Transpleural Сontralateral Occlusion of the Left Main Bronchus Stump in a Patient with Bronchopleural Fistula and Chronic Pleural Empyema

Abstract


Bronchopleural fistula (BPF) is a pathological communication between the bronchial tree and the pleural cavity, the most common complication of anatomical lung resection.
BPF rarely closes spontaneously and almost always requires surgical or bronchoscopic interventions.
The main methods of treatment are sanitation of the pleural cavity with the development of empyema and re-occlusion of the bronchial stump. The development of this complication in the postoperative period is accompanied by an increase in hospitalization time, a high risk of chronic pleural empyema, exacerbation of chronic diseases and death. The mortality rate ranges from 18 to 67%. Most often, BPF is manifested after removal of the right lung (8-13%), compared with the left side (1-5%), which is due to the anatomical features of the main bronchus.
The presented clinical case describes a non-standard surgical approach in the treatment of bronchopleural fistula and chronic empyema of the residual pleural cavity in a young patient.


Clinical case. In October 2018, a 19-year-old patient was admitted to the Department of Thoracic Surgery with complaints of severe weakness, shortness of breath that occurs with minimal physical exertion and an increase in body temperature up to 37.5 grams. From the anamnesis: at the age of four, the patient was diagnosed with hypoplasia of the left lung, about which the lower lobectomy was performed with resection of the reed segments of the upper lobe of the left lung. In the long-term postoperative period, he was repeatedly hospitalized with a diagnosis of pneumonia of the residual segments on the left. He underwent inpatient treatment annually for a protracted course of purulent triheobronchitis. Upon further examination, a diagnosis of bronchiectatic transformation of the remaining lung was established. In 2012, a final left pneumonectomy was performed in the volume of resection of S1-2.3 segments. 

In 2018, he noted the appearance of general weakness, malaise, an increase in body temperature in the evening hours, shortness of breath. On examination, according to the computed tomography of the chest organs (Fig. 1): Condition after left-sided pneumonectomy. The residual pleural cavity has a transverse size of 61x16 mm and a length of 80 mm, with a small amount of gas, a volume of up to 25 ml with a small amount of liquid. The length of the stump of the left main bronchus is about 2.5 cm, FFT with a diameter of up to 6 mm with a residual pleural cavity on the left. The right lung is straightened, there are no focal and infiltrative changes, its compensatory hypertrophy with migration to the left half of the chest is noted. Free liquid and gas in the right pleural cavity was not detected. With a diagnosis of bronchopleural fistula on the left, chronic empyema of the residual pleural cavity on the left was sent for consultation at the N.N. AV Vishnevsky. During follow-up examination: according to bronchoscopy in the stump of the left lower lobe bronchus, two fistulous openings of a round shape, 2 and 3 mm in diameter, with a moderate intake of turbid content and air are visualized. A bacteriological study of flushing from the bronchial stump revealed Staphylococcus aureus and Enterococcus faecium, sensitive to antibiotics of the penicillin series and macrolides. According to the data of clinical and instrumental research methods, the patient was diagnosed with a bronchopleural fistula with chronic empyema of the residual pleural cavity on the left. On October 28, 2018, the patient underwent surgery: transpleural contralateral occlusion of the stump of the left main bronchus. After the surgical intervention, he was in the intensive care unit for 24 hours. therapy. Transferred to the Department of Thoracic Surgery and activated for 2 days. In the early postoperative period, a course of antibiotic therapy was carried out according to crops: ampisid, clarithromycin, zyvox together with antifungal therapy. When performing the control R-graph of the chest organs, data for pneumothorax and hydrothorax were not obtained, the right lung was expanded. The postoperative period is smooth, without complications. The patient was discharged from the department on the 14th day in a satisfactory condition. According to the results of the control examination 6 months after the operation, the residual pleural cavity on the left with a minimum amount of fluid. No data were obtained for communication of the residual pleural cavity with the bronchus and relapse of the BPS (Fig. 2). A control bronchoscopy 2 months later visualized a consistent suture of the left GB stump (Fig. 3). Discussion Bronchopleural fistula is one of the most formidable complications in thoracic surgery, with a frequency of development from 0.5% after segmentectomy to 15% after pneumonectomy [1,2 , 3]. In most cases, conservative therapy does not bring the desired results [4]. Due to anatomical features, the right main bronchus is more susceptible to the development of BPS after anatomical resections [5], this is facilitated by 3 main reasons: The right main bronchus is supplied with blood only by one right bronchial artery, while on the left most often blood supply comes from two arteries; The right main bronchus is more at risk partial disturbance of blood supply during mediastinal lymphadenectomy; The left main bronchus after pneumonectomy "goes" under the aortic arch and thus is protected by the surrounding tissues of the mediastinum, in contrast to the right main bronchus. The diagnosis is based on a combination of clinical, radiographic and bronchoscopic studies. The main symptoms include fever, chills, cough with purulent sputum, dyspnea, and resulting pleural effusion on chest x-ray. In the presented clinical case, the traditional clinical symptoms were absent in the development of BPS. The course of the disease was chronic, sluggish. During the follow-up examination, 2 fistulous tracts were diagnosed in the area of ​​the stump of the left main bronchus. Despite the lower risk of inconsistency of the left GB stump, young age and the absence of chronic diseases, the presence of the pathological length of the residual stump created favorable conditions for the development of such a complication. When planning surgery in the volume of GB stump occlusion, the fundamental factor is the choice of the most optimal access: ipsilateral rethoracotomy, transpericardial through anterior thoracotomy [6], transsternal transpericardial through a median sternotomy [7,8], transcervical using a mediastinoscope [9], contralateral thoracotomy [10]. All these techniques have both advantages and disadvantages. In the presented observation, due to compensatory hypertrophy of a single lung, its migration to the opposite half of the chest from the front and displacement of all anatomical structures of the mediastinum, the traditional in our department transsternal access to the stump of the main bronchus is extremely difficult. Based on the choice of the most functional and less traumatic approach, preference was given to the transpleural contralateral approach. The surgical intervention was accompanied by certain difficulties due to multiple previous operations on the root of the right lung, massive adhesions, as well as visualization through the pleural cavity with a single breathing lung. similar intervention according to MI Perelman, the position of the patient on his stomach, access - posterior thoracotomy on the right along the fifth intercostal space with resection of the V-VI ribs. The v.azigos arch is tied up and dissected between two ligatures. The vagus nerve is taken on a holder and laterally retracted [11]. In the present clinical observation, the operation was performed with some peculiarities: Operation progress: During the operation, the patient was positioned on the left side with the upper left limb abducted, access was lateral thoracotomy. Anesthesia - general anesthesia through mechanical ventilation. Under endoscopic control, an endoscopic tube is installed in the mouth of the right main bronchus. The patient underwent lateral thoracotomy in the fifth intercostal space up to 13 cm long with the scapula abducted in the cranial direction. After dissection of the lower pulmonary ligament along the posterior surface, the mediastinal pleura was opened. Highlighted and ligated v.Azygos and n.Vagus, set aside. The subcarinal space was mobilized along the right main bronchus to the tracheal bifurcation. The left main bronchus was isolated over a length of 4 cm. Performing traction of the bronchus, immediately at the place of its departure from the carina, a stapler was imposed. The intubation tube is pulled up into the trachea. The bronchus is stitched and crossed. Endobronchoscopy was performed - the lumen of the right main bronchus was not deformed, the suture was sound. The stump of the left main bronchus was extirpated. The right pleural cavity is drained. Layer-by-layer suturing of a thoracotomy wound. After the occlusion was performed, the patient was turned onto the right side, the left arm was taken to the side. Lateral thoracotomy on the left was performed with excision of the old postoperative scar, with subperiosteal resection of the IV and V ribs. The residual pleural cavity was opened. No significant amount of pus and fibrin was found. The residual cavity was treated with a prontosan solution. Layered sutures on the wound. Within 2 years after surgery, no recurrence of BPS was noted.Conclusion: Currently, a large number of algorithms for treating BPS have been proposed: depending on the timing of occurrence, the size of the defect, the patient's somatic state and the equipment of the medical institution. If there are indications for surgical treatment, despite the many approaches in the surgical technique, the planning and selection of the final occlusion method is individual and in most cases is based on the preferences of the operating surgeon and the specifics of a particular clinical case.

Alexey Nikolaevich Lednev

N.N. A.V. Vishnevsky "of the Ministry of Health of Russia

Author for correspondence.
Email: lednev@ixv.ru
ORCID iD: 0000-0002-3039-1183

Russian Federation, Moscow, Russian Federation

Junior Researcher

Alexey Aleksandrovich Pechetov

A.V. Vishnevsky "of the Ministry of Health of Russia

Email: pechetov@ixv.ru
ORCID iD: 0000-0002-1823-4396

Russian Federation, Moscow, Russian Federation

Ph.D.

Sergey Sergeevich Karchakov

A.V. Vishnevsky "of the Ministry of Health of Russia

Email: karchakov1@gmail.com

Russian Federation, Moscow, Russian Federation

resident

Maksim Aleksandrovich Makov

A.V. Vishnevsky "of the Ministry of Health of Russia

Email: drawcad1983@gmail.com

Russian Federation, Moscow, Russian Federation

Doctor of the Department of Thoracic Surgery

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