Closure of a Bronchopleural Fistula

Effective treatment of a chronic bronchopleural fistula after pneumonectomy, or after lobectomy with empyema and destroyed residual lung, requires three steps. First, the empyema must be widely and completely drained. Second, the fistula must be permanently closed. Third, the residual pleural space must be cleared of infection and closed, completely filled, or obliterated. Techniques for closure of a bronchopleural fistula are many and are variably applicable to individual cases. This chapter seeks only to review the use of the omentum for this problem. Detailed consideration of bronchopleural fistula is given in Chapter 43, "Postpneumonectomy Bronchopleural Fistula."

Virkkula and Ecrola described the use of the omentum for closure of fistulae.10 We have used the omen-tum to close fistulae in patients in whom the original disease was lung neoplasm—a number with prior irradiation, chronic infection, and trauma.11 Some had undergone a lobectomy with subsequent destruction of the remaining lung. Several patients were previously treated unsuccessfully with chest wall muscle flaps. It is our conclusion that the omentum is more dependable than myoplastic flaps in difficult situations such as these.7

Adequate dependent drainage of the chronic empyema is first assured. At the time of definitive closure, the omentum is fully mobilized through an upper abdominal incision and placed in a retrosternal "pocket." The abdomen is closed and chest exposure is obtained. The bronchial stump is dissected, any excess is resected, and the stump is then closed with 4-0 Vicryl sutures.

The mediastinal pleura is opened and the omentum extracted. The massively thickened pleura may make location of the "pocket" difficult. The omentum is sutured over the closed stump in at least two layers, folding it on itself. In patients in whom the fistula was completely flush with the carina, the omentum was initially sutured to the margins of the opening, in the manner of closure of a large perforation due to duodenal ulcer. Postoperative bronchoscopy demonstrated the omentum to fill the fistula. Carinal resection seems an unwise alternative in this densely scarred, contaminated, and often irradiated field.

Most commonly, the hemithorax was allowed to remain widely drained for a later Clagett procedure when healing was firm and the cavity was clean. In some cases, a small residual pleural space was filled with the bulky omentum or with the adjunct of a pedicled chest wall muscle flap, permitting closure with a draining chest tube.

A patient with an unsuturable fistula flush with the trachea, which is plugged with an omentum, may leak briefly several days after operation, but spontaneous closure should follow as granulation tissue proliferates. One failure of omental reclosure after multiple prior attempts at closure occurred, but residual carcinoma was discovered in the stump.

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