Department of Thoracic Surgery, Thoraxzentrum Ruhrgebiet, Evangelisches Krankenhaus, Herne, Germany.
Department of Respiratory and Infectious Diseases, Thoraxzentrum Ruhrgebiet, Evangelisches Krankenhaus, Herne, Germany.
Interact Cardiovasc Thorac Surg. 2021 May 27;32(6):921-927. doi: 10.1093/icvts/ivab031.
Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina.
All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice.
A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days.
Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.
肺切除术后支气管胸膜瘘和袖状肺叶切除术后吻合口裂开是严重的并发症。有几种已确立的治疗选择。对于没有胸膜感染的小瘘，建议保守治疗。对于支气管胸膜瘘和随后脓胸的患者，手术治疗是主要方法。总体而言，相关发病率和死亡率较高。对于肺切除术后残端短或袖状切除吻合口近隆突处裂开的患者，隆突袖状切除是最后的手段。
回顾性分析 2003 年至 2019 年期间在我院因肺切除术后或袖状切除术后支气管胸膜瘘而接受二次隆突袖状切除的所有患者。对于袖状肺叶切除术后吻合口裂开的患者，行全肺切除术。手术入路为前外侧开胸术；吻合口用肌肉瓣、心包脂肪或大网膜覆盖。对于脓胸患者，将聚维酮碘浸湿的毛巾引入胸腔，至少更换两次。
在我们科室，共有 17 例患者（12 例初始行袖状肺叶切除术，5 例行肺切除术）接受了隆突袖状切除术。发病率为 64.7%，30 天存活率为 82.4%（n=14）。70.6%的患者存活 90 天（n=12）。中位住院时间为 17 天，中位重症监护室停留时间为 12 天。
在没有其他治疗策略的情况下，隆突袖状切除术是肺切除术后瘘管或袖状肺叶切除术后吻合口不足患者的可行选择。然而，术后发病率较高，包括长时间入住重症监护室。
