CT Follow-Up of Postoperative Bronchopleural Fistula: Risk Factors for Progression to Chronic Complicated Infection

Purpose

Materials and Methods

Results

Conclusion

Preventive Diaphragm Plasty after Pneumonectomy on Account of Lung Cancer

Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.

Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula

BACKGROUND

We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue.

METHODS

We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months.

RESULTS

The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group.

CONCLUSION

Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.

Bronchoscopic blood patch for treatment of persistent alveolar-pleural fistula

Airway pleural fistulas remain a significant treatment challenge despite improved antimicrobial therapy and surgical techniques. We present a case of a 56-year-old female who was admitted with severe bilateral cavitary pneumonia requiring mechanical ventilation. The patient suffered bilateral pneumothoraces related to necrotic pneumonia resulting in bilateral chest tube placement. Despite conservative measures, the air leak persisted preventing chest tube removal. Bronchoscopy with Fogarty balloon (Edwards) occlusion was performed in attempts to isolate an airway responsible for the air leak. No one single airway could be bronchoscopically occluded to isolate the right-sided fistula. Efforts were focused on the left airway where the fistula could be isolated to the anteromedial basal segment. Several alternating layers of an absorbable hemostat (knitted fabric prepared by controlled oxidation of cellulose-Surgicel; Ethicon) were placed within the left anteromedial basal segment using bronchoscopy forceps. Through a cut Fogarty balloon, 3 mL of the patient's blood was delivered onto the absorbable hemostat to create an occluding blood patch. No air leak was present at the completion of the procedure. While on mechanical ventilation, the left chest tube was removed 2 days later without radiographic recurrence of her pneumothorax.

Repair of postpneumonectomy bronchopleural fistula using pedicled pericardial flap supported by fibrin glue

Effective closure of the postpneumonectomy bronchopleural fistula (PBF) with the use of different techniques still remains a challenge for thoracic surgeons. The aim of this study was to evaluate the efficacy of modified method of PBF closure using pedicled pericardial flap (PPF) supported by fibrin glue (FG). The efficacy of the late PBF closure with the use of two surgical methods was compared. In 10 patients, the edges of the PBF were covered with FG and PPF. In the second group of nine patients, myoplasty was used to close the bronchial fistula. Postsurgical follow-up was for 1 year. In the first group, the healing of the fistula was achieved in 100% of the cases, whereas in the second, myoplasty group, healing was achieved in only 66·67% of the cases. The number of complications was similar in both groups. Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of PBF in selected patients.

Comprehensive treatment approach is necessary for the closure of open window thoracostomy: an institutional review of 35 cases

PURPOSE

Although life-threatening situations can be avoided using an open window thoracostomy (OWT), the closure is often difficult. We investigated the predictors of a successful closure of an OWT at the time of OWT creation.

METHODS

Thirty-five consecutive patients who underwent an OWT at our institute between January 1991 and December 2010 were reviewed. We directly compared the patients with and without a successful OWT closure. A logistic regression analysis was employed to determine the predictive factors of a successful closure.

RESULTS

OWT closure was only achieved in 12 patients. The closure of the OWT and absence of diabetes mellitus significantly influenced the survival of the OWT patients. The OWT in patients with preceding lung resection was difficult to close, especially if the underlying disease was lung cancer. The existence of a bronchopleural fistula (BPF) was not related to successful closure. Among the post-lung resection patients, the nutritional status tended to affect the success of the closure.

CONCLUSION

Successful closure is difficult to predict at the time of the creation of an OWT. A comprehensive approach, including nutritional support and the precise timing of intervention is critical to promote a successful closure.

Comparison of different bronchial closure techniques following pneumonectomy in dogs

The comparison of the histologic healing and bronchopleural fistula (BPF) complications encountered with three different BS closure techniques (manual suture, stapler and manual suture plus tissue flab) after pneumonectomy in dogs was investigated for a one-month period. The dogs were separated into two groups: group I (GI) (n = 9) and group II (GII) (n = 9). Right and left pneumonectomies were performed on the animals in GI and GII, respectively. Each group was further divided into three subgroups according to BS closure technique: subgroup I (SGI) (n = 3), manual suture; subgroup II (SGII) (n = 3), stapler; and subgroup III (SGIII) (n = 3), manual suture plus tissue flab. The dogs were sacrificed after one month of observation, and the bronchial stumps were removed for histological examination. The complications observed during a one-month period following pneumonectomy in nine dogs (n = 9) were: BPF (n = 5), peri-operative cardiac arrest (n = 1), post-operative respiratory arrest (n = 1), post-operative cardiac failure (n = 1) and cardio-pulmonary failure (n = 1). Histological healing was classified as complete or incomplete healing. Histological healing and BPF complications in the subgroups were analyzed statistically. There was no significant difference in histological healing between SGI and SGIII (p = 1.00; p > 0.05), nor between SGII and SGIII (p = 1.00; p > 0.05). Similarly, no significant difference was observed between the subgroups in terms of BPF (p = 0.945; p > 0.05). The results of the statistical analysis indicated that manual suture, stapler or manual suture plus tissue flab could be alternative methods for BS closure following pneumonectomy in dogs.

Post-pneumonectomy empyema: Current management strategies

Post-pneumonectomy empyema is an uncommon but potentially life-threatening complication. It has a strong association with bronchopleural fistula, which acts as a continued source of infection into the thoracic cavity. Numerous risk factors have been identified and strategies formulated to minimize its occurrence. When bronchopleural fistula occurs, its treatment depends on several factors including extent of dehiscence, degree of pleural contamination and general condition of the patient. Early diagnosis and assessment with appropriate investigations, and aggressive therapeutic strategies are paramount in controlling sepsis, facilitating closure of fistula, and sterilization of the closed pleural space. Recent success with repeat debridement has made routine space obliteration not mandatory in management. The development of minimal-access interventions including video-assisted thoracic surgery, endoscopic application of tissue glue and stenting may be additional tools to complement conventional surgery in post-pneumonectomy empyema management.