Asian Cardiovasc Thorac Ann 2008;16:450-453
© 2008 Asia Publishing EXchange Ltd
Fibrin Glue Administration to Support Bronchial Stump Line
Soner Gursoy, MD,
Murat U Yapucu, MD,
Ahmet Ucvet, MD,
Serkan Yazgan, MD,
Oktay Basok, MD,
Sulun Ermete, MD1
Thoracic Surgery Department
1 Pathology Department, Dr. Suat Seren Chest Disease and Thoracic Surgery Training Hospital, Izmir, Turkey
For reprint information contact: Soner Gursoy, MD Tel: 90 532 353 2403 Fax: 90 232 458 7262 Email: grssoner{at}gmail.com, 2040/7 sokak Albatros 10 Giri
4 D: 47, Mavisehir, Bostanli, Izmir, Turkey.
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ABSTRACT
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Bronchopleural fistula is an important cause of mortality and morbidity after pulmonary resection. The use of fibrin glue to reduce the tension and number of sutures in the bronchial stump was assessed in this prospective study of 20 patients between June 2002 and May 2003. They all had a high risk of bronchopleural fistula development because of bronchiectasis, tuberculosis, lung abscess, diabetes mellitus, preoperative neoadjuvant radiotherapy, or residual tumor at the surgical margin. After pulmonary resection, the bronchial stump was closed with separate nonabsorbable sutures supported with fibrin glue. Bronchopleural fistula was observed in only 1 (5%) patient during 6.45 ± 3.09 months of follow-up. There was no postoperative mortality. Closing the bronchial stump with an appropriate technique and supporting it with fibrin glue were considered effective in preventing bronchopleural fistula development after pulmonary resection in high-risk patients.
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INTRODUCTION
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Bronchopleural fistula (BPF) may develop after pulmonary resection and it is an important cause of mortality and morbidity. Treatment of BPF is difficult, and the associated mortality rate is 16%–72%.1 A number of factors carry a high risk of this complication, including infection, lung cancer, bronchiectasis, abscess, diabetes mellitus, and preoperative neoadjuvant radiotherapy (RT). Closure of the bronchus when tension has been reduced and structure has been destroyed demands great attention. Closing the bronchial stump with sutures or staples requires support with an appropriate material to minimize the risk of BPF. This study was designed to assess the efficacy of fibrin tissue adhesive in supporting bronchial suture lines to prevent BPF development in a high-risk group of patients undergoing pulmonary resection.
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PATIENTS AND METHODS
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Between June 2002 and May 2003, pulmonary resection was performed in 178 patients, of whom 20 had a high risk of postoperative BPF because of diabetes, neoadjuvant radiotherapy, residual tumor at the resection site, and benign diseases such as lung abscess, bronchiectasis, or tuberculosis. Informed consent was obtained from all 20 patients and they were enrolled into this prospective study. They were evaluated by physical examination, routine biochemical and serologic tests, plain chest radiography and computed tomography, bronchoscopy, and respiratory function tests. In cases of tuberculosis, sputum culture was also carried out. Patient characteristics are given in Table 1
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Surgical procedures according to comorbidity are shown in Table 2. Four of the 6 cases of pulmonary tuberculosis were multidrug resistant (MDR). Surgical indications in the other 2 cases were an acid-fast bacilli-positive tuberculosis cavity unresponsive to medical treatment, and tuberculosis empyema with BPF in the left lower lobe, in which decortication was undertaken. One patient underwent craniotomy because of a solitary brain metastases 1 month before a left upper lobectomy; residual tumor tissue at the bronchial surgical margin was determined on histopathological examination, but pneumonectomy could not be undertaken because of limited pulmonary reserve. Great attention was paid during dissection of the bronchus in all patients. The bronchial stump was closed using 4 to 6 separate monofilament nonabsorbable 2/0 polypropylene sutures, depending on the size of the stump. No staples were used in these cases. After the bronchial suture line had been dried with a sponge, it was covered with 1 mL of fibrin glue (Beriplast) applied vertically to the bronchial stump which was held in the same position for 1 min to allow the formation of gelatinous fibrin. To confirm the risk of postoperative BPF development, samples taken from the resected bronchial stump lines were examined. Fragmentation and destruction of bronchial cartilages were detected histopathologically. All patients underwent bronchoscopy before discharge to check for BPF. They were followed up clinically and radiologically at postoperative months 1, 3, and 6. At the 3-month examination, serological tests (applied because of the use of fibrin glue) were negative. There were no indications for bronchoscopy at follow-up as no patient had clinical or radiological signs of BPF.
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RESULTS
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There was no operative or postoperative death. Postoperative complications (Table 3) included BPF in 1 patient with MDR tuberculosis preoperatively. BPF developed on the 22nd postoperative day, and rigid bronchoscopy was performed under general anesthesia. A fistula measuring approximately 3 mm was seen on the bronchial stump. It was closed by bronchoscopic application of fibrin glue. Two of the 4 patients who developed wound infections had non-small-cell lung cancer with diabetes, one had bronchiectasis, and the other had a lung abscess. They were treated with appropriate antibiotics and daily dressing examinations. No side effects or complications related to the use of fibrin glue were determined. The mean follow-up period was 6.45 ± 3.09 months (range, 3–11 months).
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DISCUSSION
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The incidence of BPF after pneumonectomy and lobectomy is 1%–4%; it is lower after segmentectomy or more limited resections.1 Currently, the rate of BPF after pneumonectomy should be < 3%.2 Vester and colleagues3 reported BPF in 3.9% of 503 pneumonectomies, 1.1% of 1,083 lobectomies, and 0.3% of 650 segmentectomies.3 Asamura and colleagues4 had a 2.1% BPF rate in 2,359 pulmonary resections, and in the study by Hubaut and colleagues,5 the rate was 2.4% in 209 cases. Although the incidence of BPF has decreased over the years, infection, diabetes, and preoperative neoadjuvant RT still carry high risks of BPF.
In bronchiectasis, recurring infections cause the bronchus to develop abnormally and irreversibly by destroying the elastic and muscular parts of the bronchial wall. The lumen of the effected bronchus is characteristically filled with infected material. In chronic cases, fibrosis is identified on the bronchial wall and around the bronchus.6 These histopathological changes cause a high risk of BPF after bronchiectatic lobe or lung resections. Despite numerous precautions, postoperative BPF occurred in 5.8% of 119 patients who were operated on because of bronchiectasis.5 We encountered no BPF in our 6 cases of bronchiectasis. Tuberculosis also increases the incidence of BPF because of ulceration created by cavity and necrotisans infection on the bronchial wall, endobronchial tuberculosis, or tuberculosis or mixed empyema due to a cavity opening into the pleural space.1 Pomerantz and colleagues7 reported the incidence of BPF to be 10.5% after pulmonary resection in 85 patients with MDR tuberculosis. Most of those who developed postoperative BPF had been infected with atypic mycobacteria or MDR tuberculosis and had undergone a right pneumonectomy; the bronchial stumps had been supported with intercostal muscle flaps. In another study, the BPF rate after pneumonectomy due to destroyed lung was 10.1%, and the mortality rate in patients with BPF was 50%.8 Preoperative neoadjuvant RT is also a risk factor for BPF. Interstitial edema, fibrosis, and capillary thrombosis following RT affect lung parenchyma and airways as well as the bronchial arteries, promoting the development of postoperative BPF.6 The reported incidence of postoperative BPF after preoperative neoadjuvant RT is 9.6%–12.1%.9,10 Patients with chronic obstructive pulmonary disease, hyperglycemia, hypoalbuminemia, previous steroid therapy, poor predicted post-resection forced expiratory volume in 1 sec, long bronchial stumps, right-sided pneumonectomy, or mechanical ventilation also have a high risk of BPF.11,12
In studies comparing stapling with manual suture techniques, it was shown that neither technique was superior. Today, closing the bronchial stump with viable tissue such as an intercostal or latissimus dorsi muscle flap or omentum, or supporting it with a tissue adhesive is considered essential when there are patient-dependent risk factors.1,13,14 Kesler and colleagues15 found that the "carinoplasty" airway closure technique reduced the risk of BPF. Using a manual suture technique with nonabsorbable monofilament 2/0 polypropylene (because of its low infection rate) and supporting the suture line with fibrin glue, we encountered similar rates of BPF in the high-risk group and the other 158 patients who underwent lung resection (5% and 3.8%, respectively). Fibrin glue imitates the late phase of hemostasis and thus stimulates healing.16 In the presence of catalysts (factor XIII and calcium), fibrinogen and thrombin are polymerized to fibrin.17 There are few reports of prophylactic use of fibrin glue to prevent postoperative BPF. In an experimental study, Omiya and colleagues18 showed that fibrin glue protected for the 2-week period required for recovery of the bronchial stump. In clinical studies, fibrin glue provided effective hemostasis and control of air leaks, with shorter hospital stay.19,20 In our series, the postoperative drainage period and hospital stay were comparable with other reports. Blood-borne infections such as AIDS, hepatitis B and C, and parvovirus B19, as well as some complications (hypotension, anaphylaxis, bleeding) may be related to the use of fibrin glue.17 These risks have been minimized recently by improved production techniques. All our patients had serological tests postoperatively, which excluded such infections.
It was concluded that closing the bronchial stump with an appropriate surgical technique and supporting it with fibrin glue were effective in preventing postoperative BPF in this high-risk group of patients because the results were comparable with those obtained using viable tissue flaps to support the bronchial suture lines.
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REFERENCES
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- Shields TW, Ponn RB. Complications of pulmonary resections. In: Shields TW, LoCicero J, Ponn RB, editors. General thoracic surgery. Philadelphia: Lippincott Williams and Wilkins, 2000:481–505.
- Boyd AD, Spencer FC. Bronchopleural fistulas: how often should they occur? Ann Thorac Surg 1972;13:195–6.[Medline]
- Vester SR, Faber LP, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of the bronchus. Ann Thorac Surg 1991;52:1253–7.[Abstract]
- 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 [Review]. J Thorac Cardiovasc Surg 1992;104:1456–64.[Abstract]
- Hubaut JJ, Baron O, Al Habash O, Despins P, Duveau D, Michaud JL. Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer. Eur J Cardiothorac Surg 1999;16:418–23.[Abstract/Free Full Text]
- Prieto D, Bernardo J, Matos MJ, Eugenio L, Antunes M. Surgery for bronchiectasis. Eur J Cardiothorac Surg 2001;20:19–23.[Abstract/Free Full Text]
- Pomerantz M, Madsen L, Goble M, Iseman M. Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections. Ann Thorac Surg 1991;52:1108–11.[Abstract]
- Halezeroglu S, Keles M, Uysal A, Celik M, Senol C, Haciibrahimoglu G, et al. Factors affecting postoperative morbidity and mortality in destroyed lung. Ann Thorac Surg 1997;64:1635–8.[Abstract/Free Full Text]
- Yashar J, Weitberg AB, Glicksman AS, Posner MR, Feng W, Wanebo HJ. Preoperative chemotherapy and radiation therapy for stage IIIa carcinoma of the lung. Ann Thorac Surg 1992;53:445–8.[Abstract]
- Cyjon A, Nili M, Fink G, Kramer MR, Fenig E, Sandbank J, et al. Advanced non-small cell lung cancer: induction chemotherapy and chemoradiation before operation. Ann Thorac Surg 2002;74:342–7.[Abstract/Free Full Text]
- Algar FJ, Alvarez A, Aranda JL, Salvatierra A, Baamonde C, López-Pujol FJ. Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis. Ann Thorac Surg 2001;72:1662–7.[Abstract/Free Full Text]
- Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001;7:330–6.[Medline]
- 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]
- de Perrot M, Licker M, Robert J, Spiliopoulos A. Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy. Scand Cardiovasc J 1999;33:171–4.[Medline]
- Kesler KA, Hammoud ZT, Rieger KM, Kruter LE, Yu M, Brown JW. Carinaplasty airway closure: a technique for right pneumonectomy. Ann Thorac Surg 2008;85:1178–85.[Abstract/Free Full Text]
- Morikawa T, Katoh H. Improved techniques of applying fibrin glue in lung surgery. Eur Surg Res 1999;31:180–6.[Medline]
- Bayfield MS, Spotnitz WD. Fibrin sealant in thoracic surgery. Pulmonary applications, including management of bronchopleural fistula [Review]. Chest Surg Clin N Am 1996;6:567–83.[Medline]
- Omiya H, Saito Y, Imamura H, Okamura A. The pharmacokinetics of a fibrin adhesive agent applied to the rat lung. Jpn J Thorac Cardiovasc Surg 1998;46:1275–8.[Medline]
- Mouritzen C, Drömer M, Keinecke HO. The effect of fibrin glueing to seal bronchial and alveolar leakages after pulmonary resections and decortications. Eur J Cardiothorac Surg 1993;7:75–80.[Abstract]
- Fleisher AG, Evans KG, Nelems B, Finley RJ. Effect of routine fibrin glue use on the duration of air leaks after lobectomy. Ann Thorac Surg 1990;49:133–4.[Abstract]
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[Abstract]
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ABSTRACT
INTRODUCTION
