Carinoplasty With Telescope Anastomosis for Tuberculous Bronchial Stenosis
Hisaichi Tanaka, MD,
Mitsunori Ohta, MD,
Akihide Matsumura, MD,
Naoki Ikeda, MD,
Naoto Kitahara, MD,
Keiji Iuchi, MD
Department of Surgery, National Hospital Organization Kinki-chuo Chest Medical Center, Osaka, Japan
Hisaichi Tanaka, MD Tel: +81 722 523021 Fax: +81 722 511372 Email: h-tanaka{at}kch.hosp.go.jp, Department of Surgery, National Hospital Organization Kinki-chuo Chest Medical Center, 1180 Nagasonechou, Sakai, Osaka 591-8555, Japan.
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ABSTRACT
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A 25-year-old women developed severe stenosis of the right main bronchus after medical treatment for pulmonary tuberculosis in the right upper lobe. She underwent a right upper sleeve lobectomy with partial excision of the right main bronchus and right side of the carina. Reconstruction was performed using telescopic anastomosis between the carina and intermediate bronchus. Her symptoms improved immediately.
Key Words: Tracheal Stenosis • Tuberculosis, Pulmonary
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INTRODUCTION
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Tracheobronchial tuberculosis causes long-segmental and diffuse stenosis. The surgical approach may also be limited by the medical condition, operability, and a difficult local situation. We describe a successful result of a one-stoma type of carinoplasty for post-tuberculosis tracheobronchial stenosis.
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CASE REPORT
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A 25-year-old women was admitted to our hospital with pulmonary tuberculosis localized to the right upper lobe. After medical treatment with isoniazid, rifampicin, and ethambutol for 6 months, smears and cultures of sputum became negative for tubercle bacilli, and she was discharged. She complained of a productive cough, stridor, and dyspnea for 3 months after discharge. A chest radiograph showed atelectasis of the right upper lobe. Coronal reformation of chest computed tomography also showed severe stenosis of the right main and right upper bronchi (Figure 1A
). Bronchoscopic examination showed complete obstruction of the right main bronchus and cicatricial deformation of the right side of the carina and distal trachea (Figure 1B). Mycobacterium tuberculosis could not be identified in specimens obtained by bronchial brushing. Biopsy specimens showed hyaline fibrosis of the bronchus without an active lesion of tuberculosis. The patient was underwent surgery for the bronchial obstruction. A right upper sleeve lobectomy was performed through a right lateral thoracotomy (Figure 2A). Because of the cicatricial stenosis of the proximal stump, partial excision of the right side of the carina and distal trachea was also carried out for size matching with the distal stump (Figure 2A); thus size discrepancy was minimal. The tracheobronchial cicatrization also caused deformation of the carina, and the new opening was flattened to an ovoid shape. The total airway defect was linear to 3 cm. The para-endotracheal tissue was intact. After tracheal mobilization, anastomosis was performed between the intermediate bronchus and the new opening of the carina using a telescoping procedure. Anastomosis was initiated from the mediastinal side of the cartilage with 4/0 PDS-II sutures (Ethicon, Inc., Somerville, NJ, USA). Knotted sutures were placed around the cartilage, and the distal stump was inserted into the proximal stump (Figure 2B). Anastomosis of the membranous portion was undertaken with a continuous suture technique (Figure 2C). Wrapping of the anastomosis was carried out with a pedicled pericardial fat pad. The patient’s symptoms improved immediately after the operation. Bronchoscopic examination showed protrusion of the distal stump, a flat shape of the right intermediate bronchus, and regeneration of the bronchial mucosa at the anastomosis site 2 weeks after the operation (Figure 3A). The patient left hospital 1 month after the operation. One year later, virtual bronchoscopy reconstructed from computed tomography demonstrated that the protrusion of the distal trachea had disappeared, and the shape of the anastomosis was ovoid. The shape and size of the new carina had improved significantly compared to just after the operation (Figure 3B).
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Figure 1. (A) Coronal reformation of spiral computed tomography. (B) Bronchoscopic finding. LM =left main bronchus, RM =right main bronchus, RU =right upper bronchus.
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Figure 2. Diagram of the operative technique. (A) Incision line of the bronchotracheal resection: line 1 =incision of right upper sleeve lobectomy, line 2 =incision of carina and trachea. (B) Anastomosis of the cartilage portion. (C) Anastomosis of the membranous portion. C =carina, I =right intermedius bronchus, LM =left main bronchus, RU =right upper bronchus, T =trachea.
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Figure 3. (A) Bronchoscopic finding 2 weeks after the operation. (B) Virtual bronchoscopic reformation of spiral computed tomography 1 year after operation. LM =left main bronchus.
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DISCUSSION
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Tuberculosis involving the central airway occasionally results in diffuse airway stenosis, and it most frequently occurs in the distal trachea and main bronchus. When the stenosis is more limited to the main bronchus, sleeve resection can be performed with high likelihood of a good result. Stenosis limited to 2 cm is considered favorable for surgical treatment. However, a long-segment tracheobronchial stenosis may make sleeve resection difficult or impossible, and pneumonectomy or therapeutic bronchoscopy may be indicated. Complete resection of the cicatricial lesion in post-tuberculosis stenosis causes a large airway defect that requires difficult and complicated reconstruction. Muscle transposition for a large airway defect has been reported to achieve successful reconstruction.1
In our patient, the right main bronchus was completely obstructed, and fibrotic stenosis extended from the right intermediate bronchus to the right side of the distal trachea. Bronchoscopic dilatation was unsuitable due to the difficult local situation. Moreover, the cicatricial deformation was linear over 2 cm in the distal trachea, and tracheal resection was limited. Therefore, the proximal stump had a cicatricial lesion and the new carina was made in a flat shape. We were concerned that collapse of the cicatricial bronchial wall might lead to restenosis at the anastomosis. However, the shape and size of the new carina improved significantly over time. We believe that the normal distal bronchus splinted the stenotic proximal stump, like stenting, in this case. The anastomosis produced by the telescope method is one of double bronchial walls that splint each other and are airtight and morphologically rigid; therefore, stricture, kinking, and tension are avoided.2 Successful results of telescope anastomosis have been reported in high-risk patients undergoing lung transplantation, those with a high-caliber mismatch, and after induction therapy for locally advanced lung cancer.3–5 We recommend the telescope method as an effective and safe technique in a one-stoma type of carinoplasty for post-tuberculosis tracheobronchial stenosis.
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REFERENCES
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- Meyer AJ, Krueger T, Lepori D, Dusmet M, Aubert JD, Pasche P, et al. Closure of large intrathoracic airway defects using extrathoracic muscle flaps. Ann Thorac Surg 2004;77:397–405.[Abstract/Free Full Text]
- Hollaus PH, Janakiev D, Pridun NS. Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch. Ann Thorac Surg 2001;72:357–61.[Abstract/Free Full Text]
- Calhoon JH, Grover FL, Gibbons WJ, Bryan CL, Levine SM, Bailey SR, et al. Single lung transplantation. Alternative indications and technique. J Thorac Cardiovasc Surg 1991;101 816–25.[Abstract]
- Ohta M, Sawabata N, Maeda H. Matsuda H. Efficacy and safety of tracheobronchoplasty after induction therapy for locally advanced lung cancer. J Thorac Cardiovasc Surg 2003;125: 96–100.[Abstract/Free Full Text]
- Miyoshi S, Tamura M, Araki O, Yoshii N, Karube Y, Seki N, et al. Telescoping bronchial anastomosis for extended sleeve lobectomy. J Thorac Cardiovasc Surg 2006;132:978–80.[Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:307-309
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104771
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