Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter.

OBJECTIVE: Side- and sex-related differences were analysed to explain the occurrence of bronchopleural fistula (BPF) after pneumonectomy on the right-hand side in men. PATIENTS AND METHODS: Surgical pathology reports on 209 patients (15 with BPF) were retrospectively reviewed regarding sex, age, side, TNM stage, outer diameter of the resection margin (mm) and intrabronchial distance between tumour and resection margin (mm). Patients without macroscopic bronchial invasion were categorised as peripheral tumours. The t-test, U-test (Mann-Whitney) and cross-tabulation using the chi 2-test were performed for univariate statistical analysis. A logistic stepwise backwards regression model was used for multivariate analysis. RESULTS: Women were significantly younger than men, had a smaller resection margin and fewer central tumours. Stage 4 was overrepresented in women, stage 2 in men. On the right-hand side, the distance was significantly shorter, the resection margin longer and the patients younger. Fistula patients showed a longer resection margin and a shorter distance, men were dominant. Multivariate analysis only identified length of the resection margin as an independent risk factor for BPF (p = 0.024, OR 1.177 CI: 1.033 - 1.356). Gender and side significantly influenced the diameter of the resection margin (p = 0.00). CONCLUSION: The diameter of the bronchial stump is a major risk factor in the occurrence of post-pneumonectomy BPF, and explains the predominance of the male sex, the right-hand side and pneumonectomy. Where it exceeds 25 mm, prophylactic stump coverage with viable tissue should be performed.

A new method for digital video documentation in surgical procedures and minimally invasive surgery.

BACKGROUND: Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. METHODS: We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. CONCLUSION: This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

[Bronchoplastic procedures for the resection of malignant bronchial neoplasms]. / Bronchoplastische Resektionen in der Behandlung maligner Lungentumoren.

INTRODUCTION: Bronchoplastic procedures have become established in the treatment of bronchial malignancies. We report our results on 108 operations performed between 1994 and 2001. PATIENTS AND METHODS: Bronchial reconstruction techniques (wedge resection, end-to-end-anastomosis, y-sleeve), comorbidity (cardiovascular, respiratory, pulmonary, neoadjuvant chemotherapy, alcoholism), postoperative complications (septic/aseptic, light/severe), histology, tnm-stage and postoperative follow up (days) were recorded prospectively. RESULTS: The bronchial tree was reconstructed with an end to end anastomosis in 75 cases (69.4%), a y-sleeve in 17 (15.7%) and a wedge resection in 16 (14.8%). In 11 patients (10.2%), an additional angioplasty of the pulmonary artery was performed. The comorbidity rate was 89.8%. A total of 52 patients (49.1%) presented with one or more cardiovascular risk factors and 84 patients (77.8%) with one or more respiratory risk factors. The overall postoperative morbidity was 26.8% and the mortality 5.5%. Aseptic complications were observed in 12 cases (11.1%) with a mortality of 25% while septic complications occurred in 17 patients (15.7%) with a mortality of 17%. Anastomotic fistulas occurred in three patients (2.8%) and pneumonia in 11 (10.2%). Stage I was found in 46 patients (42.6%), 29 (26.8%) had stage II, 21 (19.5%) stage IIIA, five (4.6%) stage IIIB and two had stage IV (1.8%). The follow up period ranged from 64 to 2,654 days (mean 756.42+/-643.46, median 575.0). Seven patients (6.5%) died with no evidence of disease. After 2 years, 65% of all patients were alive, after five years this had dropped to 50%. CONCLUSION: Bronchoplastic procedures are a safe method for the treatment of bronchial malignancies, even in cases with high comorbidity, and should be performed whenever possible.

Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia?

OBJECTIVE: Currently epidural anesthesia is the gold standard for postoperative pain management in thoracic surgery. In a prospective randomised study, the effect of an intercostal nerve block applied at the end of the operation was compared to that of epidural anesthesia. METHODS: Thirty patients undergoing thoracotomy were randomised to each group. Patients with resection of the parietal pleura, rib resection and rethoracotomy were excluded from the study. Both groups received non-steroidal anti-inflammatory drugs every 8h as a baseline analgesic medication and were allowed to ask for supplemental subcutaneous opiate injection, limited to four injections per day. The patients in the epidural catheter group (group I) were provided with a motor pump allowing continuous infusion of bupivacain 0.125% and 2mg fentanyl/ml at a dosage of 6-10 ml per hour, dependent on the pain level over a period of 5 days. The patients of the second group (group II) received an intercostal nerve block at the end of the operation reaching from the third to the ninth intercostal space with 20 ml 0.5% bubivacaine. Pain was evaluated with a pain score ranging from 1 (no pain) to 10 (worst pain) twice daily in relaxed position and during physical activity like coughing. On the fifth postoperative day, the patients were asked specific questions concerning the subjective pain experience. Costs of both treatments were calculated. Mean pain values and costs of both groups were compared by t-tests for independent samples. A P value of less than 0.05 was considered significant. RESULTS: Eighteen male and 12 female patients, aged between 35 and 71 years (mean 59) were included in the study. Nineteen patients had lobectomy, five bilobectomy, two decortication and three wedge resection. There were 22 right sided and eight left sided procedures. In group I, the mean pain score on the operation day was 3.95 in relaxed position and 6.33 during physical activity like coughing. The mean pain score during the following 4 days was 2.19 in relaxed position and 4.28 with activity. Three patients required additional subcutaneous opiate injection. In group II, the mean score on the operation day was 2.0 in relaxed position and 3.5 during activity. The mean pain score during the next 4 days was 2.84 in relaxed position and 5.65 with activity. Twelve patients received subcutaneous opiates. In both groups, no complications were observed. COSTS: The costs for treatment of one patient was 105 in group I and 33 in group II. Patients' satisfaction was equal in both groups, there were no differences in terms of outcome and recovery. CONCLUSION: Pain management by intercostal block was superior during the first 24h after surgery whereas on the second day after surgery pain control was significantly better achieved by the epidural catheter in relaxed position. A combination of both forms of anaesthesia seems to be an ideal pain management in patients undergoing thoracic surgery.

Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch.

BACKGROUND: The efficacy of bronchial telescope anastomosis was evaluated retrospectively in patients undergoing sleeve resections with high-caliber mismatch. METHODS: The hospital charts of patients undergoing upper and lower sleeve bilobectomy and lower lobe lobectomy with replantation of the middle lobe or upper lobe into the mainstem bronchus were retrospectively reviewed. Age, sex, side, TNM stage, preoperative forced expiratory volume in 1 second (FEV1 [%]), preoperative risk factors, postoperative course, survival (months), and causes of death were recorded. RESULTS: Fifteen patients suffering from bronchial carcinoma were operated on. In 6 cases FEV1 was less than 2 L (FEV1 49% to 80%, mean 64.3, median 61). Three patients were 70 years and older. There were 7 high-risk cases presenting with coronary heart disease (n = 3), chronic alcoholism (n = 3), cerebrovascular disease (n = 1), and active tuberculosis (n = 1). Local radicality was achieved in all patients but 1, in whom pneumonectomy was contraindicated. There was no postoperative mortality. Early complications consisted of 1 anastomotic dehiscence successfully closed with an intercostal flap and 1 patient with bilateral pneumonia requiring mechanical ventilation for 5 days. One parenchymal fistula led to prolonged drainage; in 1 patient pneumothorax after removal of the chest tube required redrainage. There were no late complications, and no anastomotic stenosis developed. Survival ranged from 12 to 56 months (median 29.8, mean 30, SD 15.7). Seven patients died between 3.9 and 14 months postoperatively (mean 8.5, median 6.9) of intrabronchial local recurrence (n = 1), distant recurrence (n = 3), intrathoracic recurrence (n = 1), and nontumor-related causes (n = 2). CONCLUSIONS: Telescope anastomosis is a safe and efficient technique of bronchial sleeve resection.

[Gastrointestinal tuberculosis. A case report]. / Gastrointestinale Tuberkulose. Ein Fallbericht.

We report a case of gastrointestinal manifestation of tuberculosis (TB). A 52 year-old female patient was admitted into another hospital with unspecified gastrointestinal complaints. A computer tomography (CT) and a coloscopy showed a mild stenosis in the ileocecal region. The routine pulmonary X-ray showed a nodule, the cytology of the sputum was positive for tuberculosis. The patient was therefore transferred to our hospital. Following the anti-tuberculostastic treatment, the patient's abdominal condition improved but the symptoms reappeared weeks later. A sonography showed biliary calculus. Three days after endoscopic cholecystectomy the patient was discharged to home care and medical therapy. Four days later, she was admitted again with signs of subileus. Oral gastrografin solved the problem. The patient refused another coloscopy. Another 13 days later the patient was admitted once more with signs of an acute ileus. An emergency laparotomy with resection of the ileocoecal region was performed because of a complete stenosis. The histology showed a gastrointestinal tuberculosis. The patient had a smooth postoperative recovery and was released on the tenth day. She was on anti-TB therapy for 12 months without any complaints. In July 1999 the tuberculostatic treatment was stopped. It has been pointed out in numerous scientific publications that the clinical picture can be untypical and uncharacteristic, so that only the principal integration of TB in the differential diagnosis can allow the correct diagnosis. Surgical therapy should only be performed in emergency cases. In normal cases, medical therapy is the adequate treatment for tuberculosis.

Videothoracoscopic debridement of the postpneumonectomy space in empyema.

OBJECTIVE: Simple irrigation has proven to be an efficient method to treat postpneumonectomy empyema provided that bronchopleural fistula is not present or successfully closed. However, with this treatment modality, infected material inside the thoracic cavity is not removed and this can be a potential source of empyema recurrence if the patient's immune system is compromised. The removal of the infected material should result in a lower recurrence rate. METHODS: As soon as diagnosis of postpneumonectomy empyema was established, a chest tube drainage was inserted. A concomitant bronchopleural fistula was evaluated bronchoscopically. If the fistula was smaller than 3 mm, bronchoscopic sealing with fibrin glue (Tissucol, Immuno, Vienna) was initiated. Fistulas closed surgically were excluded from this analysis. The thoracic cavity was cleared of infected material by videothoracoscopy and bacteriological samples were taken. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection; WBC and CRP were controlled. RESULTS: Nine patients (five men, four women) between 55 and 72 years (mean 61, SD 6), all initially operated on for malignancy, were successfully treated with this regimen. In three cases a concomitant bronchopleural fistula was successfully closed before videothoracoscopy. The interval between primary operation and empyema was between 7 and 436 days (mean 93, SD 141). There was no postoperative mortality and no procedure related morbidity. Operating time ranged from 45 to 165 min (mean 92.7, SD 36.6), the suction volume (consisting of blood, debris and pus) was 300 to 1000 ml (mean 880, SD 600). Duration of thoracic drainage was 12-38 days (mean 22, SD 9), duration of hospital stay after videothoracoscopy 21-46 days (mean 29, SD 9). During the follow-up period of 204-1163 days (mean 645, SD 407) no recurrence of tumour or empyema was observed. CONCLUSIONS: Videothoracoscopic debridement of the postpneumonectomy space with postoperative antibiotic irrigation of the pleural space is an efficient method to treat postpneumonectomy empyema, provided that a concomitant bronchopleural fistula can be closed successfully. No early empyema or fistula recurrence were observed. However, late recurrence may occur many years after operation, therefore close follow-up is indicated.

Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap.

OBJECTIVES: The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively. METHODS: Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded. RESULTS: Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed. CONCLUSION: The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.

Glove perforation rate in open lung surgery.

OBJECTIVE: In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS: Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS: One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS: The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.

BACKGROUND: The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. METHODS: The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. RESULTS: Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment. CONCLUSIONS: Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases.

BACKGROUND: Various therapeutic approaches to bronchopleural fistula have been reported. Its natural history, which may be key to the best therapeutic management, early detection, and possibly, prevention of fistula formation, has received little attention. METHODS: The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at primary bronchoscopic diagnosis, time of occurrence after operation (days), cause of death, and survival after fistula formation (days) were analyzed. Management consisted of bronchoscopic closure with fibrin sealant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thoracostomy. RESULTS: Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) died during the observation period; in 25, the cause of death was aspiration pneumonia. Only 2 patients who died of aspiration pneumonia had development of a fistula after 90 postoperative days. The aspiration rate dropped with increasing interval between operation and fistula occurrence (p = 0.000). Patient survival after fistula formation was positively correlated to this interval (p = 0.002). Successful fistula closure was achieved by surgical intervention in 21 patients and endoscopically in 11 patients. The overall postoperative mortality rate irrespective of treatment method was 31%. CONCLUSIONS: The incidence of aspiration pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently represents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postoperative months should detect bronchopleural fistula before aspiration occurs.