Abstract

Background: Despite modification of surgical methods, improving of sewing material quality, stepling devices, there is still a problem of main bronchi stumps fistullae. Special difficulties arise at 'non-stump main bronchus resection', or at wedge resections, when there is a short stump (less than 1 cm) or, there is a defect on its place in the trachea.

Patients and Methods: Since 1979 in the Regional Thoracic Surgery Center the operation was carried out on a total of 97 patients from the Southern region of the Nothern Caucasus for main bronchi fistullae. From them 29 patients (30%) had fistulla of left main bronchus stump (LMB), 67 patients (70%) fistulla of right main bronchus stump (RMB). According to the classification short stump is less than 1 cm, long stump is more than 1 cm, branchy on the level of lobar bronchi, we have chosen 61 patients with main bronchus stump less 1 cm. Twelve patients were treated without surgical treatment. Fourty nine patients (53.5%) were operated on. In 19 patients there was a defect in the trachea 5--15 MM in diameter, as a consequence of pneumonectomy or transpleural stump reamputation of the main bronchus fistulla (5 pat.). It was associated by pleural empyema. The long follow-up period for patients was between 1 and 3 years. Indication for pneumonectomy in 12 patients was tuberculosis, in 27 ñ COPD, in 8 ñ lung cancer, in 2 ñ trauma. Eight patients had undergone transpleural thoracomioplastic operations with reamputation of main bronchus stump, 7 ñ transpleural resection of long stump. Within 21--50 days all patients underwent sanation of empyema ñ single or repeated videothoracoscopic necrectomy. Five oncological patients had tumour reccurence along the edge of defect (in 3 ñ sleeve resection of bifurcation and 2 ñ wedge resection) In all cases stump was closed with hand-made seam. Wedge resection was performed in 34 patients, sleeve bifurcation resection with main bronchus and trachea anastomosis in 15 cases. Bronchial seam was covered with omentum, residual thimus, pericardial scrap with pericardial fat. A maximum of resected tracheal and bronchial semirings were 4.

Results: A total of 2 patients (5.8%) had bronchoplastic seam failure after wedge resection, 5 patients (30%) ñ after sleeve resection of bifurcation, 2 of them (13%) died due to the infectous complications and respiratory insufficiency. In other cases anastomotic defect was closed in various terms (time rate 2 weeks up to 3 months). Lately a total of 6 patients (37.5%), with tracheobronchial anastomosis, developed granulation stenosis along the anastomotic line, healed bronchoscopically with laser photodestruction. In 2 of them we performed all endoprosthetic appliance of stent (Dumon-stents). Oncological patients survival was: 2 patients ñ 3 years, 4 patients ñ 2--3 years, 1 patient - 1 year, none survived more than 3 years.

Conclusions: Surgical treatment through the trans sternal approach with bronchoplasty for fistullae of main bronchi short stumps allows to achieve fistulla closure in the aseptic conditions at the low rate of postoperative morbidity.