Peter H. Hollaus

Natural history of bronchopleural fistula after pneumonectomy: A review of 96 cases

BACKGROUND Various therapeutic approaches to bronchopleural fistula have been reported. Its natural history, which may be key to the best therapeutic management, early detection, and possibly, prevention of fistula formation, has received little attention. METHODS The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at primary bronchoscopic diagnosis, time of occurrence after operation (days), cause of death, and survival after fistula formation (days) were analyzed. Management consisted of bronchoscopic closure with fibrin sealant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thoracostomy. RESULTS Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) died during the observation period; in 25, the cause of death was aspiration pneumonia. Only 2 patients who died of aspiration pneumonia had development of a fistula after 90 postoperative days. The aspiration rate dropped with increasing interval between operation and fistula occurrence (p = 0.000). Patient survival after fistula formation was positively correlated to this interval (p = 0.002). Successful fistula closure was achieved by surgical intervention in 21 patients and endoscopically in 11 patients. The overall postoperative mortality rate irrespective of treatment method was 31%. CONCLUSIONS The incidence of aspiration pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently represents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postoperative months should detect bronchopleural fistula before aspiration occurs.

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax

BACKGROUND Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy. METHODS We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis. RESULTS There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation. CONCLUSIONS Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

BACKGROUND The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. METHODS The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. RESULTS Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment. CONCLUSIONS Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Glove perforation rate in open lung surgery

OBJECTIVE In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.

Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap

OBJECTIVES The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively. METHODS Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded. RESULTS Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed. CONCLUSION The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.

Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis

BACKGROUND This study was designed to identify risk factors responsible for postoperative complications after bronchoplastic procedures. METHODS Excluding sleeve pneumonectomies between January 1994 and December 2001, 108 patients underwent bronchoplastic procedures for bronchial malignancy. Prospectively documented data were age, gender, side, type of bronchial reconstruction, extended resection, histology, TNM stage, diseased lobe, and bronchial tumour occlusion. Cardiovascular (CV) risk factors included heart disease, arterial hypertension, cerebro-occlusive disease, peripheral artery disease of the lower extremities, diabetes mellitus, and abdominal aortic aneurysm. Patients were grouped according to the presence/absence of any CV risk factor and the absolute number of CV risk factors present (zero to four). Non-CV risk factors included neoadjuvant chemotherapy, alcoholism, lung disease, sleep apnea, history of recent pneumococcal sepsis, and repeat thoracotomy. Groups were assembled according to the presence or absence of any non-CV risk factor, neoadjuvant chemotherapy, and alcoholism. Respiratory risk factors included lung function and blood gas analysis. Groups were assembled according to the absolute number of respiratory risk factors in each person (zero to three) and the combination of respiratory and CV risk factors. Complications were defined as septic (pneumonia, empyema, brochopleural fistula, colitis) and aseptic. For univariate statistical analysis, t test, cross-tabulation, and chi2 test were used. All factors with a significance of p < 0.1 were entered into a binary backwards-stepwise logistic regression model. RESULTS The combination of respiratory and CV risk factors (p = 0.012, OR = 0.165) was predictive for overall complications. Coronary artery disease (p = 0.02, OR = 0.062) and the combination of two respiratory risk factors (p = 0.008, OR = 0.062) were predictive for septic complications. Peripheral artery disease (p = 0.024, OR = 0.28), moderate (p = 0.01, OR = 0.13) and severe chronic obstructive pulmonary disease (p = 0.018, OR = 0.11), and extended resections (p = 0.003, OR = 0.017.) were predictive for aseptic complications. CONCLUSIONS Comorbidity significantly influences the postoperative complication rate and is therefore crucial for evaluation of patients for bronchoplastic procedures. Different risk factors are responsible for the occurrence of septic and aseptic complications after bronchoplastic procedures.

Videothoracoscopic debridement of the postpneumonectomy space in empyema

OBJECTIVE Simple irrigation has proven to be an efficient method to treat postpneumonectomy empyema provided that bronchopleural fistula is not present or successfully closed. However, with this treatment modality, infected material inside the thoracic cavity is not removed and this can be a potential source of empyema recurrence if the patients immune system is compromised. The removal of the infected material should result in a lower recurrence rate. METHODS As soon as diagnosis of postpneumonectomy empyema was established, a chest tube drainage was inserted. A concomitant bronchopleural fistula was evaluated bronchoscopically. If the fistula was smaller than 3 mm, bronchoscopic sealing with fibrin glue (Tissucol, Immuno, Vienna) was initiated. Fistulas closed surgically were excluded from this analysis. The thoracic cavity was cleared of infected material by videothoracoscopy and bacteriological samples were taken. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection; WBC and CRP were controlled. RESULTS Nine patients (five men, four women) between 55 and 72 years (mean 61, SD 6), all initially operated on for malignancy, were successfully treated with this regimen. In three cases a concomitant bronchopleural fistula was successfully closed before videothoracoscopy. The interval between primary operation and empyema was between 7 and 436 days (mean 93, SD 141). There was no postoperative mortality and no procedure related morbidity. Operating time ranged from 45 to 165 min (mean 92.7, SD 36.6), the suction volume (consisting of blood, debris and pus) was 300 to 1000 ml (mean 880, SD 600). Duration of thoracic drainage was 12-38 days (mean 22, SD 9), duration of hospital stay after videothoracoscopy 21-46 days (mean 29, SD 9). During the follow-up period of 204-1163 days (mean 645, SD 407) no recurrence of tumour or empyema was observed. CONCLUSIONS Videothoracoscopic debridement of the postpneumonectomy space with postoperative antibiotic irrigation of the pleural space is an efficient method to treat postpneumonectomy empyema, provided that a concomitant bronchopleural fistula can be closed successfully. No early empyema or fistula recurrence were observed. However, late recurrence may occur many years after operation, therefore close follow-up is indicated.

Telescope anastomosis in bronchial sleeve resections with high-caliber mismatch

BACKGROUND The efficacy of bronchial telescope anastomosis was evaluated retrospectively in patients undergoing sleeve resections with high-caliber mismatch. METHODS The hospital charts of patients undergoing upper and lower sleeve bilobectomy and lower lobe lobectomy with replantation of the middle lobe or upper lobe into the mainstem bronchus were retrospectively reviewed. Age, sex, side, TNM stage, preoperative forced expiratory volume in 1 second (FEV1 [%]), preoperative risk factors, postoperative course, survival (months), and causes of death were recorded. RESULTS Fifteen patients suffering from bronchial carcinoma were operated on. In 6 cases FEV1 was less than 2 L (FEV1 49% to 80%, mean 64.3, median 61). Three patients were 70 years and older. There were 7 high-risk cases presenting with coronary heart disease (n = 3), chronic alcoholism (n = 3), cerebrovascular disease (n = 1), and active tuberculosis (n = 1). Local radicality was achieved in all patients but 1, in whom pneumonectomy was contraindicated. There was no postoperative mortality. Early complications consisted of 1 anastomotic dehiscence successfully closed with an intercostal flap and 1 patient with bilateral pneumonia requiring mechanical ventilation for 5 days. One parenchymal fistula led to prolonged drainage; in 1 patient pneumothorax after removal of the chest tube required redrainage. There were no late complications, and no anastomotic stenosis developed. Survival ranged from 12 to 56 months (median 29.8, mean 30, SD 15.7). Seven patients died between 3.9 and 14 months postoperatively (mean 8.5, median 6.9) of intrabronchial local recurrence (n = 1), distant recurrence (n = 3), intrathoracic recurrence (n = 1), and nontumor-related causes (n = 2). CONCLUSIONS Telescope anastomosis is a safe and efficient technique of bronchial sleeve resection.

A new method for digital video documentation in surgical procedures and minimally invasive surgery.

Background: Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. Methods: We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1–17), and the median storage volume was 49 MB (range, 3–360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. Conclusion: This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

From a sore throat to the intensive care unit: the Lemierre syndrome.

ZusammenfassungDas Lemierre Syndrom, auch als Post-Angina-Sepsis bekannt, ist eine akute oropharyngeale Infektion verbunden mit einer Jugularvenenthrombophlebitis und metastatischen Abszessabsiedlungen. Die Infektion wird meist durch Fusobacterium necrophorum hervorgerufen. Im Folgenden berichten wir über einen 19-jährigen Patienten, welcher mit Fieber, Halsschmerzen, und progredienter Atemnot an unserer Abteilung aufgenommen wurde. In der Computertomographie von Hals und Thorax zeigten sich ein parapharyngealer Abszess, eine Jugularvenenthrombose, eine nekrotisierende Mediastinitis sowie bilaterale intrapulmonale Konsolidierungen mit Kavernenbildung. Die Blutkultur zeigte eine anaerobe Bakteriämie mit Fusobakterium necrophorum. Durch eine rasche und umfassende chirurgische Sanierung der Abszessformationen im Hals und Thorax, verbunden mit einer Breitband-Antibiotikatherapie und intensivmedizinischer Betreuung gelang es das Krankheitsbild zu beherrschen.SummaryLemierre syndrome is characterized by an acute oropharyngeal infection, suppurative thrombophlebitis of the internal jugular vein and metastatic infections. The infection is usually caused by Fusobacterium necrophorum. We report on a 19-year-old male patient who was admitted with a five-day history of fever, sore throat and progressive dyspnea. Computed tomography of the neck and chest revealed a parapharyngeal abscess, jugular vein thrombosis, descending necrotizing mediastinitis and multiple areas of bilateral consolidation and cavitations within the lungs. Fusobacterium necrophorum was identified in the blood culture. Early combined abscess drainage with neck and chest incisions, together with broad spectrum intravenous antibiotic treatment and medical management in an intensive care unit resulted in a good clinical outcome.