Thoracoscopic surgery using omental flap for bronchopleural fistula
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A bronchopleural fistula (BPF) can lead to empyema and death after pulmonary resection. A minor leakage from a BPF has been reported to be successfully closed endobronchially, although thoracoplasty is usually needed.
A case of successful thoracoscopic BPF closure using an omental flap in a 74-year-old man with emphysema who developed a BPF after right lower lobectomy for lung cancer is reported. Reoperation was performed to close the BPF using an omental flap. After successful closure of the BPF, the empyema resolved with intravenous antibiotics.
Thoracoscopic single-stage omentoplasty without thoracotomy might be a useful treatment method when a BPF is diagnosed early.
KeywordsBronchopleural fistula VATS Omental flap
Video-assisted thoracic surgery
A bronchopleural fistula (BPF) is one of the most difficult complications after major lung surgery because it can decrease patients’ activities and quality of life and predispose them to severe infections, such as pyothorax and pneumonia, which have a high mortality. In cases that develop pyothorax/intrathoracic infections, fenestrations in the chest wall are usually created by resection of several ribs to allow drainage, and plastic surgery is required more than 6 months after the first re-operation.
A case of successful management of a BPF by a single-stage closure with an omental flap through video-assisted thoracic surgery (VATS), which enabled control of a Pseudomonas aeruginosa infection with antibiotic treatment for 2 weeks, is reported.
A 74-year-old man was admitted for right lower lobectomy with lower mediastinal and hilar lymph node dissection for squamous cell carcinoma. He had pulmonary emphysema secondary to smoking more than 50 pack-years. He had no diabetes mellitus, no history of steroid intake, and had not received chemotherapy or radiotherapy.
The incidence of a BPF after lobectomy or pneumonectomy has been reported to be 1 to 4% [1, 2], and it carries a high risk of mortality or prolonged hospital stay. Uramoto and Hanagiri reported that primary closure of a BPF was successful in only 15.8% of cases, and the mortality rate was 57.9% . Schneiter et al. reported the treatment outcomes of 75 patients with postpneumonectomy empyema, including 44 patients with a BPF . The success rate after the first treatment was 86.7%, although the median number of interventions until final closure was 3.
Early diagnosis and early repair of BPFs are important. Although treatment options, such as endoscopic closure, have been reported , the usual choice of operation has been fenestration with open thoracotomy and partial resection of two to three ribs in order to control the empyema [5, 6]. In such cases, the gauze dressing needs to be changed after fenestration. The operator then needs to select between either suturing and closing the BPF or re-stapling the central bronchus of the fistula, resulting in pneumonectomy or bi-lobectomy; both methods need a muscle flap for closure. Park et al. reported the use of a serratus anterior musculocutaneous flap for BPF closure, with a mean operation time of 5 h and 32 min .
The omentum, rather than the intercostal muscle or latissimus dorsi muscle, has been considered to be better for flaps, not only because it promotes angiogenesis and healing, but also because of its anti-inflammatory role. Some surgeons recommend that omentoplasty be done as the first choice for empyema with/without a BPF [3, 7]. It should be noted that some patients complain of abdominal complications, such as diarrhea, anorexia, distention, and ileus, after omentoplasty . Because the remodeling stage of healing begins 2–3 weeks after the onset of the lesion , an adequate drainage period after a second operation should be considered.
Nakajima et al. reported that single-stage closure may be appropriate when using a musculocutaneous flap . They reported that single-stage closure without open treatment could be used in cases of good infection control by antibiotic administration and tube drainage. We believe that single-stage closure is appropriate for localized and early infections.
Single-stage thoracoscopic omentoplasty without open thoracotomy (VATS omentoplasty) might be suitable for modern salvage surgery when treating acute empyema with a BPF after VATS lobectomy. The outcomes have fortunately been good, and although postsurgical drainage must be done more cautiously, this technique is appropriate in cases of BPFs that are diagnosed early and in those with a limited space affected by empyema.
The authors would like to thank Forte Science Communications (Tokyo, Japan) for English language editing by a native English speaker.
HE and RY designed the surgical concept and performed the surgery. HE and YS drafted the manuscript. HE wrote the paper, including the first draft, under the supervision of NN and YS. All authors have read and approved the final manuscript for submission.
Ethics approval and consent to participate
The present study was conducted in accordance with the ethical standards of our institution.
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The patient provided informed consent for publication of this case report and the accompanying images.
The authors declare that they have no competing interests.
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