Asian Cardiovasc Thorac Ann 2001;9:204-207
© 2001 Asia Publishing EXchange Pte Ltd
Closure of Bronchial Defects Using Glutaraldehyde-Treated Pericardium
Rajinder S Dhaliwal, MCh,
Deepak Puri, MCh,
Kuldip S Sidhu, MCh1
Department of Cardiovascular and Thoracic Surgery Postgraduate Institute of Medical Education and Research Chandigarh, Punjab, India
1 Department of Cardiovascular and Thoracic Surgery Government Medical College Amritsar, Punjab, India
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For reprint information contact: Rajinder S Dhaliwal, MCh Tel: 91 172 71 1070 Fax: 91 172 74 4401 email: rsdhaliwal{at}glide.net.in Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, P.O. Box 1515, PGI Campus, Chandigarh, Punjab 160012, India.
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Abstract
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From September 1992 to December 2000, closure of bronchial defects in 9 patients was achieved with a glutaraldehyde-treated autologous free pericardial patch. Four patients underwent an upper lobectomy and 2 had a lower lobectomy. Two patients had traumatic disruption of the main bronchus, and 1 had disruption of the right bronchus intermedius. Airtight closure of the bronchial defect was accomplished in all cases, and the remaining lung expanded easily. There was no suture line breakdown, bronchial stenosis, or obstruction during follow-up ranging from 3 to 96 months. Pericardial patch bronchoplasty is a technically simpler and safe alternative to complex bronchoplasty procedures.
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INTRODUCTION
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Various complex bronchoplasty procedures have been described for closure of bronchial defects due to traumatic tracheobronchial rupture or parenchyma-conserving pul-monary resections for benign or malignant diseases.1–3 However, these procedures require great surgical expertise and are associated with technical problems such as disparity in the size of the bronchial stumps or an excessive length of pulmonary artery after resection of a long bronchial segment. Major complications include air leak, fistula formation, granulation tissue, and delayed bronchial stenosis. To overcome these problems, simpler techniques such as use of a pedicled pericardial flap, pedicled latissimus dorsi, or pectoralis major muscle flaps have been suggested.4,5 Even ringed vascular grafts were used on an experimental basis but they were found to be unsuitable.6 The use of a glutaraldehyde-treated free pericardial patch as a simple alternative to complex bronchoplasty procedures is described.
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PATIENTS AND METHODS
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Glutaraldehyde-treated free pericardial patch broncho-plasty was performed in 9 patients between September 1992 and December 2000. Three patients had traumatic disruption of the bronchus, 5 had lung parenchyma-conserving resection for bronchial carcinoma, and 1 had resection for bronchial carcinoid (Table 1
). Indications for the procedure were bronchial defects greater than 2 cm close to or extending into the orifice of the remaining lobe, or traumatic disruption with loss of bronchial wall and lung adherent to the chest wall. Bronchial disruption was suspected in the 3 cases of chest trauma because of extensive subcutaneous emphysema, persistent massive air leak through the intercostal drain, and chest radiographs showing persistent fallen lung sign (Figure 1). Fiberoptic bronchoscopy demonstrated disruption of the main bronchus in 2 patients, and disruption of the right bronchus intermedius in the other. The clinical details, procedures, and indications for free pericardial patch bronchoplasty are summarized in Table 1.
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Figure 1. Chest radiograph of a patient with traumatic disruption of the right bronchus intermedius, showing persistently collapsed right lung (arrow) even after insertion of an intercostal drainage tube, and extensive subcutaneous emphysema over the chest wall.
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Through an anterolateral thoracotomy, the bronchial defect was clearly defined after the involved lobe was resected in cases of bronchogenic carcinoma or after exploration in traumatic bronchial disruption. The defects ranged from 2 to 3.5 cm in diameter. An appropriately sized section of pericardium was removed medial to the phrenic nerve to avoid injuring it. The pericardial patch was fixed in 0.6% glutaraldehyde solution for 7 to 10 minutes and washed with normal saline. It was stretched tight and sutured to the margins of the bronchial defect using a continuous suture of 4/0 polypropylene. The resultant pericardial defect could be easily closed with interrupted sutures. Fiberoptic bronchoscopy was performed on the 7th postoperative day to check for breakdown of the suture line or any bronchial obstruction. All patients were followed up at 1 month, 3 months, and subsequently every 6 months by chest radiography, spirometry, and fiberoptic bronchoscopy.
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RESULTS
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Airtight closure of the bronchial defect was possible in all patients and the remaining lung expanded easily on the operating table. Postoperative chest skiagrams showed full expansion of the remaining lung in all cases with no residual space. In follow-up ranging from 3 to 96 months (mean, 48 months), there was no evidence of bronchial stenosis at the repair site or local recurrence of the tumor on fiberoptic bronchoscopy. Pulmonary function tests showed no evidence of obstructive physiology. Forced expiratory volume in 1 second was over 85% in all patients. In postoperative computed tomography scans (at 6 to 12 months), the diameter of the bronchi on which the pericardial patch was sutured was found to be normal. There was no paradoxical movement of the patch on fiberoptic bronchoscopy in any patient.
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DISCUSSION
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Bronchoplasty procedures were initially devised by D'Abreau and MacHale7 in 1952 to preserve lung parenchyma while removing benign proximal bronchial lesions. The development of double-lumen endotracheal tubes greatly enhanced the anesthetic management of such patients. Bronchoplastic procedures have been projected subsequently as the ideal surgical procedure for benign endobronchial lesions and tumors of low-grade malignant potential.8,9 A portion of the bronchus is removed with or without lobectomy, as a sleeve or wedge resection, and primary reimplantation of the bronchial stump or closure of the defect using a bronchial wall flap is performed. Similar techniques have been used for repair of traumatic airway injuries and benign strictures, but this may not always be feasible.10 These procedures are not only technically difficult but are also associated with major complications. Disparity in the size of the bronchial segments after resection of long portions of bronchi makes a perfect tension-free anastomosis impossible, and delayed stenosis may occur at the site of anastomosis. 11 Recon-struction following resection of long bronchial segments may result in an excessively long pulmonary artery that requires an additional shortening angioplasty procedure to prevent kinking.12 Rigid tracheobronchial cartilage does not usually allow a perfect tension-free repair and there is a constant risk of suture line breakdown or fistula formation and stenosis. Mucosal swelling is known to occur distal to the tracheobronchial end-to-end anasto-mosis, causing retention of mucus. Bronchial mucosal blood flow is markedly reduced due to extensive detach-ment of surrounding connective tissue, which can cause stenosis or dehiscence of the bronchial anastomosis.13
During the period of this study, conventional bronchoplasty was performed in 11 patients (6 with benign tumors and 5 with bronchogenic carcinoma). One patient died after 3 weeks due to massive hemoptysis caused by broncho-vascular fistula, 2 developed bronchopleural fistula that closed slowly on conservative treatment, and 3 developed narrowing at the bronchoplasty site during follow-up of 6 years. Sleeve resection with a properly performed bronchoplastic procedure is now well established as the ideal technique for both benign bronchial tumors and early bronchogenic carcinoma.8 However, bronchoplastic procedures are not commonly performed by the majority of thoracic surgeons as they are technically demanding. Interruption of ciliary epithelium and lymphatics, and partial denervation of the reimplanted lobe may be responsible for the high incidence of retained secretions and atelectasis.12 Such problems were not encountered after free pericardial patch bronchoplasty as more than half of the circumference of the bronchial wall and lumen is retained, and the suture line is limited to the area overlying the defect. Our mortality rate was 4.2% for standard lung resections and 8.2% for sleeve resection and bronchoplasty, compared to no mortality for the pericardial patch bronchoplasty procedure.
We tried the autologous glutaraldehyde-treated free pericardial patch procedure in our first patient out of necessity as no other option was available. The patient had a right main bronchus lesion following blunt chest trauma and was referred 3 months after the injury. Fiberoptic bronchoscopy showed a large tear in the anterior wall of the right main bronchus. On exploratory thoracotomy, a 3-cm defect was found in the anterior wall of the main bronchus, the posterior cartilages were intact, and the lung was adherent to the chest wall. Sleeve resection and reimplantation were not possible; a pneumo-nectomy seemed to be the only choice. In order to save the lung, this technique was tried. To our surprise, the lung expanded fully on the operating table and there was no problem in the immediate postoperative period or on follow-up. This excellent outcome encouraged us to use the method subsequently in suitable patients. The good results of this technique are attributed to fixation of the patch with glutaraldehyde to make it firm, as well as tight stitching around the defect. This method was found to be especially useful for closure of bronchial defects close to the orifices of the remaining lobes where primary closure was either impossible or would have resulted in significant narrowing with compromised function of the remaining lobe. The operative mortality reported for bronchoplastic procedures ranges from 3.65% to 17%, and the incidence of postoperative atelectasis and anastomotic stricture varies from 7% to 20%.9,13 Because of the superior outcome of no mortality and minimal morbidity with free pericardial patch bronchoplasty in our patients, we recommend its use in bronchial defects close to or over the orifice of a remaining lobe or where mobilization of a disrupted bronchus is difficult or hazardous due to adhesions to surrounding vital structures.
Presented at the 8th Annual Meeting of The Asian Society for Cardiovascular Surgery, Fukuoka, Japan, September 6–8, 2000.
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References
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Abstract
INTRODUCTION
