INDICATIONS/CONTRAINDICATIONS

Bronchopleural fistula (BPF) remains a life-threatening complication of pneumonectomy occurring between 2% and 13% of such procedures. While early postpneumonectomy BPF requires immediate surgical repair with the help of a vascularized tissue patch, late BPF (i.e., weeks to years after pneumonectomy) requires emergent positioning of a chest tube draining the empyema cavity followed by definitive therapy of both empyema and BPF. Open-window thoracotomies (Clagett window), which are the most widely used procedures, have the advantage of treating empyema and BPF at the same time. Even though it is an effective and technically simple procedure allowing a small BPF to potentially close with regular dressings, it raises the problem of a second stage chest wall closure, outpatient management of dressings, and large BPF closure. The use of vascularized flaps (omentum, muscles) to close the BPF and fill the cavity through a redo thoracotomy may be considered. The transsternal transpericardial approach offers good exposure to the tracheobronchial bifurcation allowing bronchial closure or carinal resection in good conditions with healthy surrounding tissue. It allows dissection of the healthy tracheobronchial tree at a distance from infected tissue and without opening the contralateral pleura. Usually, this approach is considered as a salvage procedure when initial attempts at repair of BPF through rethoracotomy have failed, the rethoracotomy is contraindicated, or the stump length does not allow direct closure and carinal resection is required. Debilitated and malnourished patients should not be selected for this procedure. Previous sternotomy is not a contraindication. Some authors have reported transsternal transpericardial BPF repair in patients who had coronary artery bypass grafts highlighting that it was easier to go through postoperative adhesions than through infected tissue. However, previous mediastinal surgery may remain a relative contraindication.

PREOPERATIVE PLANNING

As soon as the diagnosis of late BPF is suspected, chest cavity drainage should be instituted promptly to avoid life-threatening aspiration. A flexible bronchoscopy is useful to confirm the diagnosis of BPF, assess the contralateral bronchial tree, clear it from secretions, and above all assess the length of the bronchial stump. Indeed, the bronchial stump length would determine the technique of bronchial repair between direct reclosure and carinal resection. If pneumonectomy is performed for cancer, the preoperative workup includes a chest CT scan screening for a possible recurrence at the level of the bronchial stump or the remaining lung. Given that transsternal surgery deals with bronchial closure alone, the empyema and pleural cavity need to be treated properly prior to the surgery. Hence, broad spectrum antibiotic therapy should be started before and be continued after the procedure. Open-window thoracostomy may be considered if the empyema is not controlled by antibiotics and drainage.

SURGERY

A variety of anesthesia techniques can be used to ventilate the patient in the presence of a BPF including double-lumen tubes (left- and right-sided), long armored single-lumen tube inserted into the left main bronchus, or endobronchial blocker in the pneumonectomy stump. Our preference is to use the long armored single-lumen bronchial tube when possible. The positioning of the tube is controlled by flexible bronchoscopy. A peripheral arterial line is inserted as well as two peripheral venous lines for volume expansion if necessary. A venous central line may be useful for CVP monitoring and prolonged postoperative antibiotic therapy. An O₂ saturation probe should be adequately placed and should work accurately. A nasogastric tube is placed for localization of the esophagus during the surgery.

Positioning

The patient is placed in a supine position, both arms along the body for a standard median sternotomy. An inflatable roll placed behind the shoulders can be used to improve exposure, particularly if a carinal resection is anticipated. The skin is prepped and draped from the chin down to the thighs. Safety requires a groin exposure, as femoral vessels access may be needed to institute cardiopulmonary assistance in case of complications. The operating surgeon stands on the right side and the assistant is on the left.

Technique

A median sternotomy is performed exposing the pericardium. Care must be paid not to open the contralateral pleura, which could be behind the sternum because of the mediastinal shift and the compensatory hypertrophy of the remaining lung. The pericardium is opened longitudinally from the ascending aorta to the diaphragm and suspended with silk stitches. The left innominate vein is dissected and thymic veins divided before retracting the sternum to avoid any tear. The superior vena cava (SVC) is freed from the pericardial reflection, mobilized and encircled with a Penrose drain to aid retraction laterally to the right to expose the ascending aorta. The ascending aorta is then dissected from the right and main pulmonary arteries up to the aortic arch allowing its lateral retraction to the left (Fig. 48.1). The space between the SVC and the ascending aorta is then exposed and the posterior pericardium is opened. The right pulmonary artery is encircled and retracted inferiorly or reresected to improve the exposure (Fig. 48.2). The lower trachea and carina is exposed taking care to avoid injury to the left laryngeal nerve. Complete mobilization of the ascending aorta and the pulmonary artery allows safe dissection of the carina and the left main bronchus even after left pneumonectomy and significant left mediastinal shift. The bronchial stump is dissected at the level of the carina, isolated and divided. The new stump must always be divided to ensure that the edges heal adequately. It is closed preferentially with a TA stapler or sewn with interrupted sutures (Fig. 48.3

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