Asian Cardiovasc Thorac Ann 2007;15:45-48
© 2007 Asia Publishing EXchange Ltd
Bronchopleural Fistula After Lobectomy for Lung Cancer
Itaru Nagahiro, MD,
Motoi Aoe, MD,
Yoshifumi Sano, MD,
Hiroshi Date, MD,
Akio Andou, MD,
Nobuyoshi Shimizu, MD
Department of Cancer and Thoracic Surgery, University of Okayama Medical School, Okayama, Japan
For reprint information contact: Itaru Nagahiro, MD Tel: 81 79 294 2251 Fax: 81 79 296 4050 Email: inagahiro{at}hrc-hp.com, Department of General Thoracic Surgery, Himeji Red Cross Hospital, 1-12-1 Shimoteno, Himeji, 670-8540, Japan.
 |
ABSTRACT
|
|---|
Bronchopleural fistula after lung resection is a fatal complication. The aim of this study was to determine the risk factors for bronchopleural fistula after lobectomy for lung cancer. Clinical records of 767 patients who underwent lobectomy or bilobectomy for lung cancer in our institution were reviewed. Twelve patients (1.6%) suffered a bronchopleural fistula, of whom 5 died because of this complication (mortality rate, 41.7%). Multivariate analysis revealed squamous cell carcinoma, preoperative chemotherapy, lower lobectomy, and middle and lower lobectomy were risk factors for bronchopleural fistula. In such cases, particular care must be exercised to maintain blood flow through the bronchial stump during surgery, and reinforcement, such as stump coverage, must be employed.
|
INTRODUCTION
|
|---|
Despite advances and improvements in surgical technique and perioperative patient management, the morbidity rate following lung resection is still around 25%.1,2 Bronchopleural fistula (BPF) is a fatal postoperative complication of lung surgery. The prevalence is 1%–4% according to previous reports, and the mortality rate is 16%–72%.2–5 Thorough investigations revealed some risk factors, such as right pneumonectomy, resection following full-dose radiation, and preoperative infection; however, few reports have focused on BPF after lobectomy for lung cancer.5 In this paper, we reviewed the clinical records of patients who underwent lobectomy or bilobectomy for lung cancer, and tried to identify the risk factors for postoperative BPF.
|
PATIENTS AND METHODS
|
|---|
The clinical records of 767 patients who underwent lobectomy or bilobectomy for lung cancer from January 1993 to December 2002 in our institution were reviewed. In this study, pneumonectomy and sleeve lobectomy were excluded to focus on simple lobectomy. Standard resection of the entire lobe or lobes where the tumor was located, and systematic hilar and ipsilateral mediastinal lymph node dissection were performed in most patients. In elderly patients or those with limited cardiopulmonary reserve, less extensive lymph node sampling was performed. Perioperative prophylactic antibiotic administration was routine in all patients. Bronchopleural fistula was suspected from the clinical course and chest radiograph, and it was confirmed by bronchofiberscopy. The following factors were reviewed: sex, age, tumor location (right side, left side, central, and peripheral), histologic type (adenocarcinoma, squamous cell carcinoma, and others), preoperative chemotherapy, method of bronchial closure (stapling and manual suturing), and type of lobectomy performed (upper lobectomy, middle lobectomy, lower lobectomy, upper and middle lobectomy, or middle and lower lobectomy).
The unpaired Student t test and the chi-squared test were employed to examine the relationships between the variables and the occurrence of BPF. Univariate logistic regression was used to examine the odds ratios of all variables, followed by multivariate logistic regression to test all variables significant on univariate analysis. Data are expressed as the total number of cases or a mean ± standard deviation of the mean. Probability ( p-value) less than 0.05 was considered significant.
|
RESULTS
|
|---|
Twelve patients developed postoperative BPF (1.6%). The mean interval from the operation to the detection of BPF was 20.8 days (range, 8–47 days). After the detection of BPF, 9 patients received surgical interventions (completion pneumonectomy and omental wrapping of the bronchial stump in 7 cases, and middle lobectomy and omental wrapping in 2 cases; 4 patients died). Seven of the 9 patients were operated on the day BPF was detected, and 2 were operated on 7 and 13 days after the detection of BPF. The other 3 underwent bronchoscopic occlusion using fibrin glue; 1 died. Thus, 5 of these 12 patients died because of BPF (mortality rate, 41.7%). The causes of death were sepsis and respiratory insufficiency due to pneumonia in the residual lungs in all patients.
The relationships between BPF and patient variables are shown in Table 1
, and the results of univariate and multivariate analysis are shown in Table 2. Tumor location (peripheral vs central), tumor histology, preoperative chemotherapy, the method of stump closure, and lobectomy site correlated significantly with the development of BPF. Univariate logistic regression analysis revealed that the same variables were significant, but multivariate analysis showed only tumor histology, preoperative chemotherapy, and lobectomy site to be significant risk factors.
|
DISCUSSION
|
|---|
Three important points regarding BPF are indisputable. First, BPF is more common after pneumonectomy than a lesser resection. Second, BPF is more common after right than left pneumonectomy. Third, BPF following pneumonectomy is clinically more devastating than after lobectomy or segmentectomy.5 Although the incidence of BPF after lobectomy is lower and its prognosis seems to be better than that of pneumonectomy, it is worthwhile to identify the risk factors of BPF after lobectomy because some deaths after lobectomy are due to BPF. Although the incidence of BPF was low (only 1.56%) in this series, once BPF occurred the mortality rate was high (41.7%). The incidence of BPF after lobectomy was comparable to that stated in a previous report.3 The mortality rate after re-operation (44.4%; 4 out of 9 cases) was also comparable to that in a previous report.6 The high mortality rate after re-operation was mainly due to persistent infection in the thoracic cavity, difficult-to-control pneumonia in the residual lungs, and resulting acute respiratory distress syndrome and sepsis.
Multivariate analysis revealed squamous cell carcinoma, preoperative chemotherapy, and lower lobectomy or middle and lower lobectomy were significant risk factors of BPF after lobectomy for lung cancer. Squamous cell carcinoma of the lung predominantly occurs in the central bronchial region and it might require more extensive dissection around the bronchus than peripheral lung cancer to completely resect the cancer. This might cause reduction of bronchial blood flow through the stump and result in BPF. Preoperative chemotherapy may affect the healing of the bronchial stump because chemotherapy often causes fibrosis. In addition, tissue planes may be obliterated because of mediastinal fibrosis, which makes bronchial dissections and maintaining bronchial blood flow more difficult.7 Reduced blood flow in the bronchial stump may be exacerbated after lower or middle lobectomy than after upper lobectomy, because the distance from the mediastinal structure to the stump is longer after the former surgery.
The method of stump closure (stapling or manual suturing) has been controversial for a long time, but now the consensus is that bronchial closure by stapling is usual, and manual sewing of the bronchus may be indicated in particular circumstances, an example being to ensure that the bronchial resection is proximal to an endobronchial tumor.8–12 The present study (like previous studies) found no difference between staple closure and manual closure in multivariate analysis, but staple closure was better than manual closure in univariate analysis.
Much has been written and many dogmas are held about the optimal means of avoiding BPF. Clearly, prevention is the key. Less clear, however, is the optimal means of prevention.5 Some tips for prevention of BPF have been advocated, such as less extensive peribronchial dissection and reinforcement of the bronchial stump by various adjacent tissues including a pedicled pericardial fat pad, intercostal muscle flap, and pedicled pericardium flap.13 Maintaining the blood flow in the bronchial stump is very important in lung cancer surgery, especially to avoid BPF. Additionally, complete resection is the main goal of cancer surgery. No residual cancer should be left in order to maintain the blood flow in the bronchial stump, but surgeries such as sleeve lobectomy must be performed to achieve complete resection when residual cancer in the bronchial stump is suspected. Controversies still exist about the need for, and the benefit of, coverage of the bronchial stump; however, covering the bronchial stump is recommended in those patients with risk factors for BPF, i.e., preoperative chemotherapy, lower or middle lower lobectomy, and squamous cell carcinoma.
|
REFERENCES
|
|---|
- Harpole DH Jr, DeCamp MM Jr, Daley J, Hur K, Oprian CA, Henderson WG, et al. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 1999;117:969–79.[Abstract/Free Full Text]
- Stephan F, Boucheseiche S, Hollande J, Flahault A, Cheffi A, Bazelly B, et al. Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors. Chest 2000;118:1263–70.[Medline]
- 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]
- Vester SR, Faber LP, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:1253–8.[Abstract]
- Ponn RB. Complications of pulmonary resection. In: Shields TW, editor. General thoracic surgery. Philadelphia: Lippincott, Willams & Wilkins, 2005:554–86.
- Muysoms FE, de la Riviere AB, Defauw JJ, Dossche KM, Knaepen PJ, van Swieten HA, et al. Completion pneumonectomy: analysis of operative mortality and survival. Ann Thorac Surg 1998;66:1165–9.[Abstract/Free Full Text]
- Singhal S, Shrager JB, Kaiser LR. Multimodality therapy for non-small-cell lung cancer. In: Shields TW ed, General Thoracic Surgery. Philadelphia: Lippincott Willams & Wilkins, 2005:1653–79.
- Wright CD, Wain JC, Mathisen DJ, Grillo HC. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management. J Thorac Cardiovasc Surg 1996;112:1367–71.[Abstract/Free Full Text]
- El-Gamel A, Tsang GM, Watson DC. The threshold for air leak: stapled versus sutured human bronchi, an experimental study. Eur J Cardiothorac Surg 1999;15:7–10.[Abstract/Free Full Text]
- Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures. Eur J Cardiothorac Surg 2000;17:106–10.[Abstract/Free Full Text]
- Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa M, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000;18:519–23.[Abstract/Free Full Text]
- Fell SC, Kirby TJ. Technical aspects of lobectomy. In: Shields TW, editor. General thoracic surgery. Philadelphia: Lippincott, Willams & Wilkins, 2005:433–57.
- Klepetko W, Taghavi S, Pereszlenyi A, Birsan T, Groetzner J, Kupilik N, et al. Impact of different coverage techniques on incidence of postpneumonectomy stump fistula. Eur J Cardiothorac Surg 1999;15:758–63.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M. L. Tedde, P. R. Scordamaglio, H. Minamoto, V. R. Figueiredo, C. C. Pedra, and F. B. Jatene
Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device.
Ann. Thorac. Surg.,
September 1, 2009;
88(3):
e25 - e26.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. R. Kramer, N. Peled, D. Shitrit, E. Atar, M. Saute, D. Shlomi, A. Amital, and E. Bruckheimer
Use of Amplatzer Device for Endobronchial Closure of Bronchopleural Fistulas
Chest,
June 1, 2008;
133(6):
1481 - 1484.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
