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Use of Transternal Transpericardial Approach For Bronchial Stump Fistula After Pneumonectomy

This document summarizes the use of a transternal transpericardial approach for treating bronchial stump fistulas after pneumonectomy. It describes how the approach involves a median sternotomy to provide direct access to the bronchial stump through the pericardium. The approach was used in 18 patients between 2001-2008, with successful closure of the fistula in 16 patients (89%). Complications were low, with no postoperative deaths and only two recurrences. The summary concludes that this approach provides a simple, effective technique for treating bronchial stump fistulas.

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Ionut Gramaticu
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88 views31 pages

Use of Transternal Transpericardial Approach For Bronchial Stump Fistula After Pneumonectomy

This document summarizes the use of a transternal transpericardial approach for treating bronchial stump fistulas after pneumonectomy. It describes how the approach involves a median sternotomy to provide direct access to the bronchial stump through the pericardium. The approach was used in 18 patients between 2001-2008, with successful closure of the fistula in 16 patients (89%). Complications were low, with no postoperative deaths and only two recurrences. The summary concludes that this approach provides a simple, effective technique for treating bronchial stump fistulas.

Uploaded by

Ionut Gramaticu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Use of transternal transpericardial approach for bronchial stump fistula after pneumonectomy
Ioan Cordo Ciprian Bolca Cristian Paleru
National Institute of Pneumology Marius Nasta Bucharest

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

The best treatment of bronchial stump fistula is to prevent it through:


Rigurous fulfilling of technical requirements, Avoid bronchial stump devascularization

Resection of the bronchia in normal healthy tissue


Bronchial stump covere with well vascularized tissues (pleura, pericardium, thimus, mediastinal fat, intercostal muscle-bundle)

The influence of original operation on final outcome is striking

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

For direct closure, the bronchus may be approached through the midline, the homolateral pleural space or for left sided fistula through the right side or even through mediastinoscopy

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

History:
Padhi and Lynn (1960) the first trans-strenal approach of the pulmonary hilum Abruzzini (1961) the first extra-pericardial approach Perelman (1966) and Bogus (1967) published transpericardial approach technique Azorin (1996) left bronchial stump fistula approach through mediastinoscopy

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Indications:
surgical treatment of late bronchopleural stump after pneumonectomy (empyma, short bronchial stump fistula, recurrence) carinal tumor surgical treatment two-step pneumonectomy

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Advantages:
median sternotomy is well tolerated with minimal operative aggression

aseptic operative field


clear and preserved anatomical aspects simple and uneventful postoperative course long-term re-stadialization in neolplasic pathology

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

March 2001 March 2008


18 cases

M:F = 16:2
ages between 40 and 66 y, median age 52 y

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

7, 39%

11, 61%

NSCLC

TB

7 neoplasic (39%) 11 TB (61%)

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

left

right

5, 28%

8, 44% 10, 56% 13, 72%

early fistula

late fistula

right side 10 (55%)

5 cases early (<30d) fistula

left side 8 (45%)

13 cases late fistula

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Preoperative all patiens received an Elloeser procedure for post-penumonectomy empyema, all closed in 2 weeks after procedure Trans-sternal trans-pericardial approach of bronchial stump was concluded with tangential to carina bronchial resection, which was subsecquently covered with thimic fat No carinal resection

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Results:
No postoperative deaths
Procedure successful in 16 patients (89%) 2 recurrences of the fistula on patients with TB history. One of them healed spontaneously after 1 month, and on the other patient we performed covering thoracoplasty. All patients with benign underlying disease are alive and well. On 7 cancer patients, 3 died of malignancy after more than1 year.

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Authors Ginsberg et al 1989 Stamatis et al 1996 de la Riviere et al 1998 Porhanov et al 2000

No 13 19 55 49

Mortality 2 (10,5%) 13 (24%) 16%

Recurrence 3 (23%) 2 (10,5%) 13 (24%) 13,3%

Athanassiadi et al 2004

11

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Discussions:
Carinal resection are technically difficult and limited to: (1) very short-bronchial stump fistula; and (2) neoplasic positive bronchial stump limits Stamatis & al. 1996 Riviera & al. 1997

Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta Bucharest

Conclusions:
Bronchial

stump fistula closure approached through sternotomy is simple technical procedure with great efficiency Sterile operative field with anatomical preserved aspects No post-operative ventilatory dysfunction

Long stump-standard reamputation/short stump carinal resection

THANK YOU!

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