Bronchial Stump Insufficiency Research Articles

Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer.

Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications. All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively. Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes. Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

Rescue surgery in palliative indication as last therapeutic option for complicated advanced stage lung cancer

ObjectiveTo evaluate the role of rescue surgery in complicated initially not operatively intended advanced stage lung cancer. Materials and methodsRetrospective analysis of 30 patients with advanced lung cancer who underwent rescue surgery for control of life-threatening, non-conservatively manageable tumor related complications like post-obstructive pneumonia, super-infected tumor necrosis or active bleeding. Study parameters included tumor stage, histology, type of resection, and patients’ characteristics as well as postoperative outcomes. ResultsThe study cohort consisted of 12 female and 18 male patients, among those 29 were diagnosed with Non-Small Cell Lung Cancer (NSCLC) and one with Small Cell Lung Cancer (SCLC). On initial tumor-diagnosis 20 patients had been classified as stage IV and 9 with stage III; 1 patient had not yet been completely staged at time of surgery for active tumor bleeding. In all patients, the indication for rescue surgery was not oncologic-therapeutic but to control non-conservatively manageable complications which either contradicted any tumor-specific systemic therapy or acutely threatened life. Types of resections included pneumonectomy, bi-lobectomy, lobectomy and segmentectomy. The mean overall survival was 13.3 (median 11.2) months, the 1-year-survival-probability of the cohort was 45,2%. The 30- and 90-day mortality was 13,3 and 30%, respectively. The reasons for early postoperative mortality were ARDS, multiorgan failure and bronchial-stump insufficiency. ConclusionsRescue surgery for tumor- or therapy-induced life-threatening complications in patients with advanced stage lung cancer is associated with high morbidity and mortality. However, if all other treatment options have failed it nevertheless may be indicated as the last therapeutic chance and if surgery succeeds in controlling the acute event it may also set the condition for subsequent tumor-specific therapies. Future research should focus on elaborating effective criteria regarding patient selection and timing of surgery in order to restrict these high-risk-operations to only those patients, who most likely will benefit.

Best Evidence Topic: Avoidance and Treatment of a Bronchial Stump Insufficiency following Major Lung Surgery

Objectives: Almost a century after the first successful pneumonectomy postoperative insufficiency of the bronchus stump remains one of the most feared complications in thoracic surgery. This complication is not only associated with high mortality and morbidity, but also the treatment itself is challenging for the surgeon.

Complex pleural empyema can be safely treated with vacuum-assisted closure

ObjectiveFor patients with postoperative pleural empyema, open window thoracostomy (OWT) is often necessary to prevent sepsis. Vacuum-assisted closure (VAC) is a well-known therapeutic option in wound treatment. The efficacy and safety of intrathoracal VAC therapy, especially in patients with pleural empyema with bronchial stump insufficiency or remain lung, has not yet been investigated.MethodsBetween October 2009 and July 2010, eight consecutive patients (mean age of 66.1 years) with multimorbidity received an OWT with VAC for the treatment of postoperative or recurrent pleural empyema. Two of them had a bronchial stump insufficiency (BPF).ResultsVAC therapy ensured local control of the empyema and control of sepsis. The continuous suction up to 125 mm Hg cleaned the wound and thoracic cavity and supported the rapid healing. Additionally, installation of a stable vacuum was possible in the two patients with BPF. The smaller bronchus stump fistula closed spontaneously due to the VAC therapy, but the larger remained open.The direct contact of the VAC sponge did not create any air leak or bleeding from the lung or the mediastinal structures. The VAC therapy allowed a better re-expansion of remaining lung.One patient died in the late postoperative period (day 47 p.o.) of multiorgan failure. In three cases, VAC therapy was continued in an outpatient service, and in four patients, the OWT was treated with conventional wound care. After a mean time of three months, the chest wall was closed in five of seven cases. However, two patients rejected the closure of the OWT. After a follow-up at 7.7 months, neither recurrent pleural empyema nor BPF was observed.ConclusionVAC therapy was effective and safe in the treatment of complicated pleural empyema. The presence of smaller bronchial stump fistula and of residual lung tissue are not a contraindication for VAC therapy.

A four-muscle-flap for thoracomyoplasty in patients with sacrificed thoracodorsal vessels

Defects after prior posterolateral thoracotomy and with concomitant bronchiopleural fistula remain a challenge for the plastic surgeon. In most of the cases, the thoracodorsal artery division after posterolateral thoracotomy impairs the vascularisation supply of the latissimus dorsi, resulting in the loss of this option for closure of the pleural cavity. Therefore, the adequate filling of residual empyema space and/or surgical closure of the bronchial stump insufficiency needs additional tissue to overcome this situation. We present an alternative approach using a four-muscle-flap technique including the infraspinatus, the subscapularis and the teres major and minor muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing the residual empyema space and bronchial stump insufficiency. Between 2002 and 2008, we performed the four-muscle-flap on seven patients (mean age 68±7.9 years) with residual empyema space. Three cases were combined with a bronchopleural fistula. All patients received a two-stage procedure. First, the thoracic surgeons performed an open-window thoracostomy. This procedure was followed by the definitive surgical treatment after 3-6 months. In cases with an additional bronchial insufficiency, the stump was covered in with a subscapularis muscle. The infraspinatus and the teres muscle group were used to fill the pleural cavity, in combination with the thoracoplasty. In this series, no mortality connected to the procedure was noted. The mean postoperative stay in the intensive care unit (ICU) was 3±2.9 days and the patients were discharged from the hospital after 15±7.6 days. Minor postoperative complications occurred in two cases. Shoulder abduction in all patients was possible up to 90° and has decreased around 15±10° postoperatively. The division of the thoracodorsal pedicle and the consecutive loss of the latissimus as a reconstructive option remain challenging. The lower shoulder girdle muscles (infraspinatus, subscapularis, teres minor and major) are an adequate alternative for filling residual empyema spaces. The constraint in shoulder movement is minor and acceptable in such situations.

A New Treatment Concept for Bronchial Stump Insufficiency

Bronchial stump insufficiency (BSI) remains one of the most feared complications with an incidence of 0-12% in the literature. The present retrospective study reviewed the medical records of 11 patients with BSI. Patients were divided into two groups, depending on treatment. In group A, 5 patients were treated initially unsuccessfully using other therapeutic procedures such pectoralis flap transposition, omentum majus transposition and fibrin glue applications and subsequently treated successfully with vacuum therapy (VT). In 6 patients (group B), only VT (a combination of bronchial suture, thoracoplasty, latissimus muscle transposition and VT) was performed. VT represents a closed dressing system allowing moist wound treatment in full contact with the wound surface as well as protection against contamination with nosocomial pathogens by means of continuous drainage of wound secretions. Of the 11 patients reviewed in this study, closure of the bronchial stump with VT was achieved in 8 patients. Of the 8 patients with successful closure of the bronchial stump, 4 patients were in group A and 4 in group B. Based on this preliminary experience, the combination of bronchial suture, thoracoplasty, latissimus muscle transposition and VT appears to be a promising concept for the management of bronchial stump insufficiency.

Modified Technique for Thoracomyoplasty after Posterolateral Thoracotomy

Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency. Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3-6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty. Mean age was 68 +/- 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 +/- 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 +/- 2.9 days. The thoracic drains were removed after 5 +/- 2.3 days. Total hospital stay was 15 +/- 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 +/- 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted. Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.

Video-mediastinoscopic resection of a long bronchial stump and reclosure of bronchial insufficiency after pneumonectomy

Bronchial stump insufficiency after pneumonectomy is a severe problem and there is still debate about the appropriate method (transthoracic or transsternal) for reclosure. Access through a sterile operative field for a successful redo-procedure seems to be important so an alternative to the open methods could be the video-mediastinoscopy as it allows approaching the bronchial stump via the mediastinum. Previously in 1996 Azorin performed the first mediastinoscopic reclosure by stapling an early insufficiency after left pneumonectomy. We report the first case to our knowledge of resection and reclosure in bronchial stump insufficiency via mediastinoscopy. An HIV-positive man presented with late bronchial stump insufficiency after left pneumonectomy for lung cancer. The cause was a long bronchial stump and there was no sign of tumour recurrence. Decision was made for a video-mediastinoscopy and resection and reclosure successfully performed by using an endostapler device. Postoperative bronchoscopy at six months revealed a well-healed stump and two years postoperatively the patient is doing well. The mediastinoscopic approach is a novel option in highly selected patients. It warrants minimal surgical trauma; however, one has to be prepared to convert to an open technique immediately.

Current surgical treatment of thoracic empyema in adults

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

Early Detection of Bronchial Stump Insufficiency After Bilobectomy

A 79-year-old male was referred for evaluation of a mass in the lower lobe of the right lung. Bronchoscopic biopsy revealed squamous cell carcinoma. Preoperative bronchoscopic exam demonstrated right intermediate bronchus invasion, without right upper-bronchus involvement. Excision of the lung cancer was undertaken electively in the fashion of right middle and lower bilobectomy. The patient weaned off ventilator smoothly and transferred to the ordinary ward in the next day. The pathologic report showed a solid, moderate, differentiated squamous cell carcinoma in the T2N1 stage. The resection margin was free from malignancy. The patient developed episodic fever, dyspnea, leukocytosis, and progression of right-lung infiltration on the seventh day after surgery (Figure 1). Bronchoscopic examination was arranged under the impression of sputum impaction with secondary infection of right upper lobe. Sputum coverage and uneven mucosa healing were found over the stump of right intermediate bronchus (Figure 2). Because of suspicion of bronchial stump insufficiency, chest tomography with 3D reconstruction was deployed for further confirmation. Unusual minimal air density was detected just around the previous automatic metallic staples of the bronchial stump (Figure 3). These findings were compatible with bronchial stump insufficiency after bilobectomy through clear chest tube drainage. Rescuing operation via previous thoracotomy was done, and the right intermediate bronchial stump was identified. The stump was dehiscent, even with a suction tip protruding from endotracheal tube into the surgical field. The chest cavity and the stump were not severely soiled because of early detection of the bronchial stump insufficiency. The right intermediate bronchus was repaired with second automatic stapling 0.5 cm proximally and buttressed with intercostal muscle flap. Concomitant tracheostomy was done to facilitate early weaning off the ventilator, thus decreasing further barotraumas to the right intermediate stump. The patient recovered uneventfully.1–3

Early Detection of Bronchial Stump Insufficiency After Bilobectomy

Early Detection of Bronchial Stump Insufficiency After Bilobectomy

Vakuumtherapie beim Pleuraempyem - Erste Erfahrungen mit der Anwendung im Pleuraspalt

Meanwhile vacuum-assisted closure (V.A.C.) therapy belongs to the standard procedures in cardiovascular surgery. Its intra-thoracal application is mentioned in one unique case-report in literature. We like to show our first experiences with this technique demonstrating three cases with pleural infection. One patient with bronchial stump insufficiency, one with pleural empyema and one with penetrating abscess of the chest was treated with V.A.C.-therapy. We applied a combination of microporous silicon fleece and polyurethane foam in direct neighbourhood to ventilated lung areas inside the thoracic cavity. One patient died of metastasis of his cancer disease, while wound situation and bronchial stump insufficiency could be treated well. Two patients could be treated successfully and be discharged out of the hospital. No complications due to V.A.C.-therapy could be seen, such as fistulas of the lung or bleeding of the mediastinal organs. Intra-thoracal V.A-C.-therapy can be performed as a good therapeutic option in the treatment of septic diseases inside the chest.

Bronchopleurale Fistel nach Lobektomie - eine Herausforderung der postoperativen Intensivtherapie

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.

Preoperative chemotherapy with and without additional radiochemotherapy: benefit and risk for surgery of stage III non-small cell lung cancer?

Multi-modality approaches are increasingly employed to improve prognosis in surgically treated stage III non-small cell lung cancer (NSCLC). Risk and benefit of the preoperative therapeutic chemotherapy or combined radiochemotherapy on surgical morbidity and mortality are still a matter of debate. In 1995, a national phase III trial was started to compare (arm A) preoperative chemotherapy followed by twice-daily chemoradiation and consecutive surgery, with (arm B) preoperative chemotherapy alone followed by surgery and consecutive radiotherapy. An interim analysis with 277 patients was performed to assess surgical risk and complication rates. of the 358 patients, 273 (71%) underwent thoracotomy, 130 (73%) in arm A and 143 (69%) in arm B. Of the 273 patients undergoing thoracotomy, 168 had stage IIIB disease. Complete resection (R0) was achieved in 212 patients (78%), 104 in arm A (80%) and 108 in arm B (76%) (P=n.s.). There was no difference in the proportion of complex resections between treatment arms (41% in arm A; 48% in arm B). Whilst bronchial stump insufficiency (3.8 vs 2.1%) and bleeding requiring re-thoracotomy (1.5 vs 0.7%) prevailed slightly in arm A, the occurrence of pneumonia divided similar in both treatment arms (4.6 vs 4.9%). Surgical mortality reached 6.1% in arm A (8/130) and 5.6% in arm B(6/143) (P=n.s.). In both treatment arms, a similar percentage of patients could be forwarded to surgery, even in stage IIIB disease. Bimodality induction seems to be superior with regard to resection rates (R0) (n.s.), but was associated with a higher complication rate, especially bronchial stump insufficiency.

Short- and long-term outcome after lung resection for invasive pulmonary aspergillosis.

Lung resection for invasive pulmonary aspergillosis (IPA) is controversial. Neutropenia, thrombopenia and poor general condition may increase perioperative morbidity and mortality, and the redeeming benefit is questionable. Therefore we analyzed short- and long-term outcome after lung resection for IPA. 41 patients with hematological disease underwent lung resection for suspected IPA: lobectomy (23 patients), wedge-resection (16) and enucleation (2). 4 (10%) patients developed major complications: pleural aspergillosis, bronchial stump insufficiency, severe bleeding, ARDS. 11 (27%) patients showed minor complications: pleural effusion (6), pneumothorax (2), seroma (2) and hematothorax (1). 30-day mortality was 10 % (4 of 41 patients): two died of bacterial septicemia, two of disseminated aspergillosis. One (2%) death was possibly surgery-related. IPA was cleared in 87% of patients, fungal relapse occurred in 4 (10%) patients. Overall survival was 65%, 58% and 40% at 6 months, 12 months and 5 years. Lung resection for IPA even in profound cytopenia is feasible with acceptable morbidity and mortality. Fungal infection can be cured in more than 80 % of patients. Long-term outcome can be achieved if the hematological disease is under control.

Use Of Mechanical Sutures In Pulmonary Surgery

In a ten years period, Six hundred and twenty patients under surgical treatment for different kinds of pulmonary diseases. Pulmonary tuberculosis was the indication for 395 thoracotomies and 115 patients were operated for lung cancer. Ninetyone thoracotomies were performed chronic non-specific diseases of the lung and in 19 cases indications for pulmonary resection were other diseases. In all cases various types of mechanical staplers were used for individual suturing of the culmonary vessels and bronchus. Operations performed included 207 pneumonectomies, 341 lob and bilobectomies, 49 segementectomics and 23 combined resections. Chronometry was done in seventyone thoracotomitromies with average time spent for each operation being one hour and fortyseven minutes only. Out of this time, only four minutes and thirtyfour seconds (4.2%) were spent for individual suturing of the pulmonary vessels and bronchus. During the operation insufficiency of mechanical sutures were seen in few cases and dealt with accordingly. Arterial and bronchial stump insufficiency were noted in the percent cases each, whereas venous suture insufficiency was seen only in 1.3 percent cases. Five huudred and fortysix patients (88.1%) had a benign course, whereas fortythree patients (6.9%) experienced postoperative complications. But only in sixteen cases (2.6%) could the mechanical sutures be related theoretically for those complications. There were thirtyone hospital deaths (5%). Our results show that the use of mechanical sutures is safe, considerably reduces the time for pulmonary resection and is associated with relatively very few intraoperative and postoperative complications.

Accelerated treatment for early and late postpneumonectomy empyema

Background. Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. Despite use of various therapeutic approaches and techniques during the last five decades, successful therapy remains difficult and is often associated with high morbidity and prolonged hospitalization. Methods. We evaluated a concept for accelerated treatment, which consists of radical debridement of the pleural cavity and packing with wet dressings of povidone-iodine. This was repeated in the operating theater every second day, until the chest cavity was macroscopically clean. If present, bronchial stump insufficiency was closed and secured by omentopexy. Finally, the pleural space was obliterated with antibiotic solution. Results. Twenty patients, 13 with early postpneumonectomy empyema (10 to 89 days; mean, 37 days) and 7 with late postpneumonectomy empyema (124 to 7,200 days; mean, 1,126 days) were treated. Fifteen patients presented with bronchopleural fistula (11 right, 4 left), which developed after chemotherapy (n = 6) or after radiotherapy (n = 3) (unknown cause in 4 patients). Six patients were referred after previously unsuccessful surgical attempts. Pleural cultures were positive in 17 cases for one or several bacteria including fungoides (n = 2). The average number of interventions was 3.5 (3 to 5). The chest was definitively closed in all patients within 8 days. Mean hospitalization time was 17 days (7 to 35 days). During the same hospitalization, 2 patients needed reoperation because of an undetected bronchopleural fistula. Postpneumonectomy empyema was successfully treated in all patients. There was no in-hospital or 3-month postoperative mortality. Conclusions. Repeated surgical debridement combined with closure of bronchopleural fistula and antimicrobial therapy enables successful treatment of early and late postpneumonectomy empyema within a short period and is a well-tolerated concept.

Bronchial stump insufficiency after pneumonectomy: etiology, risk factors, therapy

Although the incidence of postpneumonectomy bronchopleural fistula has decreased in recent years due to new surgical refinements and a better understanding of the bronchial stump healing it remains a major problem. We reviewed our most recent experience on BPF after pneumonectomy to determine methods by which the risks may effectively be reduced. From 1983 to 1997, 315 patients underwent pneumonectomy for lung cancer, and other malignancy and benign causes (infection with destroyed lung). Main bronchial manual suture was performed in 204 cases and stapled suture in 111 cases. The overall main BPF rate was 3.7% (12/315). The mortality rate was high with 38.4% (5/12). Death was caused by aspiration pneumonia and ARDS in 3, empyema with sepsis and cachexia in 1, and distant tumor recurrence in 1 patient. Risk factors for BPFs were right pneumonectomy (p=0.03) and barotrauma due to postoperative mechanical ventilation (p=0.003). Other previous mentioned risk factors like age, preoperative infection and/or radiation, diabetes mellitus, steroid medication reached no statistical significance. Primary reexploration through the previous thoracotomy incision was performed in 9 patients. After debridement and refashioning the bronchial stump was reclosed with the hand suture technique. The stump was covered with intercostal muscle in 5, pericardial fat pad in 3, and omental flap in 2 patients. Three cases with a pinhole fistula and poor overall condition were treated endoscopically using fibrin sealant and spongy iliacal bone. In 2 patients the fistula persisted and the stump had to be surgically reclosed.¶Conclusions: Postpneumonectomy BPF is one of the most serious complications after lung surgery associated with a high mortality. BPF is more common after right pneumonectomy and is frequently associated with postoperative mechanical ventilation. Rethoracotomy with refashioning, reclosure and covering of the bronchial stump with a vascularized flap is recommended. Endoscopical treatment is reserved only for small BPF associated with poor general condition.

Diagnostic and therapeutic thoracic surgery in leukemia and severe aplastic anemia

Background: Pulmonary complications often occur in patients with leukemia and severe aplastic anemia. Particularly in patients having undergone bone marrow transplantation, respiratory diseases account for a significant number of deaths. In a retrospective study, we evaluated 41 patients with leukemia and severe aplastic anemia who were operated on consecutively from 1980 to 1995. Methods: Fourteen open lung biopsies, four video-assisted lung biopsies, and 24 lung resections were performed in 24 male and 17 female patients. Mean age was 32.2 years. Results: Eleven (27%) early deaths occurred (30-day mortality): ten in patients after lung biopsy (56%) and one after lung resection (4%) ( p < 0.001). Perioperative morbidity relating to pulmonary disease or operation included 10 (24.4%) cases of prolonged (>24 hours) postoperative mechanical ventilation and two (4.8%) cases of bleeding or hematoma. In one (2.4%) patient a slowly developing, contained bronchial stump insufficiency appeared after lobectomy, which was successfully operated on 3 weeks later. Conclusion: We conclude that resection of localized pulmonary lesions, be it for diagnostic or therapeutic (or combined) purposes, can be carried out with low morbidity and mortality in patients with leukemia and severe aplastic anemia. However, early mortality is high after open or thoracoscopic lung biopsies in patients with acute-onset diffuse pulmonary disease, and little therapeutic benefit is realized in these cases. (J Thoracic Cardiovasc Surg 1997; 113: 982-8)

Photodynamic therapy with chlorins for diffuse malignant mesothelioma: initial clinical results

Four patients underwent intraoperative photodynamic therapy after surgery with meso-tetra-(hydroxyphenyl)-chlorin (mTHPC-PDT) for diffuse malignant mesothelioma. Preliminary procedures were performed in two patients in order to establish the efficacy of mTHPC-PDT and to optimise its tumoricidal effect. The tumoricidal effect was related to the mTHPC dose, light dose and the time interval between sensitation and activation. 0.3 mg kg-1 mTHPC activated after 48 h with 10 Joules cm-2 of non-thermal laser light at 650 nm resulted in a 10 mm deep tumour infarction, due to tumour vessel necrosis and thrombosis. The mTHPC tissue concentration was up to 14 times higher in the tumour than in normal tissues. Skin photosensitivity was mild, dose dependent and occurred 3 to 10 days after administration of mTHPC. According to the results obtained, intraoperative mTHPC-PDT was performed following pleuropneumonectomy in two, pleurectomy and lobectomy in one and pleurectomy in one patient. Ten Joules cm-2 were delivered to the diaphragm and the costophrenic sulcus and 5 Joules cm-2 to the remaining thoracic cavity. The postoperative course was marked by loss of appetite, fluid retention, hypoproteinemia and severe chest pain. One patient succumbed from aspiration pneumonia. The remaining patients developed no neural or vascular alterations and no bronchial stump insufficiency during follow-up. mTHPC-PDT following surgical tumour resection deserves further evaluation in good risk patients with diffuse malignant mesothelioma.