TRANSSTERNSL TRANSPERICARDIAL CLOSURE OF

POSTPNEUMONECTOMY BRONCHOPLEURAL FISTULA

Professor

Abdulsalam Y Taha

School of MedicineUniversity of Sulaimani

Iraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

INTRODUCTION

Bronchopleural fistula (BPF) is a communication between the bronchial tree and the pleural space.

Types: Postresectional (postlobectomy &

postpneumonectomy) Without lung resection● Postpneumonectomy BPF is more serious and

more difficult to treat than postlobectomy BPF.

INTRODUCTION

Early( acute) BPF: up to 2 weeks after pneumonectomy.

Late (chronic): even years after operation. Regardless the time of occurrence or cause

of BPF, it is always serious. Once postpneumonectomy BPF occurs, then the patient's life is in danger as there is immediate flooding of the remaining single lung with fluid or pus( drowning).

INTRODUCTION

BPF is usually associated with empyaema, this will complicate the picture.

The diagnosis is based on clinical & radiographic grounds.

Cough, expectoration of serosanguinous or purulent fluid, SOB and fever.

CXR: a new gas-fluid level or lowering of a previous gas-fluid level.

INTRODUCTION

Immediate management: positioning of patient with pneumonectomy side lower down and tube thoracostomy drainage of the pleural space.

Antibiotics. Supportive measures: correction of anaemia &

malnutrition. Late management: definite closure of BPF and

obliteration of the space.

INTRODUCTION

There is no standard treatment for this complication and the successful management is a challenge to the thoracic surgeon.

Most of the treatment options are staged procedures.

Transsternal transpericardial closure (TSTP) is attractive as it is a one stage operation, that avoids the infected pneumonectomy space and does not result in patients disfigurement.

INTRODUCTION

TSTP was first used in Italy in 1961 and then used extensively in the former Soviet Union.

It can be used for late postpneumonectomy BPF which failed to close by other methods

Or as a primary repair option. It can be used for R or L side fistulae. Technique….

INTRODUCTION

The single disadvantage of TSTP closure is that it does not address the problem of the pneumonectomy space.

Herein, we report a case of chronic BPF after pneumonectomy successfully closed via the transsternal transpericardial approach.

The relevant literature is reviewed to throw light on the indications and the results of this operation.

CASE

A 38 yrs old lady. Fever, SOB & productive cough for few months. R pneumonectomy 2 yrs earlier in another city for

BGC. No op notes but a histopathological report of

bronchial tumour: large-cell anaplastic carcinoma. O/E: toxic-looking dyspnoic patient. Bronchial

breathing on R chest.

CASE

A gas-fluid levelgetting lower with repeat films.

CASE

The clinical & radiographic picture was consistent with postpneumonectomy BPF.

Initial management: Tube thoracostomy: air & thick offensive pus. Antibiotics. Position: semi-recumbent avoiding lying on L side. Significantly improved despite persistent large air leak. Continuous irrigation of the pleural space via a catheter

in 2nd intercostal space with N/S and antibiotics.

Irrigating catheterand

a chest tubein right pleural space.

CT scan:thickened pleura

CT scan:R side

mediastinalshift

CT scan: RMB communicates with pneumonectomy space.

CASE

Fiberoptic bronchoscopy: no evidence of recurrent tumour, long bronchial stump opening into the pleural space at bronchus intermedius level.

DEFINITE MANAGEMENT

Under GA via a single lumen ET tube in supine position.

Median sternotomy. Dissection of thymus off the pericardium. Opening of anterior pericardium; retracted by stay

sutures. Dissection & encirclement of AA; retracted to left. Retraction of SVC to the right.

TSTP CLOSURE

R main pulmonary artery is dissected and encircled by a tape; divided and its 2 ends are sutured by 2 layers of continuous 4-0 prolene.

R bronchial stump was dissected and encircled by a tape; divided and its 2 ends are sutured by 2-0 vicryl sutures. The proximal stump was enforced by thymic tissue.

TSTP CLOSURE

Haemostasis. Anterior mediastinal drain. Routine wound closure. In theatre extubation. Air leak immediately & completely stopped. ICU admition. Mediastinal drain removed after 24 hrs.

POSOPERATIVE MANAGEMENT

Irrigation of pneumonectomy space continued for 3 weeks.

Open window thoracostomy was done 3 weeks later for drainage of the space.

Discharged home well. Follow-up for 6 months: no recurrence of fistula. Home management: frequent dressing change.

TSTP REPAIROF BPF

TSTP REPAIROFBPF

TSTP REPAIROFBPF

TSTP REPAIROFBPF

TSTP REPAIROFBPF

TSTP REPAIROFBPF

DISCUSSION

Postpneumonectomy empyaema (PNE) occurs in 3% of cases.

80% of PNE have a BPF. Mortality of PNE with a BPF is 11 to 13%. Small uncomplicated BPFs may heal spontaneously. In 20% of patients, BPFs will close with drainage

only. The remaining 80% of cases (persistent BPFs)

require surgery.

DISCUSSION

The occurrence of a BPF after pneumonectomy is an infrequent but severe complication accompanied by a high morbidity and mortality.

The incidence of BPF after pulmonary resection varies from 0.5% to almost 10% in different series and has reached 28% after pneumonectomy for TB.

DISCUSSION

In the early postoperative phase and up to 2 weeks after lung resection, immediate operation through the pneumonectomy cavity with resection and reclosure of the stump is the recommended surgical procedure.

However, the management of chronic BPF and empyaema has been a subject of controversy. Both the time of intervention and the type of surgical technique reported by various authors differ.

No technique can be applied to all patients. Even for similar defects, an individual treatment plan

must be made.

DISCUSSION

Bronchoscopic cauterization of the fistula, application of fibrin glue and bone spongiosa are only effective in a limited number of patients and are accompanied by a high percentage of relapses.

Recently, a video-assisted approach through the mediastinum is described.

DISCUSSION

Various systemic factors and therapeutic interventions often contribute to the risk of PNE and BPF, including age in men above 70, preoperative radiation, malnutrition, and prolonged steroid therapy. In addition, technical factors such as prior lung resection, infection at a long bronchial stump site, and residual sepsis in the pleural space may further contribute to the development of this complication.

PREVENTION

PNE & BPF are best prevented by: Minimization of preoperative sepsis. Careful closure of the bronchial stump. At the time of pneumonectomy, care should

be taken to avoid devascularization and excessive length.

The use of vascularized flaps to reinforce the bronchial stump.

DISCUSSION

The goals of surgery in postpneumonectomy BPF are:

Drainage of the infected pneumonectomy space.

Closure of the BPFObliteration of the space.

DISCUSSION

Drainage can be achieved by tube thoracostomy initially and later by open window thoracostomy.

Obliteration of the space can be achieved by thoracoplasty, thoracomyoplasty or omentoplasty.

DISCUSSION

Thoracoplasty is resection of most of the ribs on one side in 3 stages to allow the muscles of the chest wall to fall down and obliterate the pleural space. The operation results in significant disfigurement of the patient.

Thoracomyplasty is a plastic operation in which muscles of chest wall like latissimus dorsi, serratus anterior, pectoralis major or rectus abdominus are mobilized as vascularized flaps to obliterate the pleural space and reinforce the bronchial stump closure.

THORACOMYOPLASTYAND

THORACO-OMENTOPLASTY

DISCUSSION

Muscle-flap closure of BPFs has been associated with a more than 80% success rate.

The main disadvantage of the previous methods of fistula repair is the access via infected pneumonectomy cavity and a long period of hospitalization.

DISCUSSION

TSTP closure of BPF was first described in Italy in 1961. In 1985, its use was renovated in North America by Baldwin and Mark.

This approach has valid theoretical advantages: a relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and chronic sepsis, and the avoidance of chest wall deformity.

DISCUSSION

The single disadvantage is that the residual empyaema space is not dealt with at the same session, unlike thoracoplasty or thoracomyoplasty.

Ginsberg and colleagues have suggested that the TSTP approach is the most effective method for closure when other strategies have failed, or when a direct approach through the thoracotomy space is not warranted.

DISCUSSION

Prior to surgery the pneumonectomy cavity needs to be drained by a chest tube, and rinsed and cleaned with normal saline solution or povidone iodine daily.

Preoperative bronchoscopic inspection of the size and length of the bronchial stump as well as its course is necessary. If the stump is shorter than 1 cm, a direct closure is improbable.

DISCUSSION

Shorter stumps can be amputated level with the carina and the resultant defect is either primarily closed or the omentum is used for closure.

The distal bronchial stump can be resected or left in situ after cauterization of the mucosa.

The detection of a cancerous tissue is a contraindication for this operation.

CONCLUSIONS

BPF after pneumonectomy is associated with significant morbidity and mortality.

It has no standard therapy. The successful management is a challenge

to the thoracic surgeon. TSTP approach is highly effective and offers

advantages over the direct approach through the infected empyaema cavity.

THANKS FOR LISTENING