Asian Cardiovasc Thorac Ann 2005;13:211-216
© 2005 Asia Publishing EXchange Ltd
Omentoplasty in Treatment of Early Bronchopleural Fistulas after Pneumonectomy
Dmitry Chichevatov, MD,
Alexander Gorshenev, MD
Thoracic Surgery Department, Penza Regional Oncology Health Center, Penza, Russia
For reprint information contact: Dmitry Chichevatov, MD Tel: 7 8412 478 698 Fax: 7 8412 434 501 Email: rohthor{at}sura.ru, Flat 15, 74 Prospect Stroitelei, 440066 Penza, Russia.
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ABSTRACT
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This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.
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INTRODUCTION
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For the treatment of bronchopleural fistula (BPF) after pneumonectomy, many surgeons prefer an early second operation for BPF closure and sterilization of the pleural cavity.1–4 Rapid re-operation usually avoids thoracoplasty and improves the quality of life. The efficacy of early re-operation is due to the high degree of reliability in preventing a recurrence of BPF. To this end, flaps of muscle, diaphragm, or greater omentum have been employed.2,4–6 The aim of this study was to assess the efficacy of omentoplasty (OP) in the early treatment of BPF after pneumonectomy.
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PATIENTS AND METHODS
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Between 2000 and 2003, 12 men aged 44 to 64 years (median, 59 years) underwent OP for BPF after pneumonectomy in Penza Regional Oncology Health Center. Eleven patients had lung cancer and one had lung sarcoma. The distribution of cancer stages was 5 (45%) patients in stage IIIa, 2 each (18%) in stages IIIb and II, and 1 each (9%) in stages I and IV. Extended mediastinal unilateral lymph node dissection was implemented in all cases. This technique consisted of total removal of mediastinal fat tissue and lymph nodes, with the exception of the contralateral paratracheal and tracheobronchial corner groups. In 2 patients, pneumonectomy was followed by cuneiform carinal resection, and another 2 underwent sleeve carinal pneumonectomy. All BPF had formed within 16 days after pneumonectomy (lower quartile (Q25), 4 days; median, 7 days; upper quartile (Q75), 13.5 days). In 10 cases, OP was performed within 10 hours (Q25, 4 hours; median, 4 hours; Q75, 6 hours) after diagnosis of BPF; the other 2 patients underwent re-operation at 28 and 31 hours. The first stage of OP was preparation of a flap of greater omentum (GO). Mobilization of the GO was performed through an upper median laparotomy without a retractor. The entire GO was used. Depending on the side of the thoracotomy, a pedicle was formed using the right or left gastroepiploic blood vessels (Figure 1
). The GO was separated from the transverse colon in the avascular part of the gastrocolic ligament. The left gastroepiploic vessels were cut near the spleen (in the case of a right-side omental flap), or the right gastroepiploic vessels near the pylorus (in the case of a left-side omental flap). The GO was separated from the stomach by cutting the rectus rami and saving the gastroepiploic vessel arch in the omentum. When preparing a right-side omental flap, it is important to mobilize the GO along a wide curve distal to the pylorus (Figure 2). It is essential to prevent stomach deformation due to traction on the GO after transposition into the pleural cavity. The mobilized GO was placed in the subphrenic area. The usual time for mobilization of the GO was 55–60 minutes. The second stage of OP was a thoracotomy, after which the pleural cavity was debrided carefully. The BPF was closed with noose sutures of 3/0 Vicryl (Ethicon, Edinburgh, Scotland, UK). If possible, resection of the bronchial stump and re-suturing were undertaken. Through an incision in the diaphragm, the GO was transposed into the pleural cavity; the site of this incision was chosen so as to ensure a straight position of the omental pedicle (without angulation). Usually, the transposed omentum could reach a cupola of the pleural cavity. Omentopexy was performed by placing 5 U-shaped relaxation sutures: an upper suture through the lateral tracheal wall 1.5 cm proximal to the bronchial stump (Figure 3, see 1); a front suture through the anterior wall of the bifurcation of the trachea or, in cases of sleeve carinal resection, through the anterior wall of the contralateral principal bronchus and trachea (Figure 3, see 2); a lower suture through the medial wall of the contralateral principal bronchus 1 cm distal to the bronchial stump (Figure 3, see 3); a rear lower suture through the periaortic or paravertebral fascia 1–1.5 cm caudal to the level of the bronchial stump (Figure 3, see 4); and a rear upper suture through the periaortic or paravertebral fascia 1–1.5 cm cranial to the level of the bronchial stump (Figure 3, see 5).
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Figure 1. The completely mobilized greater omentum. 1 = pedicle of omentum, 2 = stumps of the rectus rami.
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Figure 3. The 5 U-shaped relaxation sutures. 1 = upper suture, 2 = front suture, 3 = lower suture, 4 = rear lower suture, 5 = rear upper suture, 6 = bronchial stump.
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The upper, front, and lower sutures were passed through all layers of the tracheobronchial wall. By duplication, triplication, or quadruplication, a piece of omentum 5–8 mm thick was prepared, U-shaped sutures were inserted (Figure 4A), and it was placed into the mediastinum (Figure 4B). The U-shaped sutures were knotted in the following sequence: rear, lower, upper, and front. As a result, the bronchial stump or ipsilateral semicircle of the tracheobronchial anastomosis could be tightly covered with a thick wrap of omentum (Figure 5). The rest of the omentum was placed over the mediastinal structures as the next covering layer, and fixed to the pericardium and mediastinal pleura (Figure 6). The pleural cavity was drained with two tubes. In the postoperative period, the pleural cavity was flushed daily by injection, leaving antibiotics intrapleurally. The drain tubes were removed on the 3rd day, and the pleural cavity was punctured until the pleural effusion became sterile and its fraction of lymphocytes rose to more than 50% of all leucocytes.
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Figure 4. Fixation of the omental flap. (A) Omental wrap with U-shaped sutures inserted. (B) Omental wrap placed in the mediastinum.
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Figure 5. The 5 U-shaped relaxation sutures are knotted. 1 = trachea, 2 = bronchial stump tightly covered with omentum, 3 = esophagus.
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RESULTS
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In 11 patients (92%), OP was effective and the BPF did not recur. In one patient, a second acute BPF formed. Among the 11 patients with no fistula on follow-up fiberoptic bronchoscopy, 4 suffered dehiscence of the bronchial stump or tracheobronchial anastomosis; nevertheless, fistulas did not form again and all defects granulated and closed spontaneously. This was confirmed visually by further bronchoscopy. In 3 patients, pulmonary and heart failure developed in the postoperative period. In one of these, pulmonary failure required tracheostomy, the tracheostomy tube caused a decubitus ulcer of the lateral wall of the trachea, and a tracheopleural fistula formed. Acute pleural empyema developed after OP in 4 (33%) patients. In one, it was a consequence of tracheopleural fistula, and in another, it followed a recurrence of BPF; both were treated by tube drainage of the pleural cavity. In the 2 cases of pleural empyema without a fistula, the empyema resolved completely with pleural puncture within 14 to 16 days. In these patients, the drainage tubes were removed on the 3rd day after OP, and pleural puncture was performed daily with lavage of the pleural cavity using a 0.9% solution of sodium chloride and intrapleural injection of 240 mg of gentamicin. Such procedures were performed until 3 negative bacteriological analyses of the pleural effusion were obtained. Systemic antibiotic therapy included 800 mg of pefloxacin and 1,000 mg of amikacin intravenously per day. The patient with the recurrent BPF was discharged after 99 days. It is noteworthy that his BPF was thin and curved owing to OP, which is why, in our opinion, there was no respiratory disorder or aspiration of pleural effusion into the bronchi of the single lung in this patient. His pleural cavity and BPF granulated and closed up spontaneously within 3 months. The patient with a tracheopleural fistula was discharged on the 58th day. He had chronic empyema that was successfully closed by thoracomyoplasty after 4.3 months. There were no other complications of OP.
One patient died on the 22nd postoperative day due to early progression of stage IV lung carcinoma, with multiple hematogenous metastases. This patient had neither a BPF nor empyema. Nine patients without a fistula were discharged between 12 and 53 days after OP (Q25, 22 days; median, 31 days; Q75, 43 days). Eleven patients were followed up in the out-patient department for 0.5 to 49.4 months (Q25, 2.3 months; median, 12.7 months; Q75, 35.4 months). Two patients died from cerebral crisis at 2.3 and 3.4 months, and 2 died at 0.5 and 2.1 months due to progression of hematogenous metastases. There was no recurrence of BPF or empyema in these 4 patients. The other 7 patients survived with no recurrence of BPF or empyema.
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DISCUSSION
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The mortality rate is higher among patients with early BPF, which is attributed to aspiration pneumonia.7–8 We consider this to be a serious argument in favor of re-operation to eliminate the BPF as early as possible.1,9 None of our patients had aspiration pneumonia, but treatment of empyema is more effective without a BPF and, as a rule, correction of the residual pleural cavity is not necessary. Various pedicled flaps have been used for reinforcement of the bronchial stump. Kalweit and colleagues1 described 7 successful closures of BPF with a delay of less than 12 hours after diagnosis, using a petiolated pectoral muscle graft. Pairolero and colleagues5 achieved satisfactory results with serratus anterior, latissimus dorsi, pectoral and rectus abdominis muscles. They concluded that reinforcement of the bronchial stump with muscle flaps was an effective procedure for postpneumonectomy BPF. Muscle flaps have several advantages: they are well supplied with blood, they have sufficient mechanical fastness, they are located near the pleural cavity, and mobilization is rapid and simple. Nevertheless, we believe that muscle flaps have some significant drawbacks. Muscle is strong material but it can be stratified easily along the bundles of fibers. This makes it most suitable for tamponade of a long chronic granulating BPF but not for tight covering of a bronchial stump. Separated muscle retains the ability to contract, so after mobilization, pectoral, latissimus dorsi, and serratus anterior muscle flaps may shorten. In addition, resection of one or more ribs must be implemented to transpose the muscle flap into the pleural cavity.
A diaphragmatic flap has been used for reinforcement of the bronchial stump in a few reports. Mineo and Ambrogi2 are proponents of this method and used it with great success. Having all the positive properties of a muscular flap, a diaphragmatic flap has additional helpful qualities: it has a two-sided serous cover that provides additional strength and preserves the solidity of the flap. On being mobilized, a diaphragmatic flap generally does not contract and shorten, it is quite thin, and can be fitted well. However, even the diaphragmatic flap has drawbacks. In our experience with asthenic patients, mobilization of a diaphragmatic flap through the usual thoracotomy in the 4th or 5th intercostal space can be very difficult, so that resection of the lower rib or an additional thoracotomy in the 8th or 9th intercostal space is required. In some of these patients, the pleural cavity is high, and sufficient length of diaphragmatic flap cannot be prepared. The need for BPF closure in conditions of septic or aseptic inflammation of the pleural cavity is obvious, but the diaphragm is usually covered with fibrin and edematous. These factors can decrease the elasticity of the flap. Such disadvantages limit the use of a diaphragmatic flap in the treatment of BPF. We employ a diaphragmatic flap widely and effectively for BPF prevention during primary pneumonectomy, but rarely for reinforcement of the bronchial stump after a second closure.
The GO has several advantages over other plastic materials. Having been mobilized, it can reach any area of surgical interest in the pleural cavity and mediastinum, whereas muscular flaps have less mobility. Unlike muscle flaps, mobilization of the GO is less traumatic and does not result in dysfunction of the extremities or cosmetic defects. The property of adhesion and immunologic reactions of GO are useful in acute inflammation of the bronchial stump.10 The GO has a greater ability than other plastic materials to enhance revascularization of attached organs.10 This function of the GO is important for patients who have undergone surgery for lung cancer as it can provide revascularization of the bronchial stump and tracheobronchial wall after extended mediastinal lymph node dissection.11
The GO can be fixed to the surrounding soft tissues of the mediastinum or sewn directly to the bronchial stump. Sleeve turning of the bronchial stump or tracheobronchial anastomosis is possible, and tamponade of the BPF can also be performed. However, the technique described herein was preferred mainly because of the peculiarities of pneumonectomy for lung carcinoma, which routinely includes mediastinal lymph node dissection. The trachea, contralateral principal bronchus, esophagus, and main mediastinal vessels become completely denuded. Sometimes, the pericardium needs to be resected due to tumor invasion. Thus, there is a deficit of mediastinal soft tissues to which the GO can be fixed. We believe that it is quite dangerous to fix the GO to the esophagus or main mediastinal vessels. It is difficult to tamponade a BPF after pneumonectomy for cancer because the bronchial stump is frequently inadequate. Sleeve turning of the bronchial stump with GO can be a very reliable procedure, but there is a danger of external compression of the airways due to edema of the GO. We observed such a complication in 2 patients, although airway permeability had been monitored during OP. Direct fixation of GO to the bronchial stump is quick and easy, but sutures led through the stump can be unsatisfactory due to continued inflammation and marginal necrosis. We encountered this situation when BPF recurred because of failure of fixation of the GO. Therefore, the GO should be fixed to mechanically strong tissues beyond the bronchial stump. U-shaped sutures were employed to draw in the GO tightly so that in the event of BPF recurrence, it would protect the pleural cavity as a stand-alone patch.
We do not believe that the pleural cavity has to be cleared before using plastic flaps, as some authors suggest.6,12–13 Our technique of OP allows adequate sterilization of the pleural cavity. As the GO is strongly fixed, it can protect the pleural cavity irrespective of the security of the bronchial stump or tracheobronchial anastomosis. In 4 patients, dehiscence of the bronchial stump did not lead to BPF formation. Furthermore, recurrent pleural empyema in 3 patients did not lead to recurrence of BPF. The one case of OP failure may be explained by the anatomy of the GO in this patient, which was very thin, lacking in fat tissue, and flimsy. Inexperience may also have been a factor as this was one of the first patients in whom the technique was employed. The efficacy of early OP in BPF reduced the recovery time of our patients compared to those in other reports.4,9 The quality of life is better in patients without BPF and empyema, and such patients rarely require thoracoplasty. There was only one case of thoracoplasty among our 12 patients; however, this was due to a tracheopleural fistula after OP (the tracheobronchial anastomosis closed up after OP).
Delayed re-operation is appropriate for chronic BPF or pleural empyema, which generally require thoracoplasty. Such operations are very traumatic and result in irreversible defects of the chest and dysfunction of the upper extremity. Moreover, thoracoplasty does not have guaranteed effectiveness in all cases.14 Transsternal transpericardial closure (TTC) of a BPF is not an alternative to early OP. Usually, some months pass between pneumonectomy and TTC.15 During this period, there is a risk of aspiration complications and the quality of life is poor. Rasping fibrosis is formed in the mediastinum as a consequence of mediastinal lymph node dissection in patients who have undergone pneumonectomy for lung cancer. Eventually, the advantage of TTC in providing an opportunity to operate in the mediastinum with preserved syntropy and differentiated layers, is lost. Fistula recurrence and a high rate of hospital mortality may result from TTC.16
The results of our study agree with the data reported by Schneiter and colleagues4 who achieved satisfactory results of rapid treatment of BPF using OP. Our experience confirms that GO, being a unique plastic material, is highly reliable in the repeatedly sutured bronchial stump. The technique of GO fixation provides effective prevention of BPF recurrence, even in the event of further insufficiency of the bronchial stump or tracheobronchial anastomosis. It was concluded that early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.
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REFERENCES
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- Kalweit G, Feindt P, Huwer H, Volkmer I, Gams E. The pectoral muscle flaps in the treatment of bronchial stump fistula following pneumonectomy. Eur J Cardiothorac Surg 1994;8:358–62.[Abstract]
- Mineo TC, Ambrogi V. Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps. Ann Thorac Surg 1995;60:714–5.[Abstract/Free Full Text]
- Gharagozloo F, Trachiotis G, Wolfe A, DuBree KJ, Cox JL. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema. J Thorac Cardiovasc Surg 1998;116:943–8.[Abstract/Free Full Text]
- Schneiter D, Cassina P, Korom S, Inci I, Al-Abdullatief M, Dutly A, et al. Accelerated treatment for early and late postpneumonectomy empyema. Ann Thorac Surg 2001;72:1668–72.[Abstract/Free Full Text]
- Pairolero PC, Arnold PG, Trastek VF, Meland NB, Kay PP. Postpneumonectomy empyema. The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990;99:958–68.[Abstract]
- Yokomise H, Takahashi Y, Inui K, Yagi K, Mizuno H, Aoki M, et al. Omentoplasty for postpneumonectomy bronchopleural fistulas. Eur J Cardiothorac Surg 1994;8:122–4.[Abstract]
- Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997;63:1391–7.[Abstract/Free Full Text]
- Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456–64.[Abstract]
- Hollaus PH, Huber M, Lax F, Wurnig PN, Böhm G, Pridun NS. Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap. Eur J Cardiothorac Surg 1999;16:181–6.[Abstract/Free Full Text]
- Liebermann-Meffert D, White H, editors. The greater omentum. Anatomy, physiology, pathology, surgery, with an historical survey [Russian]. Moscow: Medicina, 1989:100–1.
- Turrentine MW, Kesler KA, Wright CD, McEwen KE, Faught PR, Miller ME, et al. Effect of omental, intercostal, and internal mammary artery pedicle wraps on bronchial healing. Ann Thorac Surg 1990;49:574–9.[Abstract]
- Regnard JF, Alifano M, Puyo P, Fares E, Magdeleinat P, Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection. J Thorac Cardiovasc Surg 2000;120:270–5.[Abstract/Free Full Text]
- Conlan AA, Lukanich JM, Shutz J, Hurwitz SS. Elective pneumonectomy for benign lung disease: modern-day mortality and morbidity. J Thorac Cardiovasc Surg 1995;110:1118–24.[Abstract/Free Full Text]
- Icard P, Le Rochais JP, Rabut B, Cazaban S, Martel B, Evrard C. Andrews thoracoplasty as a treatment of postpneumonectomy empyema: experience in 23 cases. Ann Thorac Surg 1999;68:1159–64.[Abstract/Free Full Text]
- Stamatis G, Martini G, Freitag L, Wencker M, Greschuchna D. Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy. Eur J Cardiothorac Surg 1996;10:83–6.[Abstract]
- de la Riviere AB, Defauw JJ, Knaepen PJ, van Swieten HA, Vanderschueren RC, van den Bosch JM. Transsternal closure of bronchopleural fistula after pneumonectomy. Ann Thorac Surg 1997;64:954–7.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
