72-Year-Old Female With a Bronchopleural Fistula Status Post Completion Right Pneumonectomy

Abstract

SESSION TITLE: Cardiovascular Disease Case Report PostersSESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PMINTRODUCTION: Incidence of bronchopleural fistula (BPF) after pneumonectomy is reported to be 1-5% for cancer resections, with a reported mortality of 30-50%. It is more common after right-sided pneumonectomy secondary to various considerations including lack of local tissue coverage. Other risk factors include completion pneumonectomy, previous mediastinal/hilar radiation, prolonged mechanical ventilation, post-pneumonectomy empyema, residual tumor at the bronchial stump, and technical factors including devascularization, incomplete bronchial stump closure, or failure to provide supplemental tissue coverage of the bronchial stump. When the bronchial stump remains elongated, this leads to pooling of airway secretions and resultant BPF development.CASE PRESENTATION: 72 year old female who presented with low grade fevers and shortness of breath one and a half weeks after undergoing an open right lobectomy converted to completion pneumonectomy for bronchogenic adenocarcinoma. Intraoperatively it was noted that the bronchial stump was difficult to manage, requiring oversewing and application of tissue adhesive. One month later, the patient was transferred for definitive treatment which included debridement of the right pleural space, resection of the elongated bronchial stump, and intrathoracic transposition of a pedicled right serratus anterior muscle flap. Following serial operative packing exchanges, the modified Clagett procedure was completed with chest closure 8 days after re-exploration.DISCUSSION: Treatment of BPF is divided into acute and chronic phases. If BPF develops early after surgery (within 2 weeks) it is likely related to technical failure of the bronchial stump closure. Clinically it may present as a persistent or continuous air leak, progressive subcutaneous emphysema, and/or respiratory insufficiency/failure. If the BPF develops later in the postoperative course, it is likely due to inadequate healing or rupture of the bronchial stump. These patients usually present with fevers and/or productive coughs and are in danger of aspiration though the bronchial stump into the contralateral lung.CONCLUSIONS: At the time of reoperation, the bronchial stump should be covered with a vascularized pedicle of tissue including either muscle, pericardial fat pad, or omentum. If the pleural space appears clean, it may be closed using the Clagett procedure.Reference #1: Liberman M. and Cassivi SD. Bronchial Stump Dehiscence: Update on Prevention and Management. Seminar of Thoracic and Cardiovascular Surgery. 2007: 19:366-373.DISCLOSURE: The following authors have nothing to disclose: Lawrence Greiten, Stephen CassiviNo Product/Research Disclosure Information SESSION TITLE: Cardiovascular Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Incidence of bronchopleural fistula (BPF) after pneumonectomy is reported to be 1-5% for cancer resections, with a reported mortality of 30-50%. It is more common after right-sided pneumonectomy secondary to various considerations including lack of local tissue coverage. Other risk factors include completion pneumonectomy, previous mediastinal/hilar radiation, prolonged mechanical ventilation, post-pneumonectomy empyema, residual tumor at the bronchial stump, and technical factors including devascularization, incomplete bronchial stump closure, or failure to provide supplemental tissue coverage of the bronchial stump. When the bronchial stump remains elongated, this leads to pooling of airway secretions and resultant BPF development. CASE PRESENTATION: 72 year old female who presented with low grade fevers and shortness of breath one and a half weeks after undergoing an open right lobectomy converted to completion pneumonectomy for bronchogenic adenocarcinoma. Intraoperatively it was noted that the bronchial stump was difficult to manage, requiring oversewing and application of tissue adhesive. One month later, the patient was transferred for definitive treatment which included debridement of the right pleural space, resection of the elongated bronchial stump, and intrathoracic transposition of a pedicled right serratus anterior muscle flap. Following serial operative packing exchanges, the modified Clagett procedure was completed with chest closure 8 days after re-exploration. DISCUSSION: Treatment of BPF is divided into acute and chronic phases. If BPF develops early after surgery (within 2 weeks) it is likely related to technical failure of the bronchial stump closure. Clinically it may present as a persistent or continuous air leak, progressive subcutaneous emphysema, and/or respiratory insufficiency/failure. If the BPF develops later in the postoperative course, it is likely due to inadequate healing or rupture of the bronchial stump. These patients usually present with fevers and/or productive coughs and are in danger of aspiration though the bronchial stump into the contralateral lung. CONCLUSIONS: At the time of reoperation, the bronchial stump should be covered with a vascularized pedicle of tissue including either muscle, pericardial fat pad, or omentum. If the pleural space appears clean, it may be closed using the Clagett procedure. Reference #1: Liberman M. and Cassivi SD. Bronchial Stump Dehiscence: Update on Prevention and Management. Seminar of Thoracic and Cardiovascular Surgery. 2007: 19:366-373. DISCLOSURE: The following authors have nothing to disclose: Lawrence Greiten, Stephen Cassivi No Product/Research Disclosure Information