Complex surgical management of main bronchus stump failure: a case report highlighting treatment challenges and successful outcome

Introduction

One of the most serious postoperative complications in thoracic surgery is bronchial stump failure after pneumonectomy. This complication can often lead to postoperative mortality (1-4). The frequency of bronchial fistulae after pneumonectomy depends on various factors, such as the etiology of the pulmonary process and the somatic condition of the patient. Concomitant diseases and the type of bronchial suturing, as well as the length of the stump, all play a role. In general, bronchopleural fistulas are more common after pneumonectomy for tuberculosis than during operations for lung cancer. The authors cite the experience of 64 pneumonectomies for patients with tuberculosis, with an overall complication rate of 31.3%. This includes the incidence of bronchopleural fistulas at 14.1%, and a hospital mortality rate of 6.2% (4). In a series of 455 lung cancer pneumonectomies, the incidence of bronchopleural fistula is 7.47% (5). In specialized thoracic departments, the frequency varies from 2.5% to 13.3% (6). This clinical case demonstrates the complexities of surgical treatment for recurrent bronchial fistulas after a pleuropneumonectomy for fibrous-cavernous tuberculosis that had extensively drug-resistant tuberculosis (XDR-TB). We present this article in accordance with the CARE reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-24-13/rc).

Case presentation

Patient of 28 years old, was admitted to the Surgical Department of Clinical Center of Phthisiopulmonology, with a diagnosis of fibrous-cavernous tuberculosis of the right lung, with bilateral infection, complicated by empyema and bronchial fistula, hemoptysis and respiratory failure of grade 3 (vital capacity =41%, forced expiratory volume in one second =39%). Mycobacteria tuberculosis+, XDR-TB. Concomitant diagnoses: chronic bronchitis with isolated left-sided bronchiectasis and chronic gastroduodenitis, myocardiodystrophy. The medical history was unremarkable and there was no record of contact with tuberculosis patients.

The patient had complaints of cough with purulent sputum, fever up to 39 ℃, dyspnea with little exercise, hemoptysis, nausea, and poor appetite.

Prior to admission for surgical treatment, the patient received conservative anti-tuberculosis therapy for 3 months. The patient also underwent the process of cleaning the empyema cavity with antiseptic solutions through drains for 3 months. She was given levofloxacin 0.5 orally, capreomycin 1.0 intramuscularly, linezolid 200 mg intravenously and protionamide 0.75 orally (Figure 1).

Figure 1 Treatment plan.

The tolerability of these medications was satisfactory. The patient had a low body weight (height 170 cm, weight 48 kg). On auscultation, breathing on the right side was weakened and wheezing was heard. The SpO₂ level was 91%.

The computed tomography of the chest before surgery revealed destruction of the right lung and subtotal empyema as well as contamination of the left lung and isolated left bronchiectasis (Figure 2A).

Figure 2 Computed tomography before pleurectomy and the macropreparation. (A) Computed tomography of the chest before surgical treatment showed a subtotal cavity in the right empyema. (B) The right lobe of the removed lung with a sac containing a subtotal empyema at the incision.

There were no issues with the patient’s diagnostic examination due to religious or financial concerns.

Against the background of intensive conservative therapy, in combination with daily drainage of the empyema cavity for 3 months, there was no positive dynamic (intoxication, fever, respiratory failure persisted). At an interdisciplinary meeting with the participation of thoracic surgeons and phthisiologists, it was decided to proceed with surgical treatment. Despite the high risk of life-threatening complications, pleuropneumonectomy of the right lung was performed. Above the main bronchial stumps and blood vessels, the mediastinum was sealed hermetically with a suture, attaching the flap of the mediastinal pleura to the bronchial stump. This was done to prevent the formation of a bronchial fistula. In the removed lobe, multiple fibrous cysts, drainage foci, and an empyema cavity filled with pus were identified at the incision site (Figure 2B).

The early postoperative period went smoothly. A month later, the right half of the chest was evenly dark on a chest X-ray and partial resorption of the foci was seen on the left side (Figure 3).

Figure 3 An overview X-ray 1 month after pleuropneumonectomy. The right hemithorax is darkened, there are no signs of bronchial fistula.

Taking into account the single-lung infection, XDR-TB, and the highest risk for tuberculosis reactivation, the delayed 4-rib anterior-posterior thoracoplasty was performed on the right side (Figure 4A); 1.5 months after pleuro-pneumonectomy and 14 days after delayed thoracoplasty, without any data on infection in the pleural cavity, the main bronchus stump failure developed. Patient’s extremely low respiratory reserves worsened his condition, emergency surgery: thoracomyoplasty with suturing of the latissimus dorsi muscle to the bronchial defect was performed. The operation was done using a lateral approach, excising the old postoperative scar and resecting 2–9 ribs (Figure 4B).

Figure 4 Operational access. (A) Size of decostation during delayed thoracotomy; (B) access during thoracomyoplasty.

Despite local sanitation and usage of an elastic dressing, a week later, the bronchus stump failed again, with a recurrence of empyema, and a gradual enlargement of the bronchial defect (Figure 5).

Figure 5 MSCT scan of the lungs of the patient, 3 months after the pleuropneumonectomy. There is a defect in the area of the tracheal bifurcation, which extends through the entire lumen of the right main bronchus and connects with the residual cavity of empyema around the latissimus dorsi muscle in the right hemithorax. MSCT, multi-slice computed tomography.

Taking into account the negative changes in the patient’s condition and the developed erosive bleeding from the residual cavity, the new operation was performed a month after right thoracomyoplasty circular resection of the trachea from the transsternal approach (Figure 6A).

Figure 6 Stages of surgery and fibrobronchoscopy. (A) Performing circular resection of the tracheal bifurcation from a transsternal approach; (B) crossed trachea, a breathing shunt tube in the left main bronchus; (C) appearance of the anastomosis; (D) endophotography of the tracheobronchial anastomosis 3 weeks after performing a circular resection of a tracheal bifurcation.

As a result of the tuberculosis-related purulent process, a significant defect in the lateral wall of the trachea formed. Due to this, it was not feasible to perform a carinal resection of the trachea, and it was therefore necessary to carry out a circular resection with anastomosis. During the operation, a tracheal bifurcation was isolated in the aortocaval space and cut off from the wide fistula, which had a size of 3 cm × 2 cm. The left main bronchus was intubated through the wound using a “breathing shunt” tube. The area of the defect in the trachea was excised in a circular manner. All sutures of the tracheobronchial anastomosis were provisionally applied with separate, atraumatic stitches using monofilament 3-0 thread (Figure 6B). After the removal of the breathing tube, all the sutures were tightly closed to form an anastomosis (Figure 6C).

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Results

The postoperative course was uncomplicated, but severe. During the first 10 days after the operation, daily fibrobronchoscopic examinations were performed to prevent the eruption of sutures because of productive cough. Three weeks after the surgery, the anastomosis passed well and was epithelized (Figure 6D).

Subsequent healing of the area in the right hemithorax progressed slowly with open management of a residual cavity through a wound defect. In the only lung, the process stabilized, and the patient continued to be abacillated persistently. Thirteen months after the pleuropneumonectomy, there was no residual pleural cavity detected on multi-slice computed tomography (MSCT). Multiple foci and a single bronchiectasis with no dynamics were detected in the single lung (Figure 7).

Figure 7 MSCT of the patient, 13 months after pleuropneumonectomy on the right side. MSCT, multi-slice computed tomography.

Discussion

Patients with fibrous-cavernous tuberculosis, complicated by empyema, with XDR-TB, represent a group with the highest risk of main bronchus stump failure after pneumonectomy (1,4). Surgical methods for the treatment of bronchopleural fistula after pneumonectomy can be classified into three groups:

• Repeated suturing of the resulting gap, most commonly using various tissues to close the bronchial suture, or plastic closure of the defect with frequent thoracoplasty.
• Occlusion of the main bronchus stump in the mediastinal tissue, with abandonment of the peripheral stump.
• Reamputation of the bronchial stump through transpleural or transmediastinal approaches, also with possible simultaneous thoracomyoplasty.

Surgical tactics for treating patients with bronchial fistula depend on when stump failure occurs. With early failure, it is justified to attempt to reamputate the main bronchial stump. If pleural empyema has developed, staged treatment involving the elimination of a bronchopleural fistula and sanitation of an empyema cavity may be more appropriate. Currently, there are various methods of treating patients with main bronchus stump. These include both surgical and endoscopic methods (7-9). The most commonly used radical surgical techniques for eliminating empyema and bronchial fistulae after pneumonectomy include transsternal, transpericardial occlusion of the main bronchus stump in uninfected tissues of the mediastinum (6,10-14) and thoracomyoplasty (closing or suturing the fistula) or resection of the bronchi (13). Circular resection of the tracheal bifurcation is rarely performed to patients with tuberculosis (14). The patient reports a significant improvement in her quality of life after multi-stage surgery. Her shortness of breath has decreased and her temperature has returned to normal.

Conclusions

This clinical observation demonstrates the complexity of surgical management of bronchopleural complications with these patients. To achieve ultimate success in our case, numerous traumatic interventions were necessary, such as pleuro-pneumonectomy, thoracoplasty, thoracomyoplasty with suture of the fistula, and trans-sternal circular resection of the tracheal bifurcation.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-24-13/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-24-13/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-24-13/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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