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Interact CardioVasc Thorac Surg 2008;7:638-641. doi:10.1510/icvts.2008.177782 © 2008 European Association of Cardio-Thoracic Surgery
The posterior membranous flap technique for bronchial closure after pneumonectomyDepartment of Thoracic Surgery, ‘G. Hatzikosta’ General Hospital of Ioannina, Ioannina, Greece Received 12 February 2008; received in revised form 29 April 2008; accepted 30 April 2008
*Corresponding author. 11, Kiouptsidou, GR 55133, Thessaloniki, Greece. Tel.: +30-2310-451214; fax: +30-2310-451214.
Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients – 89%), small cell lung cancer (one patient – 2.2%), mixed and other types of cancer (two patients – 4.4%), and non-neoplastic etiology (one patient – 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.
Key Words: Bronchopleural fistula; Postpneumonectomy complications; Pneumonectomy; Manual bronchial closure; Posterior membranous flap technique
Bronchopleural fistula (BPF) is a pathologic communication between a bronchus and the pleural cavity. It can be a life-threatening condition leading to high morbidity and mortality, in particular after pulmonary resection [1]. The postpneumonectomy stump dehiscence is the main cause of BPF. The postoperative BPF can be classified as acute, subacute or chronic and it usually occurs within 8–12 days after surgery, having an incidence from 0 to 28%. The surgical technique and the experience of the surgeon are of great importance for the prevention of this complication [1, 2]. The technique of bronchial closure during pneumonectomy is a subject for discussion for many years. In terms of prevention of BPF, two methods of bronchial suturing are available to thoracic surgeons in pneumonectomy: the mechanical suture using staplers and the manual suture using interrupted or running material. In this study we analyze the incidence of BPF by collecting a consecutive series of 45 patients undergoing pneumonectomy by the same operator and we describe the posterior membranous flap technique, a manual method of bronchial closure. It is the technique which was first proposed by Gordon Jack in 1965.
2.1. Patients From 1999 to 2005, 45 pneumonectomies were performed using the posterior membranous flap technique in our department – the clinical characteristics of the series are shown in Table 1.
2.2. Surgical procedure The described technique is based on the construction of a pliable posterior flap from the membranous bronchial wall, which eventually will be stitched to the cartilaginous trachea and bronchus, leaving no stump and no tension in the suture line.
2.2.1. Right pneumonectomy
2.2.2. Left pneumonectomy A right-sided double lumen tube is used. The left bronchus is dissected free to the main carina and all glands are excised. A clamp is placed on the distal bronchus and the lung is removed. With traction on the bronchus by the assistant, two stay stitches are inserted, one into the carina, the other into the lowest trachea. An incision is made on the membranous tracheal wall (Fig. 2), heading to the bronchus in a curved fashion. The resultant membranous flap may be trimmed if it is considered bigger than is required. The closure of the bronchial opening starts from above, by taking a wedge of the cartilaginous portion and inserting the first two stitches while the assistant exerts traction on the stay stitches. The rest of the closure is completed in a similar way to that of the right side, excising the cartilaginous part flush to the carina. Periodical ventilation is carried out by the anesthetist while the surgeon closes the bronchial opening with a swab. The ‘tapering’ of the membranous part into the cartilaginous bronchus is achieved by taking small bites on the flap and bigger bites on the cartilage. The bronchial closure is tested and the esophageal and pericardial tissue are approximated over the suture line as described above. On releasing the stay stitches, the construction is pulled into the mediastinum, underneath the aortic arch. Again, neither tension nor bronchial remnant exists.
2.3. Study protocol and patient follow-up All data were collected from our database (the operation reports, hospitalization notes and outpatients visits). The follow-up period was defined at 12 months postoperatively. The main criterion for the evaluation of our technique was the incidence of BPF that was defined as any disruption situated on the bronchial stump suture line, regardless of its size. The current clinical condition of the patient and the chest X-ray were the two initial criteria of suspicion for BPF development.
Pneumonectomy with posterior membranous flap was the one technique which was performed and carried out in 45 patients. Our experience in this technique and our excellent results in previous institutes were the main criteria for applying that procedure as the only choice for pneumonectomy. The limited number of pneumonectomies can be explained by our strategy to give priority to less invasive procedures (lobectomy or sleeve lobectomy) over the pneumonectomy. Sixteen right (35.5%) and 29 left (64.5%) pneumonectomies were performed. The postoperative respiratory restriction and the increased morbidity and mortality associated with the right pneumonectomy led us to be highly hesitant over that procedure. None of the patients had BPF in a 12-month period of postoperative follow-up. One patient developed empyema in the pneumonectomy space but no fistula was found in this patient. The empyema was treated by drainage without further consequences. The mean postoperative hospital length of stay was 9.2 days (range 7–14). Three patients died within a 30-day period postoperatively – all because of cardiorespiratory insufficiency unrelated to the surgical technique – 30-day operative mortality 6.6%.
4.1. The incidence, the etiology and the risk factors for BPF The incidence of BPF after pneumonectomy varies from 0 to 28% [2, 3]. This variation is associated with the etiology, the existence of risk factors, the surgical technique and the experience of the surgeons [4]. In terms of etiology, the development of BPF is strongly associated with the presence of lung cancer, especially in the case of advanced cases, residual tumor on the stump and the use of chemotherapy [1]. Many putative risk factors are discriminated into preoperative, intraoperative and postoperative. The preoperative risk factors include the neoadjuvant treatment, the fever, the use of steroids, the anemia and the elevated erythrocyte sedimentation rate [1, 5]. The performance of right pneumonectomy [6], the excessive stump length [7], the bronchial closure under tension [8], the residual tumor at the bronchial mucosa [6], the extended mediastinal lymph node dissection [3], the invasive chest procedures (central line placements) [1] and the experience of the surgeon [4, 7], are thought to be of great importance as intraoperative risk factors that increase the incidence of BPF. The postoperative factors that have been implicated are the need for mechanical ventilation [3], tracheostomy or bronchoscopy after the operation, the diameter of air leak [9], the timing of the chest tube removal [10], the leukocytosis and the fever. Additionally, a large number of systemic factors like bronchiectasis, tuberculosis, the ARDS which requires high pressures on ventilator, COPD, malnutrition, advanced age, immunosuppression, DM or parenchymatic lung abnormalities seem to participate in the pathogenesis of BPF [1]. The lack of statistical power due to the insufficient number of BPF in the literature makes the statistical meaningfulness of these risk factors relatively weak. 4.2. The role of bronchial stump closure technique The method of bronchial closure is a very important factor for the prevention of BPF but remains a controversial topic. There are no randomized studies to allow statistically safe conclusions about which technique is best. Many authors support the advantages of stapled bronchial sutures [6, 11]. The minimized contamination of the operative field and the shorter time which is required for the closure are the main advantages of mechanical stapled suturing [3]. One of the disadvantages of stapler usage is that not all stumps can be closed with a stapler, leading the surgeon to close a difficult stump without much experience or confidence in a sutured closure [2].On the other hand, there are Institutes that support the superiority of the manual suturing of the bronchus [5, 8, 12, 13]. Being supporters of manual closure, we also had no incidence of BPF in our center in 45 performed pneumonectomies with the above described technique. We believe that the manual closure by the posterior membranous flap is a reliable technique which minimizes the risk of injury to the microcirculation of the bronchus. Two major factors for the occurrence of BPF are: (a) the tension in the suture line and (b) the incomplete removal of the stump from the resected bronchus. The manual suturing of the open bronchus is nowadays the gold standard technique for all cases of an intraoperative negative bronchial margin, assessed by frozen section, and should be always performed when the stapled closure should be avoided due to calcification of the cartilaginous part of the bronchial wall or when massive hilar adenopathy co-exists. An advantage of the manual suturing of the bronchus is that it can be applied in tumors close to the carina when stapling will endanger incomplete resection. The easy inspection of the bronchial mucosa, the easy assessment of the length and quality of the bronchial opening, the aspiration of bronchial secretions and, in some cases, the recovery of tumor fragments are also significant benefits of the manual closure technique [5]. The coverage of the bronchial stump is another topic for discussion relative to the prevention of BPF [14]. Vascularized tissue coverage of the closed main bronchial stump reduces the incidence of BPF and is extremely useful when previous radiation or right pneumonectomy had taken place [2]. Our technique includes in its final step the coverage of the bronchial closure by suturing the pericardium to the esophageal wall both in left and right pneumonectomy. This covering is performed without significant tension because of the absence of bronchial stump and requires only a small number of sutures. Thus, with this technique an adequate bronchial coverage is performed making our method safer. 4.3. The prevention of the BPF The optimal approach to postpneumonectomy BPF is prevention. Preoperative conditions like anemia, COPD, DM and malnutrition must be first addressed and treated prior to the operation. Antimicrobial therapy is necessary for patients with infections because of the risk of empyema. Anti-tuberculus therapy is needed in case of pulmonary tuberculosis which requires pneumonectomy.During the operation the surgeon should be very careful to avoid the excessive bronchial devascularization or the ligation of bronchial arteries as well as the excessive use of electrocautery. Although stapling of the bronchus has the advantage of avoidance for the contamination of the pneumonectomy space, the potential injury to the microcirculation of the stump is an important issue to consider. Nonabsorbable braided sutures (silk or polyester) should be avoided in the closure of the bronchus, as granuloma formation has been reported. Vascularized tissue coverage (pericardium, omentum, pleura etc.) should be considered as a final step for the prevention of BPF at the completion of the operation [2]. As we mentioned above, there are no valid statistical data relative to which technique is the safest for the prevention of BPF. The surgeon must balance the advantages and disadvantages in order to select the most appropriate approach for the patient. Postoperatively, early signs of infection might indicate BPF or empyema and should be treated with thoracoscopic or open drainage [15]. A prolonged drainage of a sterile hemithorax after pneumonectomy should also be avoided. The tube can function as a source of transferred skin bacteria into the pleural fluid. In summary, the results of our study suggest that the manual closure with the formerly described posterior membranous flap technique is an excellent method for the avoidance of BPF. In accordance with the previous researchers who performed the same technique, we found no incidence of BPF, confirming in this way the effectiveness of the method.
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Abstract
1. Introduction
ar A, Dudu C, Arman B. Detecting the limits of bronchial closure methods in an animal model. Thorac Cardiovasc Surg 2006;54:193–197.
