Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach

Treatment of late left bronchopleural fistula after left pneumonectomy through right thoracic approach assisted by extracorporeal membrane oxygenation

BACKGROUND

Bronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO).

CASE PRESENTATION

We report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO).

CONCLUSIONS

Advanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula

INTRODUCTION

This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula.

MATERIALS AND METHODS

The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated.

RESULTS

The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence.

CONCLUSIONS

The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Management of Postpneumonectomy Bronchopleural Fistula: From Thoracoplasty to Transsternal Closure

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.

Tuberculosis: mother of thoracic surgery then and now, past and prospectives: a review

Knowledge on ontogenesis of thoracic surgery is essential not only for understanding present concepts and debates on surgery for tuberculosis, but it also contributes to the further developments in operative treatment of lung cancer. Both diseases have been the leading cause of death in their respective ages. History of tuberculosis follows the classic algorithm: diagnostic, casuistic and therapeutical stages. Villemin followed by Virchow, and, finally, Koch revealed the pathoanatomy and the cause of tuberculosis. The therapeutic phase of lung cancer has been reached without identified cause of the disease. Chest surgery, eradication of the macroscopic focus by physical interference with the involved tissue mass, in both diseases preceded medical treatment. Identification of phenotypes of lung cancer-if it is a single disease at all-does not contravene the concept: the tumor mass should been eliminated. However, causation is not an absolute sine qua non of an effective treatment, as the tuberculosis-lung cancer analogy also proves. Surgical approach of both diseases suffered from the same paraoxon: eradication without direct interference with the causative factor. While lung cancer seems to be controlled by an emerging array of new drugs, tuberculosis poses a new challenge, as multidrug resistant and extensively drug resistant Koch bacteria are emerging and fragile societies' immunity is weakening. Thoracic surgery has a significant share in the fight against tuberculosis, when drugs and/or society fail. Palliative and radical adjuvant surgery multiplies the chance of cure in those cases, where not much hope is left. The jury is still out in a series of questions, but it is obvious, that surgery is only an option and not a panacea where medicines and their providers fail. Deeper understanding of our past and present failures with tuberculosis and its surgery might contribute to new concepts in coping with lung cancer as well.

Management Strategies for Complex Bronchopleural Fistula

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.

Comparative study of the resistance of manual and mechanical sutures in the bronchial stump of dogs submitted to left pneumonectomy

OBJECTIVE

To compare the resistance of manual suture with that of mechanical suture immediately after the suture of the left bronchial stump of dogs submitted to pneumonectomy.

METHODS

A total of 15 mixed-breed dogs of both genders, each weighing between 8 and 23 kg, were randomly divided into 2 groups. In group I (n = 7), the bronchial stump was sutured manually (the Sweet method) and, in group II (n = 8), it was stapled. Immediately after the closure of the bronchial stump, the intratracheal pressure was progressively increased in a controlled manner.

RESULTS

The mean rupture pressure of the bronchial stump suture line was 33.71 mmHg in group I and 89.87 mmHg in group II (p < 0.01).

CONCLUSION

These data allowed us to conclude that mechanical suture of the bronchial stump, submitted to pressure immediately after closure, is more resistant than is manual suture in dogs submitted to pneumonectomy.

Postpneumonectomy and Postlobectomy Empyema

Although similar strategies are used in the management of PPE and PLE, these conditions need to be viewed as two separate entities. For the purpose of devising the appropriate management strategy, PPE should be divided into early and late, with and without mediastinal induration and extensive pleural space contamination. If at all possible, PLE should be managed as a postpneumonic empyema with prolonged chest tube drainage. The key to these conditions is prevention.

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

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.

A simple solution for management of the postpneumonectomy empyema cavity

Postpneumonectomy bronchopleural fistula with empyema is a difficult problem. Once the fistula is healed, successful closure of the pleural space is associated with varying degrees of success, as well as the potential for major reconstructive surgery. My colleagues and I describe a simple approach for the definitive management of the open pleural space involving split-thickness skin grafts to marsupialize the pleural cavity.

Management of empyema after lung resections (pneumonectomy/lobectomy)

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.

Postpneumonectomy empyema

Empyema is a serious complication after pneumonectomy. It is often associated with a bronchopleural fistula. Several risk factors have been associated with an increased incidence of these two challenging complications. Therapy aims at simultaneously treating the infected pleural space and the fistula. The authors describe their favorite methods which include repeated open debridements of the pleural space, primary closure of the fistula, and covering of the bronchial stump using intrathoracic transposition of extrathoracic skeletal muscle followed by delayed closure of the chest wall after instillation of an antibiotic solution (Clagett and modified Clagett procedures). The goals of treatment remain a healthy patient with a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients. Failure is often associated with a persistent or recurrent bronchopleural fistula.

Transsternal transpericardial closure of a postlobectomy bronchopleural fistula

We report a case of chronic empyema and bronchopleural fistula after lobectomy for tuberculosis. The patient had undergone four different surgical procedures to correct his bronchopleural fistula during an interval of seven years. Finally, he had a successful closure of the fistula using the transsternal transpericardial approach.

Management of postpneumonectomy empyema and bronchopleural fistula

Empyema after pneumonectomy is often associated with a bronchopleural fistula (BDF) and has a significant mortality. Management options include systemic antibiotics and observation, adequate pleural drainage, appropriate parenteral antibiotics, removal of necrotic tissue, and obliteration of residual pleural space. We prefer to treat the empyema with the procedure originally described by Clagett and Geraci in 1963. They demonstrated that postpneumonectomy empyema could be successfully treated by open pleural drainage, frequent wet-to-dry dressing changes, and when the thorax was clean, secondary chest wall closure with obliteration of the pleural cavity with an antibiotic solution. Failure was most often caused by a persistent or recurrent fistula. Because of this, when a BPF is present, the original Clagett technique was modified to include transposition of a well-vascularized muscle to cover the stump at the time of open drainage to prevent further ischemia and necrosis. Our preference is intrathoracic transposition of extrathoracic skeletal muscle. The goals of therapy for postpneumonectomy empyema remain a healthy patient with a a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients by using the Clagett procedure and intrathoracic muscle transposition when a BPF is present.

Management of the recalcitrant postpneumonectomy bronchopleural fistula: the transsternal transpericardial approach

The authors review the management of postpneumonectomy bronchopleural fistulae and describe the place of the transsternal transpericardial approach, especially in the management of recalcitrant postpneumonectomy bronchopleural fistulae. The technique is described in detail, and the results of the published series are analyzed. The authors do recommend the use of this approach in the recalcitrant fistula that has failed standard approaches.

Transsternal approach to closure of bronchopleural fistulas after pneumonectomy. A fifteen cases report

A treatment method for main bronchus fistula after pneumonectomy via median sternotomy was described by P. Abruzzini in 1961. This operation is performed in an area not involved with infection. Fifteen patients underwent the procedure in our surgical department; one of them died of myocardial infarction while all the others survived for different periods of time, closely associated with the original disease; seven were long-term survivors. The transmediastinal approach seems an effective means of managing such a difficult complication.

Transsternal transpericardial approach for the repair of bronchopleural fistula with empyema

BACKGROUND

Numerous surgical approaches have been reported for the repair of bronchopleural fistula. Recently the transsternal transpericardial approach has shown great promise with its positive results in cases of bronchopleural fistula complicated with empyema. The aim of this retrospective study was to assess the results of bronchopleural fistula treatment using the transsternal transpericardial approach.

METHODS

Bronchopleural fistula developed in 16 of the 172 patients who had pneumonectomy between 1982 and 1996. In one case closure with fibrin sealant by bronchoscopy was tried. In the remaining cases fistula was closed by the transsternal transpericardial approach.

RESULTS

The interval between pneumonectomy and fistula occurrence was 10 days or less in 5 patients and 10 days to 1 month in 11 patients. In all patients the empyema space was treated by continued drainage through the thoracostomy tube. Fibrin sealant was tried unsuccessfully for closure of moderate-sized bronchopleural fistula in one case. In three cases of right bronchopleural fistula, carinal resection and anastomosis of the trachea to the left main stem bronchus were performed. In the remaining cases bronchopleural fistula was closed using a hand suture technique. One patient died within 30 days after operation (6.25%) because of renal insufficiency. There was no recurrence of bronchopleural fistula.

CONCLUSIONS

Transsternal transpericardial approach seems to be a safe and effective method with an easier technique in cases of bronchopleural fistula complicated with empyema. It has the added advantage of less recurrent fistula formation and enables resection in cases without sufficient bronchial stump.

Andrews thoracoplasty as a treatment of post-pneumonectomy empyema: experience in 23 cases

BACKGROUND

Andrew's thoracopleuroplasty has been described for treating tuberculous empyemas with bronchopleural fistulas. We report on its utilization for treating postpneumonectomy empyemas.

METHODS

During a 25 year period, 23 patients underwent thoracopleuroplasty for treating postpneumonectomy empyemas, after a period of drainage-irrigation of the cavity. Seven patients presented with persistent bronchial fistula at operation. After resection of the costal arches surrounding the infected cavity, the cavity was cleaned, and the external parietal plane was sutured to the mediastinal plane. Only drainage of the subscapular space was left in place.

RESULTS

Postoperative mortality was 4.3%. Postoperative recovery was simple in 17 cases, whereas a superficial abscess was evacuated in 3 cases. The procedure failed in 3 cases, which were treated by open thoracostomy (2), and by reenlargment of the thoracopleuroplasty (1). The sequelae were mainly a diminution of the shoulder mobility, especially when the first rib was resected.

CONCLUSIONS

Thoracopleuroplasty may safely treat postpneumonectomy empyemas, even those with bronchial fistulas. Most patients are definitively and rapidly cured with limited sequelae.

Surgical treatment of pleural empyema--changing priorities

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.

Posptneumonectomy empyema

OBJECTIVE

Postpneumonectomy empyema can be managed in many different ways, with variable results. In the presence of bronchopleural fistula treatment is much more complicated. The results of therapy of postpneumonectomy empyema managed by thoracomyoplasty and closure of the bronchial fistula by pedicled muscle flap are presented.

METHODS

Seven hundred and seventy-eight pneumonectomies had been performed for bronchogenic carcinoma. Empyema occurred in 35 (4.5%) cases. There were 22 (62.8%) patients with associated bronchopleural fistula. Depending on their management, patients were divided into two groups: I: 15 patients managed with tube and/or open-window thoracostomy only, II: 20 patients who were treated with thoracomyoplasty, which meant the excision of the fibrotic thoracic wall, combined with the transposition of the pedicled muscle flap into the empyema. There was a need to resect three to four ribs. Eight patients had large bronchopleural fistulas. Before thoracomyoplasty was conducted, tube drainage ranged from 16 to 120 days (average 46.6 days), the open-window thoracostomy ranged from 27 days to 13 years (average 574 days).

RESULTS

Only one patient from group I was cured, there were five (33.3%) deaths. Nineteen (95.0%) patients from group II were successfully cured. Eight large bronchial fistulas were closed by suturing the muscle flap into the fistula lumen. The length of hospitalisation ranged from 9 to 30 days (median 17.6). The mortality rate in this group was 0%.

CONCLUSIONS

The excision of the thoracic wall combined with the transposition of the pedicled muscle flap is safe and effective in the management of postpneumonectomy empyema. Bronchopleural fistulae can be definitely closed by suturing the pedicled muscle flap into fistular lumen.

Transsternal closure of bronchopleural fistula after pneumonectomy

BACKGROUND

Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula.

METHODS

From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done.

RESULTS

Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy.

CONCLUSIONS

Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Life-saving muscle flaps in tracheobronchial dehiscence following resection or trauma

OBJECTIVE

In the presence of acute inflammation and necrosis of the wall, tracheo-bronchial defects are difficult to manage. The absence of adequate vascularization and the contaminated area prevent successful direct re-suturing.

METHODS

In order to restore a sufficient blood supply we used a pedicled latissimus dorsi or a pectoralis major flap that was entered into the thorax after a 10-cm resection of the second rib. A portion of the muscle was fitted into the tracheo/bronchial defect by reinforced sutures. The remaining muscle was sutured to the tissue surrounding the defect. This method was applied in various septic conditions: Bronchial defects; complete dehiscence of the right (n = 6) or left (n = 1) main bronchus at the carinal level following resection for lung cancer (n = 4) or for tuberculous (n = 2) on nontuberculous pleuropneumonia (n = 1). Tracheal defects; (1) destruction of one third of the tracheal circumference involving the cricoid down to the fourth ring following tracheotomy in presence of a septic sternum after intrathoracic goiter and Bechterew's disease; (2) 30% dehiscence of the anastomosis and septic sternum following tracheal resection; (3) Mediastinitis involving tracheal and esophageal wall following a 7 cm long iatrogenous laceration of the intrathoracic trachea.

RESULTS

In one case the latissimus dorsi developed venous stasis on day 2 and was replaced by the pectoralis major muscle which showed uneventful healing. In all other patients the muscle flap resulted in an uneventful closure of the defect and recovery.

CONCLUSIONS

Large, well vascularized, pedicled muscle flaps ensure a safe closure of tracheo-bronchial defects or dehiscences even in presence of gross necrosis and sepsis.

Closure of a postpneumonectomy main bronchus fistula using video-assisted mediastinal surgery

Disruption of a mainstem bronchus is a rare but dreaded complication of pneumonectomy. After an anatomic study on cadavers, we successfully used a video mediastinoscope to close a postpneumonectomy main bronchus fistula via a cervical incision.

Bronchopleural fistula after pneumonectomy with a hand suture technique

We have reviewed the incidence of bronchopleural fistula among 530 consecutive pneumonectomies, all carried out by one surgical team using a uniform suture technique between January 1980 and November 1993. There were 7 fistulas (1.3%); all of them occurred within 15 days postoperatively. There were no cases of late fistula during a mean follow-up period of 23 months. The pathology for which pneumonectomy was undertaken was primary lung malignancies in 488 cases (92.1%), metastatic disease in 15 cases (2.8%), and benign diseases in 27 cases (5.1%). All fistulas developed after pneumonectomy for lung cancer. Other risk factors included age, preoperative radiotherapy, and the surgeon's level of experience, as only two fistulas occurred with the consultant who performed 410 pneumonectomies (0.5%). The bronchial stump was free of tumor in all cases. There were no fistulas in the 37 completion pneumonectomies (7%). All fistulas were treated within 2 days of diagnosis by resuturing the stump through the initial thoracotomy incision. That was successful in 5 patients, whereas fatal complications developed in the other 2 patients. We believe that suture closure of the bronchial stump at pneumonectomy provides a cheap and reliable technique that gives good results in all situations.

Postoperative bronchopleural fistula: endoscopic closure in 12 patients

Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (methyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopic gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (< 15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopic treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistulas occurred late after the operation (> 15 days) and all had associated empyema. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.

A case of empyema developing thirteen years after a pneumonectomy treated using pedicled omentum which was followed by intestinal obstruction

Postpneumonectomy empyema is one of the most difficult complications for the thoracic surgeon to treat. We report herein a case of a 62 year old diabetic man who developed empyema 13 years after a pneumonectomy for cancer, which was successfully treated using an omental pedicle flap. Postoperatively, the chest would healed uneventfully, however, a bowel obstruction developed which was subsequently treated by removing the remnant omentum that had adhered to the bowel.

[Extra-pleural approaches in the management of bronchial stump insufficiency following pneumonectomy]

Insufficiency of the bronchial stump is still a dreaded complication. The treatment with the use of extrapleural accesses led to a significant improvement of the therapeutical results. We have to distinguish between transpericardial techniques and the contralateral thoracotomy with transpleural or extrapleural access. If the pleural cavity is still sterile, immediate or four week postoperative insufficiency may be treated using rethoracotomy with resuturing the stump. Coverage of the stump with pedicled muscle tissue provides a rather good method for a secondary treatment of the bronchial stump. When the pleural cavity is already infected, extrapleural treatment of the bronchial stump should be undertaken immediately. In addition, all late insufficiencies are treated extrapleurally. If only a very small opening of a fistula is found, an endoscopical closure of the fistula should be attempted using acryl glue or fibrin glue. Our own therapeutic results concerning four right hand and one left hand stump insufficiency after pneumonectomy are presented in this study and we have classified the up to now published therapeutical results.