiectasis; Outcome
Occurrence of bronchiectasis has progressively lowered in the past decades thanks to the fall in tuberculosis prevalence, spreading of vaccination for pertussis, and progress in medical management of pneumonia [1, 2]. So, in industrialised countries bronchiectasis represents a relatively infrequent disease. In the majority of cases (currently 80–95%), the condition can be managed non-operatively (appropriate antibiotic treatments, postural drainage with vibratory massage, and bronchodilator in selected cases) and surgery is carried out only in cases of recalcitrant and/or specific symptoms (hemoptysis, recurrent pneumonia) rendering the non-operative management unsatisfactory or even dangerous [2, 3]. Globally, there is relatively limited experience on surgical treatment of bronchiectasis in industrialised countries in the last decades and few publications are available [2, 4]. Furthermore, little is known on long-term outcome. In the present study, we retrospectively reviewed our experience on surgery for bronchiectasis, in order to study clinical characteristics of patients, treatment modalities, short- and long-term outcome.
We retrospectively reviewed the clinical records of all the patients who underwent surgery for bronchiectasis in an 8-year period (1999–2006) by a single surgical team. In all the patients, preoperative evaluation included clinical history, physical examination, routine blood tests, chest X-ray and thoracic computed tomography (Fig. 1a,b,c), fibreoptic bronchoscopy, electrocardiography, lung function tests, and perfusion lung scan. Patients with bronchiectasis secondary to tumoral bronchial obstruction were excluded.
Indications for surgery included haemoptysis, recurrent pneumonia or bronchial infection or associated symptoms. Resection was considered functionally possible if the predictive postoperative FEV1 (calculated on the basis of spirometry and isotopic scan) was  40% of predicted FEV1 and provided that no major hypoxemia (<60 mmHg) or hypercapnia (>46 mmHg) existed, whereas it was contraindicated if the predicted postoperative FEV1 was  30%. In one case of values between 30% and 40%, resectability was judged on the basis of results of an exercise test. In each case, bacteriologic samples of bronchial secretion were obtained during work-up fibreoptic bronchoscopy. In case of microbiologically documented infection, a pre-operative 1-week targeted antibiotic treatment was administered and continued in the postoperative period. Otherwise, a perioperative short-term prophylaxis was administered and the patient was postoperatively treated only in case of documented respiratory infection.
Operations were carried out under general anaesthesia with double lumen endo-bronchial intubation. Access to thoracic cavity was achieved through either limited postero-lateral thoracotomy or video-assisted thoracic surgery with a two-port thoracoscopy and a utility mini-thoracotomy. Pain control was achieved by intrathecal morphine administration (at the end of surgery), followed by continuous patient controlled intravenous analgesia with morphinics. Intravenous proparacetamol was also administered. Supplemental subcutaneous morphinics were administered to achieve a numeric analogue score (1–10) constantly Retrospective recording of pre-surgical data included demographic information, medical comorbidities, symptoms of presentation, side and location, fiberoptic bronchoscopy data, spirometry data, indication for surgery. We also collected data about the extent of resection and the postoperative morbidity. Patients were regularly followed-up by either a member of the surgical team or the referring pulmonologist. In several cases, a late spirometry was obtained. Collection of outcome information included evolution of symptoms (graded as disparition, improvement, stability, impairment), existence of post-thoracotomy pain (absent; minimal, not necessitating treatment; moderate, necessitating occasional treatment; severe, necessitating permanent treatment), variations in exercise tolerance (stability, improvement, impairment) changes in spirometry values (preoperative vs. postoperative, at 6 months from operation), and overall patient satisfaction (very satisfied, satisfied, non-satisfied). Referring physicians were also contacted to confirm data obtained by patients’ interview.
Mean comparison was carried out by Student t-test for paired data. Percentage comparison was carried out by
3.1. Clinical characteristics A total of 45 patients underwent surgical treatment of bronchiectasis in our Institution in the study period. There were 21 men and 24 women; mean age was 42 years (range 9–68 years). Four patients were aged <18 years. With respect to aetiological factors, pneumonia in childhood, pertussis and previous tuberculosis could be found in 10, 4 and 6 cases, respectively. A single patient had Kartagener syndrome with situs inversus and bronchiectasis in a left middle lobe. Overall, no aetiological factor could be identified in 55% of cases. Patients with cystic fibrosis were excluded from the study. On CT-scan, a single bronchiectasis focus was found in 24 cases, whereas it was associated with a very limited homolateral or controlateral localisation in 9 and 11 cases, respectively. Two patients had bilateral evident foci and one of them underwent bilateral staged surgery. Bronchiectasis was responsible for lobe destruction in 22 cases and complete lung destruction in a single patient. Bronchiectasis was known since 14 years on the average (range 1–57 years), but impairment of symptoms had occurred since 22 months on the average (range 1–72 months). All the patients presented symptoms related to disease: haemoptysis (n=7), recurrent pneumonia (n=7), persistent bronchorrhea with recurrent infection (n=15), associated haemoptysis and recurrent infection (n=16). All the patients were referred for surgery after an optimal pneumologic management. Mean preoperative FEV1 was 86.8+16.7% (percent of predicted); 11 patients had a FEV1<80%. A total of 27 patients (60%) received preoperative and postoperative targeted antibiotic therapy for documented respiratory infection.A total of 23 lobectomy, 11 lobectomy with associated anatomic segmentectomy, 2 bi-lobectomies, 9 segmentectomies (single or multiple segments on the same or different lobes) (Fig. 2), and 1 pneumonectomy were performed. One patient received bilateral surgery. In total, 12 patients were treated by thoracoscopy, 10 lobectomies (middle lobe resection in all cases) and 2 segmentectomies (lingulectomy in both).
There were no intraoperative or postoperative deaths. No patient needed blood transfusion. In total 40 patients had uneventful postoperative course. Complications occurred in the remaining 5 patients (postoperative pneumonia, n=2; prolonged air-leak, residual air-space, sputum retention, and bronchial infection, 1 each). Information on long-term outcome was obtained in all but 1 patient (a foreign patient returned back) by direct interview and clinical examination. A late spirometry was performed in 32 cases. Mean follow-up was 52 months (range 2–96), median follow-up was 47 months.A complete disparition of symptoms occurred in 32 patients (71%) and 10 had an improvement considered significant. Symptoms were stable in the remaining 2 patients (1 with Kartagener syndrome), whereas no worsening was observed. With respect to haemoptysis, a single patient experienced recurrence of this symptom (a single self-limiting episode not necessitating specific management), whereas no late pneumonia was observed. With respect to symptom persistence in relation to the diffusion of bronchiectasis foci (isolated vs. multiple, unilateral or bilateral), disparition of symptoms occurred in 21 out of 25 patients with an isolated focus, in 4 out of 5 patients with double but unilateral localisation, and in 5 out of 14 patients with bilateral involvement (P=0.0069). Among these last patients, improvement of symptoms (but not disparition) occurred in 8 patients. Among the 19 patients with minimal residual bronchiectasis foci after surgery (generally contro-lateral), only two patients had significant persistent symptoms. In total, 31 patients had no post-thoracotomy pain. Persistent post-thoracotomy pain was observed in 13 patients, slight in 9; moderate in 3 and severe in 1; only in these latter patients oral drugs were required to control the pain. The remaining 31 patients presented no late post-thoracotomy pain. From a functional point of view, exercise tolerance remained stable or improved in 33 and 2 cases, respectively, whereas a slight impairment was observed in 9 cases. With respect to spirometry changes, 11 out of 35 evaluable patients had an unchanged FEV1 (variations <5%), 15/35 had a limited FEV1 lowering (<15%), and 9 had a more important functional loss (FEV1 lowering >15%). Overall, mean late FEV1 was slightly but significantly lower than the preoperative one (89.9±16.3% vs. 80.9±16.9%, P=0.0001) (Fig. 2). Overall, 35 patients were very satisfied from the results of the operation, 7 were satisfied and 3 unsatisfied because of persistent bronchial infection (n=2) or post-thoracotomy pain (n=1).
Bronchiectasis is a multiform disease whose anatomical and clinical characteristics, susceptibility to treatments, and outcome are largely variable [1, 5, 6]. The disease may be asymptomatic or oligosymptomatic but life-threatening evolution is possible (in the case of sepsis for pneumonia and/or empyema, lung or brain abscess, haemoptysis, amiloidosis, respiratory failure) [1, 5, 6]. The disease is relatively rare in industrialised countries but problems and controversies in optimal management persists [2]. Bronchiectasis is relatively common in cystic fibrosis patients, but because of particularity of this condition, patients with this underlying disease were not included in this study. Diagnosis of bronchiectasis is based on clinical history and imaging [1, 5, 6]. All the patients in our study had CT-scan with high-resolution sections. CT criteria for diagnosis of bronchiectasis are well established (internal diameter of the bronchus more than 1.5 times than that of accompanying artery and evidence of lack of tapering of bronchi) and false positive and negative rates are 2% and 1%, respectively [7, 8]. So, we never performed bronchography and agree with others that this examen is no more useful [2]. On the other hand, we systematically carried out fibreoptic bronchoscopy, which remains essential to assess the bronchial lumen and obtain samples for bacteriology. Once diagnosis is established, the optimal management is based on a multidisciplinary approach. The minority of patients with bronchiectasis require a surgical treatment because of satisfactory symptom relief by medical management: the percentage was 18.3% at the Ruhrlandklinik at Essen, Germany [3], and as low as 3.9% at the Mayo Clinic, Rochester, USA [2]. This data is not available in our study as our surgical department is a tertiary referral centre and patients are addressed by several hospitals. In all the cases of our series, patients had a specialised pneumologic management before being referred to our team for the operation and surgery was always indicated because of ineffective medical management and/or the presence of possible life-threatening symptoms. The extent of exeresis was variable: a single patient necessitated pneumonectomy because of a destroyed lung, whereas a lobar or segmental resection was possible in the remaining cases. In particular, lobar resections were carried out in 36 cases and in 11 cases they were associated with homolateral segmentectomies. On the other hand, single or multiple segmentectomies (on the same or different lobes) were performed in the remaining cases. The choice of segmental resection was systematically adopted in order to spare the maximum of lung parenchyma in this non-neoplastic condition, provided that one could deal as radically as possible with the disease on the operated side. In particular, we often performed anatomical lingular resection and preservation of S6 segment whenever possible [3] and confirmed that this last choice in the case of basal segmentectomy is not associated with increased morbidity, contrarily to previously reported experiences [9, 10]. In our experience, VATS approach was employed in the case of middle lobe or lingula resection, provided that the extent of adhesions was limited and no calcified nodes were evident on CT-scan. No postoperative death occurred and complications were recorded in 5 cases (11.1%). This incidence of complications can be considered low and is probably explained by the low number of pneumonectomies, an accurate patient selection and a careful perioperative management. In particular, respiratory infections were watchfully managed, in accordance with a standard protocol previously described [11]. Regarding symptoms, the results of surgery can be considered satisfactory in our experience: 42/45 patients (93.3%) experienced an improvement, which was complete in 71% of cases. As expected, disappearance of symptoms was more frequent in cases of single focus than in cases of multiple homolateral, or, more evidently, controlateral foci. In cases of single focus, complete resection may be more easily achieved, and this is a known important prognostic factor [2]. Furthermore, a single focus reflects, more probably, a less evolutive disease whose treatment by complete resection allows definitive cure. However, an improvement of symptoms could be achieved also in the majority of patients with multiple localisation. Resection should be radical whenever possible but preservation of function should be a rule. Thus, minimal residual disease, especially on the controlateral side is, in our policy, best managed by a non-operative approach. In fact, in this type of operation, more than just non-functional parenchyma must be often removed, as requested by anatomical conditions. This is the cause of decrease of FEV1 we observed in our series. Decrease in FEV1 occurred in 68% of evaluated patients, whereas exercise tolerance decreased in only 20% of cases and we did not find correlation between modification in exercise tolerance and FEV1; moreover, symptoms disappeared or improved in 93% of patients. This probably means that postoperative FEV1 is not a good index of long-term outcome in this type of surgery. In fact, when removing a lobe or a segment affected from bronchiectases, the impairment of lung function, due to loss of functional parenchyma, is overcome by the improvement of general clinical conditions and symptoms, due to resection of pathological tissue. In conclusion, surgical treatment of bronchiectasis may obtain satisfactory long-term results with acceptable morbidity rates. A multidisciplinary approach is mandatory to best deal with this condition. Surgery plays an important role: isolated or associated anatomical resection on the same or both sides may be required and optimal peri-operative cares allows a limited postoperative complication rate.
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Abstract
1. Introduction
2 test. Statistical significance was accepted at P<0.05. 