Surgical Management of Bronchiectasis

Transcription

1 Surgical Management of Bronchiectasis Thirugnanam Agasthian, MD, Claude Deschamps, MD, Victor F. Trastek, MD, Mark S. Allen, MD, and Peter C. Pairolero, MD Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota Background. The prevalence of bronchiectasis has decreased significantly over recent decades. We reviewed the morbidity, mortality, and outcome of surgical treatment for pulmonary bronchiectasis in the modern era of antibiotic therapy. Methods. From January 1976 through January 1993, 134 patients (55 male and 79 female patients) underwent pulmonary resection for bronchiectasis. The mean age was 48.4 years (range, 4 to 89 years). The indication for operation was failure of medical therapy in 85 patients (63.4%), hemoptysis in 26 (19.4%), lung abscess in 12 (9.0~), and a nondiagnostic mass in 11 (8.2~). Mean duration of symptoms was 6 years (range, 1 to 60 years) and included a productive cough in 104 patients, fetid sputum in 91, recurrent infections in 81, and hemoptysis in 56. Thirteen patients (9.7%) had no prior symptoms and presented with either hemoptysis, lung abscess, or unresolved pneumonia. The disease was bilateral in 26 patients (19.4~J~) and mainly confined to the lower lobe in 75 (56.0%). The mean number of segments involved was 4.4 (range, one to 14 segments). Surgical treatment included lobectomy in 86 patients (64.2%), pneumonectomy in 21 (15.7%), wedge resection or segmentectomy in 18 (13.4c7 ), and a combination of these approaches in 9 (6.7%). Disease was considered completely resected in 108 patients (80.6%). Results. The operative mortality rate was 2.2% and the morbidity rate was 24.6%. The mean follow-up in 103 patients was 6 years (range, 1 to 16 years). Overall, 61 patients (59.2%) were asymptomatic after operation. Symptoms were improved in 30 patients (29.1%) and unchanged in 12 (11.7%). Complete resection resulted in a significantly better result than incomplete resection (p < 0.O5). Conclusions. Pulmonary resection for bronchiectasis can be done with low mortality and morbidity. When possible, complete resection should be performed. (Ann Thorac SuG~ 1996;62:976-80) B ronchiectasis, which was once prevalent and disabling, has now become rare in industrialized countries because of the nearly complete elimination of measles, pertussis, and tuberculosis 11]. Improved antibiotic regimens in recent decades also have contributed to this reduction [2]. Consequently, few reports have dealt with the current surgical management of bronchiectasis in recent years. We reviewed our recent experience with pulmonary resection for this condition to evaluate the results of contempora D' surgical management. Material and Methods Methods Between January 1976 and January 1993, 3,421 patients were seen at the Mayo Clinic with a clinical diagnosis of bronchiectasis. One hundred thirty-four (3.9%) of those patients underwent pulmonary resection for bronchiectasis. The records of these 134 patients were analyzed for age, sex, symptoms, type of resection, operative morbiditv and mortality, and functional results. The pulmonad, resection was considered complete if the patient was believed to be free of bronchiectasis after thoracotomv. Bronchiectasis was considered to be bilateral if there was evidence of contralateral involvement on either chest Presented at the Thirty-second Annual Meeting o! The Society of Thoracic Surgeons, Orlando, FL, Jan 29-31, Address reprint requests to Dr Deschamps, Section of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN roentgenography, computed tomography, or contrast bronchography. Failure of medical treatment was defined as frequent exacerbations interfering with work (or school) or requiring multiple hospitalizations. All specimens had pathologic confirmation of bronchiectasis. Operative mortality included patients who died within 30 days after thoracotomy or those who died later but during the same hospitalization. Functional results were compared using a 2 test. A p value of less than 0.05 was considered significant. Clinical Findings The mean age of the 134 patients at the time of thoracotomy was 48.0 years (range, 4 to 89 years). There were 79 female and 55 male patients. Eighteen patients (13.4%) >,ere less than 20 years old. One hundred ten patients (82.1"Ji~) had chronic symptoms present for a mean of 6.0 years (range, 1 to 60 years) that included productive cough in 104 patients (94.5%), fetid sputum in 91 (82.7%), recurrent infections in 81 (73.6%), and hemoptysis in 56 (50.9%). Thirteen patients (9.7%) had no prior symptoms but presented with hemoptysis in 7 (massive in 3), lung abscess in 4, and unresolved pneumonia in 2. The remaining 11 patients (8.2%) presented with an asymptomatic lung mass discovered on chest roentgenograph. Eighty-five patients (63.4%) had received prior medical therapy for a mean of 10.4 years (range, 1 to 60 years). Fifty patients (58.8%) had been treated previously with only one antibiotic, 26 (30.6%) had been taking two, and 1996 bv The Societv of Thoracic Surgeons / Published bv Elsevier Science Inc PII $ (96)

2 Ann Thorac Surg AGASTHIAN ET AL ;62: OPERATION FOR BRONCHIECTASIS 9 (10.6%) had been taking three or more. Nine of these 85 patients (6.7%) had undergone prior operations for bronchiectasis: 7 had lobectomy, I had bilobectomy, and I had lobectomy and lingulectomy. Preoperative diagnostic studies included posteroanterior and lateral chest roentgenographs in all patients. Bronchoscopy was performed in 124 patients (92.5%), contrast bronchography in 66 (49.3%), and chest computed tomography in 44 (32.8%). The disease was unilateral in 108 patients (80.6%) and bilateral in 26 (19.4%). The mean number of segments involved was 4.4 (range, one to 14 segments). Four or fewer segments were involved in 85 patients (63.4%). Bronchiectasis involvement was predominantly in the basilar segments in 46 patients (34.3%), superior segment in 29 (21.6%), lingula in 16 (11.9%), middle lobe in 16 (11.9%), and upper lobe segments in 27 (7.5%). The probable cause of bronchiectasis was postobstructive pneumonitis in 34 patients (25.4%), childhood infections in 23 (17.2%), pneumonia in 22 (16.4%), an immunodeficient state in 5 (3.7%), immotile cilia syndome in 4 (3%), and pulmona~ sequestration in 2 (1.5%). A cause for bronchiectasis was not identified in 44 patients (32.8%). The indication for pulmonary resection was failure of medical therapy in 85 patients (63.4%), recurrent or massive hemoptysis in 26 (19.4%), lung abscess in 12 (9.0%), and an indeterminate mass in 11 (8.2%). Thoracotomy was performed in all patients. Complete resection of all bronchiectasis was done in 108 patients (81%). One hundred seven of 108 patients (99.1%) with unilateral involvement had complete resections. In contrast, 25 of 26 patients (96.2%) with bilateral involvement had incomplete resections. Eighty-six patients (64.2%) had a lobectomy, 21 (15.7%) had a pneumonectomy, 18 (13.4%) had a wedge resection or segmentectomy, and 9 (6.7%) had a combination of these approaches. Seven of the pneumonectomy patients had completion pneumonectomies. Thirteen of the patients who had pneumonectomy had the operation on the left side, and 8 on the right. A lower lobectomy was performed in 49 patients, middle lobectomy in 16, and an upper lobectomy in 15. Five additional patients had bilobectomies. One patient underwent staged thoracotomies (bilateral lobectomies). Results Complications occurred in 33 patients (24.6%) and included atelectasis requiring bronchoscopy in 9, a prolonged air leak (greater than 10 days) in 6, empyema in 5, pneumonia in 5, postoperative hemorrhage requiring reexploration in 4, arrhythmias in 3, postpneumonectomy pulmonary, edema in 3, respiratory failure in 3, and bronchopleural fistula in 1. Three patients died (2.2%), all after completion pneumonectomy. The cause of death was respiratory failure in 2 patients and intraoperative bleeding in 1. Follow-up was complete in 103 patients, with a mean of 6.0 years (range, 1 to 16 years). Overall, 61 patients (59.2%) were asymptomatic after pulmonary resection. Symptoms were improved and antibiotic requirements were decreased in 30 patients (29.1%). Twelve patients (11.7%) had no improvement. In the group that had a complete resection, 89 patients were available for follow-up. Fifty-eight (65.2%) were asymptomatic, 23 (25.8%) were improved, and 8 (9.0%) were unimproved. In the group that had an incomplete resection, 14 were available for follow-up. Three (21.4%) were asymptomatic, 7 (50.0%) were improved, and 4 (28.6%) were unimproved. Complete resection resulted in a significantly better result than incomplete resection (p ( 0.05). Seventy-four of 85 patients who had failed previous medical management were available for follow-up. Forty patients (54.1%) were asymptomatic after pulmonary resection, 26 (35.1%) were improved, and 8 (10.8%) were unimproved. Eighteen of the 26 patients who were operated on for hemoptysis were available for follow-up. Eleven patients (61.1%) were asymptomatic, 3 (16.7%) were improved, and 4 (22.2%) were unimproved. In the pneumonectomy group, 15 patients were available for follow-up. Thirteen (86.7%) were either asymptomatic or improved, and they all had complete resection. Two patients (13.3%) had incomplete resection, and they were unimproved after operation. Comment Bronchiectasis is a chronic necrotizing infection of the bronchi and bronchioles leading to irreversible abnormal dilatation of the airways. This should not be confused with pseudobronchiectasis, which is a transient (up to 6 months) cylindric dilatation of the bronchi accompanying lung infection in children. Pathologic findings in bronchiectasis [3-5] can be classified as cylindric, varicose, or cystic (saccular) and cover a spectrum from mild (cylindric) to the most severe form of this disease (cystic). Associated with these bronchial changes are varying degrees of scarring and fibrosis of the lung parenchyma. The incidence of bronchiectasis is unknown, but had been reported to be as high as one per million children per year in the late 1950s [2]. Bronchiectasis is usually caused by pulmonary infection or bronchial obstruction. About half of the patients can trace the onset of symptoms to a childhood infection. Cystic fibrosis is currently the most common cause of bronchiectasis in the white population of North America and Europe [5]. Symptoms primarily are chronic cough and expectoration of foulsmelling, purulent sputum. Once chronic, respiratory infections tend to be frequent. Pseudomonas aeruginosa and Haemophilus influenzae are the most common organisms isolated from sputum [6]. Complications of this condition include hemoptysis, pulmonary abscess, brain abscess, amyloidosis, and respiratory failure. Cor pulmonale accounts for 37% of deaths [7]. Chest roentgenographic findings that are suggestive but nondiagnostic of bronchiectasis include stranding, cystic lesions, volume loss with crowding of vessels, and areas of infiltrates and atelectasis. High-resolution computed tomography has now largely supplanted bronchography for the definite diagnosis [8]. The initial treatment of patients with symptomatic

3 978 AGASTHIAN ET AL Ann Thorac Surg OPERATION FOR BRONCHIECTASIS 1996;62: bronchiectasis is primarily medical, with the goal being to reduce airway obstruction and to eliminate bacteria from the lower respiratory tract. Therapy should include rotating antimicrobial therapy, postural physiotherapy, inhaled bronchodilators, and corticosteroids [9]. Broadspectrum antibiotics should be instituted for acute respiratory infection and exacerbations of chronic infection. The role of pulmonary resection has evolved from early curative resection for all patients [10-12] to a more palliative approach limited to either those patients who have medically resistant disease or those who have complications [13-15]. Our operative patient population in the present study was highly selected and represented only 3.4% of all patients with the diagnosis of bronchiectasis seen during this time period. The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients who have failed medical treatment [16] and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess. Appropriate selection of patients is critical for optimal results. Early pulmonary resection while the disease is still localized is preferred [17]. Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation [18]. Most of our patients had limited disease, and complete resection was possible in 81%. None had cystic fibrosis. All patients should have a preoperative bronchoscopy study to rule out a stricture, neoplasm, or foreign body. Pulmonary function studies are rarely vital in the candidate with localized disease, but they should be obtained when a more extensive or repeat resection is considered. Acute suppurative bronchitis should be treated aggressively preoperatively with appropriate antibiotics. The operation is conducted with a double-lumen endotracheal tube to decrease soiling by blood and infected secretions. Completion pneumonectomy is a high-risk procedure when performed for benign disease [19]. When indicated, precautions such as optimal exposure, intrapericardial isolation of blood vessels, and bronchial reinforcement should be used routinely [20]. More than 80% of our patients had total relief or substantial improvement of their preoperative symptoms. These results are comparable to those reported by others [16, 17, 21, 22]. Our overall operative mortality rate of 2.2% also compares favorably with that reported previously [11, 16, 17, 21-25]. Morbidity, however, was substantial, with at least one complication developing in 33 patients (24.6%). In conclusion, surgical treatment for bronchiectasis should be limited to patients with localized disease unless life-threatening symptoms are present. Complete resection should be performed whenever possible to achieve maximum benefit. In properly selected patients, pulmonary resection can be done with acceptable morbidity and low mortality rates. References 1. Raffensperger JG. Bronchiectasis. In: Raffensperger JG, ed. Swenson's pediatric surgery. Norwalk, CT: Appleton & Lange, 1990: Stockley RA. Bronchiectasis. In: Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford textbook of medicine. 3rd ed. Oxford: Oxford University Press, 1996: Robbins SL, ed. The respiratory system~lung. In: Pathologic basis of disease. Philadelphia: WB Saunders, 1974: Whitwell F. A study of the pathology and pathogenesis of bronchiectasis. Thorax 1952;7: Pare JAP. Diseases of the airways. In: Faser RS, Pare JAP, Fraser RG, Pare PD, eds. Synopsis of diseases of the chest. 2nd ed. Philadelphia: WB Saunders, 1994: Nicotra MB, Rivera M, Dale AM, Shepherd R, Carter R. Clinical pathophysiologic, and microbiologic characterization of bronchiectasis in an aging cohort. Chest 1995;108: Ellis DA, Thornley PE, Wightman AJ, et al. Present outlook in bronchiectasis: clinical and social study and review of factors influencing prognosis. Thorax 1981;36: Grenier P, Maurice F, Musset D, et al. Bronchiectasis: assessment by thin-section CT. Radiology 1986;161: Wilson R, Cole P. Respiratory tract infections. In: Barnes PJ, ed. Respiratory medicine: recent advances. Oxford: Butterworth-Heinemann, 1993: Kergin FG. The surgical treatment of bilateral bronchiectasis. J Thorac Cardiovasc Surg 1950;19: Churchill ED, Belsey R. Segmental pneumonectomy in bronchiectasis. Ann Surg 1939;109: Oschner A, DeBakey M, DeCamp PT. Bronchiectasis: its curative treatment by pulmonary resection. Surgery 1949;25: Lindskog GE. Bronchiectasis revisited. Yale J Biol Med 1986; 59: Ripe E. Bronchiectasis: a followup study after surgical treatment. Scand J Respir Dis 1971;52: Le Roux BT, Mohlala ML, Odell JA, Whitton ID. Suppurative diseases of the lung and pleural space. Part II: Bronchiectasis. Curr Probl Surg 1986;23: Annest LS, Kratz JM, Crawford FA. Current results of treatment of bronchiectasis. J Thorac Cardiovasc Surg 1982; 83: Etienne T, Spiliopoulos A, Megevand R. Les bronchectasies: indication et moment de la chirurgie. Ann Chir 1993;47: Laros CD, Van den Bosch JMM, Westermann CJJ, et al. Resection of more than 10 lung segments. A 30-year survey of 30 bronchiectatic patients. J Thorac Cardiovasc Surg 1988; 95: McGovern EM, Trastek VF, Pairolero PC, Payne WS. Completion pneumonectomy: indications, complications, and results. Ann Thorac Surg 1988;46: Gregoire J, Deslauriers J, Guojin L, Rouleau J. Indications, risks, and results of completion pneumonectomy. J Thorac Cardiovasc Surg 1993;105: Sealy WC, Bradham RR, Young WG Jr. The surgical treatment of multisegmental and localized bronchiectasis. Surg Gvnecol Obstet 1966;123: Edward AT. Treatment of bronchiectasis. Med J 1939;1: Sanderson JM, Kennedy MCS, Johnson MF, et al. Bronchiectasis: results of surgical and conservative management. A review of 393 cases. Thorax 1974;29: Vejlsted H, Hjelms E, Jacobsen O. Results of pulmonary resection in cases of unilateral bronchiectasis. Scand J Thorac Cardiovasc Surg 1981;16: Dogan R, Alp M, Kaya S, et al. Surgical treatment of bronchiectasis: a collective review of 487 cases. Thorac Cardiovasc Surg 1989;37:183-6.

4 Ann Thorac Surg AGASTH1AN ET AL ;62: OPERATION FOR BRONCHIECTASIS DISCUSSION DR L. PENFIELD FABER (Chicago, IL): 1 compliment Agasthian and associates on an excellent presentation and a very well written manuscript. In their study, they emphasize the need for preoperative bronchoscopy, and strongly support this recommendation. It is very important to rule out benign or malignant causes of obstruction and to determine the degree of inflammation in the bronchial wall itself. Severe inflammation may negate resection until better infection control has been achieved. The preoperative diagnosis of bronchiectasis today can be somewhat of a problem. Dionosil is no longer available, and now we relv on thin-cut computed tomographic scan to define bronchiectasis. In the present series, a bronchogram was done in 66 patients, and computed tomographic scan made the diagnosis in 44. However, in 24 the apparent diagnosis was made on the plain chest roentgenogram. Doctor Agasthian, how could you define true bronchiectasis on a plain chest roentgenogram? Mv mentor, Dr Hiram Langston, emphatically taught us that bronchiectasis could be diagnosed only with the bronchogram. In that same vein, it would be helpful for Dr Agasthian to explain how the computed tomographic scan is used to define the true anatomic extent of bronchiectasis. In other words, does the computed tomographic scan tell us if the superior segment of the h)wer lobe is involved, and can we plan an anatomic resection based on this scan alone? The surgical resections reported in this series are somewhat unusual for bronchiectasis. The majority were lobectomies and pneumonectomies, with very few segmentectomies. There was only one bilateral resection out of the 134 procedures done, and 26 patients had bilateral disease. Segmentectomy is the ideal procedure for bronchiectasis. Doctor Agasthian, how would you handle a symptomatic patient with saccular bronchiectasis of the basal segments of the left lower lobe and the right lower lobe? This series suggests that you would perform a lobectomy on the worst side. The basic guidelines for the operative therapy of bronchiectasis are: (1) infection control, (2) preoperative bronchoscopy, (3) precise anatomic diagnosis, and (4) precise anatomic resection. 1 am not certain that Agasthian and associates have met the last two guidelines in this series of patients. DR AGASTHIAN: Thank you, Dr Faber, for your comments. With regard to vour first question, in 24 patients, the diagnosis of bronchiectasis was made on chest roentgenogram because they presented acutely with hemoptysis and recurrent infections. The diagnosis was confirmed postoperatively by pathologic examination. High-resolution computed tomographic scan has now replaced bronchography in our practice for the diagnosis and anatomic localization of bronchiectasis. Regarding the management of bilateral disease confined to the basilar segments, we would probably start on the worse side and do a bilateral basal segmentectomy so as to preserve the superior segments on both sides, thus relieving symptoms while preserving as much lung function as possible. DR DAVID S. HUBBELL (Tampa, FL): 1 enjoyed this paper very much, and it is interesting to see a collected series of patients with bronchiectasis. [ was moved to compare it with our analysis of 215 cases published some years ago [1] in which we found multilobar disease in two thirds of the patients; in one third it was unilobar, in about one third it was on both sides, and in another third it was multilobar but on the same side. In our series, we analyzed 165 resections in 138 patients, and we also found that complete resection was important. Those who had remaining disease had about twice the postoperative complications. Late follow-up a year or more later showed that of those with complete resection, 93% considered themselves improved, compared with 74% of those who had remaining disease. I would like to know a little more about the negative predictive value of high-technique computed tomographic scans of the lungs in diagnosing bronchiectasis. Did any of your patients have bronchography as well as computed tomographic scans, so that one might compare the accuracy of the two? DR AGASTHIAN: Our series ranged over a 17-year period, from 1976 to 1993, and although bronchography was used in the earlier part of the series, high-resolution computed tomography became the investigation of choice for localization of disease in the latter years. As to the efficacy of high-resolution computed tomography as compared with bronchography, the number of patients in our series who had both computed tomographic scan and bronchography was too small to derive any significant conclusion. DR LEWIS WETSTEIN (Freehold, NJ): I also congratulate Agasthian and associates on their clear and lucid presentation. It was disconcerting, however, that when the indication for operation was hemoptysis, more than 20% of the patients either were unimproved or continued to have hemoptysis. 1 have two questions. First, why do you think this rate was so high? Second, how do you manage these patients after resection when they continue to bleed postoperatively? DR AGASTHIAN: One of the problems in the management of bronchiectasis is accurate preoperative localization. One of the possible reasons for the higher incidence of unimproved cases among those presenting with hemoptysis is that frequently, operation was performed in an emergent or semiemergent situation, precluding detailed preoperative localization studies. For patients who return after previous resection for bronchiectasis, procedures such as angiography and bronchial artery embolization should be attempted before reoperation. DR A. ALAN CONLAN (Worcester, MA): I enjoyed your paper and congratulate you. There are two questions I want to ask. First, your three deaths occurred after completion pneumonectomy for bronchiectasis. Do you continue to recommend this procedure for patients with bronchiectasis? Presumably they have had previous lobar resection for bronchiectasis and it remains uncontrolled. Second, some of your patients were children as young as 4 years. Separation of the airway and control of secretions during the resection by double-lumen tube are easy enough in adults, but what methods did you use in children? Clearly some of your patients required bronchoscopy for secretions and atelectasis postoperatively. What was the common method of bronchial separation for your resections? DR AGASTHIAN: Completion pneumonectomy for bronchiectasis should be avoided whenever possible, as the mortality rate is rather high. There was a total of three deaths after the seven completion pneumonectomies performed in our series. The procedure should be attempted only in cases of life-threatening symptoms and in those with a nonfunctioning, destroyed lung. We use bronchial blockers for isolation of the airway to

5 980 AGASTHIAN ET AL Ann Thorac Surg OPERATION FOR BRONCHIECTASIS 1996;62: prevent spillage of secretions when performing an operation for bronchiectasis in children. DR JOSEPH LoCICERO IlI (Boston, MA): The radiology literature now is full of reports on the use of high-resolution computed tomography for bronchiectasis. I have done a lot of bronchography in the past, and 1 have become convinced that it is no longer necessa~. However, for Dr Faber, the lipid-based contrast is still available, and it is used in patients who get chemoembolization. In terms of this presentation, we at New England Deaconess Hospital had a large experience with bronchiectasis in the past, but we do very few resections today for non-life-threatening conditions. We believe that patients must have some debilitating problem with their life-style because of their bronchiectasis, and we now operate only on patients who have more than six pneumonias per year. What is your usual indication for patients who have no life-threatening condition? DR AGASTHIAN: We totally agree with your comments that the operative indication in bronchiectasis is mainly confined to patients with life-threatening symptoms. Operation should be offered to those with severe, chronic, disabling symptoms only if their disease is rather localized and the chances of cure are good. We defined disabling symptoms as those that affect the quality of life by causing frequent hospitalizations, interfering with work or school, and requiring frequent medication. Reference 1. Lindskog GE, Hubbell DS. An analysis of 215 cases of bronchiectasis. Surg Gynecol Obstet 1955;100: The Annals of Thoracic Surgery Cumulative Index The Annals of Thoracic Surge~ 31-year cumulative index, volume 1 through volume 60, January 1965 through December 1995, is now available in two versions: in print (ISBN ) and on CD-ROM (ISBN ). Both print and CD-ROM versions contain subject and author indexes for the 31 years of the journal to date. The CD-ROM also contains all of the journal's published scientific abstracts; hypertext links between article titles, subject headings, authors, and abstracts; a search function that allows full-text, Boolean, and keyword searches; and functions to select and format references for future use. The CD-ROM is both DOS/ Windows and Macintosh compatible. The price is $95.00 for the CD-ROM version, $95.00 for the print version, or only $ for both the CD-ROM and print versions. Contact Elsevier Science Inc to place your order: Telephone: (212) ; Fax: (212)