Interact CardioVasc Thorac Surg 2009;8:442-443. doi:10.1510/icvts.2008.197434
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Pulmonary |
Spontaneous bronchopleural fistula following lung volume reduction surgery for emphysema
Arman Kilica,
Frank C. Sciurbab,
James D. Luketicha and
Sebastien Gilberta,*
a Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
b Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
Received 25 October 2008;
received in revised form 6 January 2009;
accepted 7 January 2009
*Corresponding author. UPMC Presbyterian, 200 Lothrop St., Suite C-800, Pittsburgh, PA 15213, USA. Tel.: +1 412-647-4786; fax: +1 412-647-3104.
E-mail address: gilbsx{at}upmc.edu (S. Gilbert).
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Abstract
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Five days following bilateral thoracoscopic lung volume reduction surgery for emphysema, a 63-year-old man underwent reoperation for closure of a massive bronchopleural fistula. It was discovered intraoperatively that the fistula was located distant from prior staple lines or resection sites from his surgery. This case is an example of what may be a unique pathophysiologic mechanism of bronchopleural fistula formation – a ‘stress rupture’ of the lung parenchyma following lung volume reduction surgery.
Key Words: Bronchoscopy/bronchus; Fistula; Lung volume reduction; Emphysema; Thoracoscopy/VATS
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1. Introduction
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We present a unique mechanism of bronchopleural fistula formation following lung volume reduction surgery – a ‘stress rupture’ of the lung parenchyma secondary to the physiologic effects of the operation.
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2. Case report
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A 63-year-old man with diffuse emphysema underwent uncomplicated thoracoscopic lung volume reduction surgery (LVRS). Approximately 60% of the right and left upper lobes were removed using a surgical stapler with bovine pericardium buttressing. No air leak was present at the end of the case and two chest tubes were placed in each hemithorax. The patient did well until the second postoperative day when he developed a large right-sided pneumothorax and air leak associated with cough. He had an acute onset of respiratory distress with rapid desaturation and tachypnea requiring intubation. The air leak persisted after intubation and positive pressure ventilation. His hemodynamic status deteriorated secondary to elevated pulmonary artery pressure related to respiratory insufficiency. On the fourth postoperative day, venoarterial extracorporeal membrane oxygenation (ECMO) was instituted. The patient was also found to have an infarcted right colon requiring urgent hemicolectomy. On postoperative day 5, the patient underwent reoperation for his persistent bronchopleural fistula (BPF). The fistula was identified in the right lower lobe at a site distant from any prior staple lines and there was no evidence of prior iatrogenic injury to the parenchyma. The right lower lobe was relatively spared from parenchymal destruction and no emphysematous blebs were seen in the area of the BPF in preoperative CT-scans. This area of the lung was resected with no complications. He was eventually weaned off of ECMO after two weeks and was transferred to rehabilitation on mechanical ventilation after a one-month stay.
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3. Discussion
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LVRS for emphysema was first described in 1959 by Brantigan et al. [1] and re-popularized by Cooper and colleagues in 1995 [2]. The most common complication of LVRS is air leak, with up to 50% of patients experiencing a prolonged air leak lasting seven days or longer [3]. Intraoperative measures to prevent air leaks include buttressing of the stapled resection with bovine pericardium, as was done in this case. Parietal pleural flaps and synthetic sealants have also been used with some reported success. Although some air leaks may develop in a delayed fashion, the majority are present from the time of surgery. Air leaks are usually managed with chest tube drainage and rarely require reoperation. Most leaks are found to originate within 2 cm of the staple line, and the affected area can be resected if the patient has sufficient pulmonary reserve [4].
Approximately 5–10% of patients undergoing LVRS require reintubation and mechanical ventilation for respiratory failure [4]. A portion of these are due to BPF, which is defined as an abnormal communication between the bronchial tree and pleural space and is most commonly seen as a complication of lung resection [3]. Inflammatory disease of the lung, larger resections, preoperative chemotherapy or radiation, diabetes, residual tumor of the bronchial stump, older age, steroid use, and right-sided resections have all been implicated as risk factors for BPF. When BPF occurs in the early postoperative period, it is thought to arise from technical factors such as incomplete stapling or suturing of the bronchial stump. These tend to manifest as massive air leaks and subcutaneous emphysema with urgent surgical closure being indicated as the treatment of choice. BPF that occurs after seven days postoperatively is usually due to ischemia or necrosis secondary to residual tumor, extension of an empyema, or inadequate vascular supply of the bronchial stump [4]. BPF can also develop during positive-pressure mechanical ventilation as a consequence of alveolar overdistension and spontaneous rupture, often referred to as ‘barotrauma’.
Given that the BPF in this patient presented in the early postoperative period, the expected source would be failure at the surgical staple line. However, this was not the case at reoperation, and, therefore, a different pathophysiologic mechanism may have been responsible for the acute BPF. Moreover, the symptomatic benefit afforded by LVRS is thought to be due to an increase in elastic recoil, with a concomitant decrease in pleural pressure (i.e. more negative intrathoracic pressure), and these effects can be appreciated in the immediate postoperative period [5]. Therefore, effective volume reduction could theoretically lead to enough outward tension on the bronchial wall to cause a ‘stress rupture’ and subsequent fistulization with the pleural space. We believe this was the scenario in our patient given the isolated location of the BPF. This case underscores the importance of a thorough exploration of the lung in LVRS patients who are undergoing reoperation for suspected BPF.
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References
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- Brantigan OC, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Ann Rev Respir Dis 1959;80:194–206.
- Cooper JD, Trulock EP, Triantafillou AN, Patterson GA, Pohl MS, Deloney PA, Sundaresan RS, Roper CL. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–116.[Abstract/Free Full Text]
- Cooper J, Patterson G. Lung volume reduction surgery for severe emphysema. Semin Thorac Cardiovasc Surg 1996;8:52–60.[Medline]
- Shen KR, Swanson SJ. Perioperative complications and their management. In: Fessler HE, Reilly JJ, Sugarbaker DJ, Lung Volume Reduction Surgery for Emphysema. New York, NY: Informa Healthcare; 2004, 280.
- Gelb AF, McKenna RJ Jr, Brenner M, Fischel R, Baydur A, Zamel N. Contribution of lung and chest wall mechanics following emphysema resection. Chest 1996;110:11–17.[CrossRef][Medline]
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Abstract
1. Introduction