Median Sternotomy for Pneumonectomy in Patients With Pulmonary Complications of Tuberculosis

Transcription

1 Median Sternotomy for Pneumonectomy in Patients With Pulmonary Complications of Tuberculosis Cliff P. Connery, MD, James Knoetgen III, MD, Constantine E. Anagnostopoulos, MD, and Madeline V. Svitak, BS, MT Division of Thoracic Surgery, St. Luke s-roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York Background. Traditionally, a thoractomy incision is used for pulmonary complications of tuberculosis. An attractive alternative is being presented by the use of midline sternotomy in such patients, which is the aim of this study. Methods. Five patients (four male, one female) with pulmonary complications of tuberculosis requiring surgical therapy in 1993 and 1994 were treated through a median sternotomy. The median patient age at time of surgery was 40.2 years and the median patient follow-up was 4.0 years (range 1.0 to 5.0 years) in this retrospective review. Results. All patients had uncomplicated operative courses and were discharged from the hospital. One patient s in-hospital postoperative course was complicated by prolonged ventilator dependency requiring temporary tracheostomy; he died 1 year postoperatively after hospital discharge due to recurrent multidrug-resistant tuberculosis. Sternal wound infections and bronchopleural fistulas were not observed in any patients. Conclusions. Surgical treatment of pulmonary complications of tuberculosis was traditionally performed through a thoracotomy approach. Many patients with tuberculous lungs have pulmonary adhesions or intrathoracic scarring from previous surgery, which would require extrapleural resection. Bleeding was a frequent complication of this procedure. Sternotomy offers excellent exposure of the intrapericardial vessels, and reduced postoperative disability compared to the standard thoracotomy, which may be an advantage given that the majority of patients in this population have poor pulmonary function. We recommend median sternotomy as an alternative operative approach in selected patients with pulmonary complications of tuberculosis. (Ann Thorac Surg 2003;75:1613 7) 2003 by The Society of Thoracic Surgeons Mycobacterium tuberculosis has reemerged as a significant public health problem in the United States, particularly in the inner city population. Pulmonary tuberculosis is usually managed successfully with medical therapy. Despite the success of chemotherapeutic agents in the treatment of pulmonary tuberculosis, complications of this disease often require surgical intervention. Indications for surgical intervention in patients with pulmonary tuberculosis include multidrug-resistant tuberculosis (MDRTB), bronchopleural fistula (BPF), destroyed lung, solitary nodule, hemoptysis, pulmonary cavity, trapped lung, empyema, and the possibility of neoplasm. Resection for pulmonary tuberculosis has traditionally been performed through a thoracotomy approach and some authors have argued against approaching these lesions through a median sternotomy [1]. Patients with pulmonary complications of tuberculosis often have severe scarring and adhesions within the thoracic cavity, as well as areas of chronic sepsis. Impaired pulmonary function is common is this patient population. These Accepted for publication Nov 27, Address reprint requests to Dr Anagnostopoulos, 45 East 89th St, New York, NY 10128; cea8@columbia.edu. conditions make surgical endeavors more difficult and potentially more dangerous. Pneumonectomy and pulmonary resections in patients with tuberculosis are often performed through a thoracotomy incision. This approach may be technically challenging and potentially hazardous in the tuberculous thorax filled with adhesions, postoperative scarring, and areas of chronic sepsis. Median sternotomy is routinely used in cardiac surgery and has been shown to be an effective approach for surgical treatment of many pulmonary conditions. Shorter operative times, adequate bilateral exposure for most pulmonary procedures, less postoperative pain, and earlier hospital discharges have been observed in median sternotomy patients when compared with thoracotomy patients [1 5]. Here we report our experience with median sternotomy for these patients and review the literature regarding median sternotomy for noncardiac thoracic surgery. Patients and Methods Five patients undergoing pneumonectomy in 1993 and 1994 for complications related to tuberculosis are the 2003 by The Society of Thoracic Surgeons /03/$30.00 Published by Elsevier Science Inc PII S (02)

2 1614 CONNERY ET AL Ann Thorac Surg STERNOTOMY FOR PNEUMONECTOMY IN TUBERCULOSIS 2003;75: Table 1. Patient Summary Patient Age/Sex Diagnosis TB Meds Preop FEV 1 ; FVC (% of predicted) 1 40/M BPF, hemoptysis 5 Drugs 1.44; 2.14 (45%; 50%) 2 30/M MDRTB, destroyed lung 5 Drugs N/A 3 44/M Pulmonary cavitation, AdenoCA Quiescent 2.41; 4.11 (76%; 97%) 4 65/M Destroyed lung, hemoptysis Quiescent 1.27; 2.55 (51%; 43%) 5 22/F Destroyed lung, hemoptysis 5 Drugs 2.02; 2.67 (64%; 68%) AdenoCA adenocarcinoma; BPF bronchopleural fistula; F female; M male; MDRTB multidrug-resistant tuberculosis; N/A not available; PLOS postoperative length of stay; Pneumo pneumonectomy; Preop preoperative; Postop postoperative; R right; RLL right lower lobe; TB Meds preoperative tuberculosis medications. subject of this article. There were 4 men and 1 woman. Patient follow-up was obtained through hospital clinic visits and hospital medical records. The surgical technique used was midline sternotomy. A longitudinal roll was placed under the operative side to tilt the patient toward the opposite side with the table rotated to make the patient supine for sternotomy, similar to the description by Urschel and Razzuk [1]. Standard chest retractors were used for the initial dissection, which started with pericardiotomy. The pulmonary artery was identified between the superior vena cava and the ascending aorta and was ligated. The right main bronchus was then controlled at the level of the carina with a stapler and transected. The right pleura was then opened and adhesions mobilized with exposure gained by angulating the sternotomy retractor or using an internal thoracic artery retractor. In some cases, extreme hyperexpansion of the left lung made exposure of the pulmonary veins difficult because of cardiac displacement and posterior rotation of the veins. Exposure was facilitated by rotation of the table to the left to try to decrease cardiac displacement during control and suture of the veins, which was performed either intra- or extrapericardially. Right costophrenic and diaphragmatic adhesions proved to be more difficult to manage than apical adhesions in this series. Planned surgical therapy was pneumonectomy or completion pneumonectomy. Two of the patients underwent surgery for treatment of destroyed lungs secondary to tuberculosis. One patient had completion pneumonectomy for treatment of a bronchopleural fistula after having undergone two previous procedures through posterolateral thoracotomies. One patient had a concomitant pulmonary adenocarcinoma. The fifth patient underwent a pneumonectomy for MDRTB. Median sternotomy incisions were used to gain proximal control of the pulmonary vessels and bronchi, to provide an uncontaminated, virgin approach to the thoracic cavities, and for the potential benefits of decreased postoperative pulmonary disability. All patients had uncomplicated operative courses and were discharged from the hospital. One patient s postoperative course was complicated by prolonged ventilator dependency requiring tracheostomy, but the patient was ultimately discharged. Preoperative and postoperative pulmonary function tests (PFTs) are documented for some of the patients (Table 1). Patient noncompliance precluded the performance of PFTs on all patients. Results J.H. was a 40-year-old man with a 3-year history of pulmonary tuberculosis complicated by intermittent hemoptysis. This was treated at an outside institution with a left apical segment pulmonary resection through a posterolateral thoracotomy. Pathologic examination revealed tuberculosis as well as an aspergilloma. A hemopneumothorax and bronchopleural fistula complicated the patient s early postoperative course, but he recovered uneventfully. The patient developed recurrent hemoptysis 2 years postoperatively, which required right upper and right middle lobe resections. This operation was also performed through a thoracotomy incision. Pathologic examination again demonstrated tuberculosis and an aspergilloma. Four years later this patient presented to our institution with a recurrent bronchopleural fistula and recurrent hemoptysis. Chest radiographs and computed tomograms are shown in Figures 1 and 2, and a postoperative chest radiograph is shown in Figure 3. Sternotomy was used in February 1993 because of the patient s poor preoperative pulmonary function, his history of multiple surgical procedures, and the recurrent Fig 1. Preoperative chest radiograph of case 1 demonstrating a right-sided bronchopleural fistula.

3 Ann Thorac Surg CONNERY ET AL 2003;75: STERNOTOMY FOR PNEUMONECTOMY IN TUBERCULOSIS 1615 Table 1. Continued Postop FEV 1 /FVC Transsternal procedure PLOS Complications Follow-up 1.00/1.53 Completion Pneumo (RLL) 14 days Empyema at 4 mo Alive, 5.0 y N/A R Pneumo 35 days Prolonged tracheostomy and ventilator Death, 1 y N/A R Pneumo 8 days Alive, 4.0 y 1.31/2.01 R Pneumo 11 days Alive, 4.50 y N/A R Pneumo 9 days Alive, 3.75 y BPF. This permitted excellent control of the bronchial stump without contamination. Pathology revealed a tuberculous right lung. The patient s early postoperative course was uncomplicated. A right hemithorax empyema developed 4 months postoperatively, which was successfully treated with a closed thoracostomy. The patient was discharged from the hospital on March 4, 1993 and was doing well at 5 years. H.N. was a 30-year-old man with a 6-year history of pulmonary tuberculosis. The patient was noncompliant with medications and his disease progressed to MDRTB, a destroyed right lung, and uncontrollable pulmonary sepsis. The patient was treated with a sternotomy and right pneumonectomy and intravenous antimicrobial therapy on September 17, This approach also permitted inspection of the left lung. Because this patient s preoperative exercise tolerance was poor, the transsternal approach was also used for the potential postoperative pulmonary function benefits. The postoperative course was complicated by prolonged ventilator dependency requiring a tracheostomy and a prolonged course in the surgical ICU. The patient was ultimately discharged after 1 month on October 21, 1993 and sputum cultures subsequently decreased to 1 (clinically insignificant levels). The patient recovered and survived for 1 year, but was again poorly compliant with his medical regimen and died 1 year after surgery. E.A. was a 44-year-old man with a 20 pack-year tobacco history and a 20-year history of pulmonary tuberculosis. He presented with shortness of breath and thoracic computed tomography (CT) revealed right lung cavitation and a right upper lobe mass with extension to the intrapleural pulmonary artery. A sternotomy and right pneumonectomy was performed on March 29, This approach permitted intrapericardial control of the hilar vessels and the bronchi. Pathologic examination revealed a tuberculous pulmonary cavity and an adenocarcinoma with pleural extension and positive peribronchial and subcarinal lymph nodes. The postoperative course was uncomplicated and the patient was discharged on postoperative day 8 on April 6, At 3 years follow-up the patient had received irradiation for the treatment of cranial adenocarcinoma metastases. A.R. was a 65-year-old man with a 10-month history of pulmonary tuberculosis and severe chronic obstructive pulmonary disease (COPD). The patient experienced a prior respiratory arrest and had required chronic bronchodilator treatment for severe bronchospasm. The patient presented to our institution with recurrent hemoptysis. Bronchoscopy demonstrated bleeding from the right lung, and a thoracic CT revealed multiple large, Fig 2. Preoperative chest computed tomographic scan of patient 1 demonstrating extensive right pulmonary cavitation. Fig 3. Postoperative chest radiograph of patient 1.

4 1616 CONNERY ET AL Ann Thorac Surg STERNOTOMY FOR PNEUMONECTOMY IN TUBERCULOSIS 2003;75: Fig 4. Preoperative chest radiograph of patient 5 revealing a destroyed right lung. right upper lobe cavities and a destroyed right lung. The patient s poor preoperative PFTs (Table 1) precluded a conventional thoracotomy. A median sternotomy was therefore used for a right pneumonectomy on October 4, The surgery and postoperative course was uncomplicated and the patient had no significant pulmonary dysfunction postoperatively. He was discharged on October 15, 1993 (postoperative day 16) and was doing well at 4.5 years postoperatively. P.P., a 22-year-old woman with a 6-year history of pulmonary tuberculosis and an 8 pack-year tobacco history, presented to our group with hemoptysis. Bronchoscopy demonstrated bleeding from the right bronchi. A chest radiograph and thoracic CT revealed a destroyed right lung (Fig 4 and 5). After sternotomy on April 20, Fig 5. Preoperative computed tomographic scan of patient 5 showing right pulmonary cavitation and a hyperinflated left lung. Arrow points to an aspergilloma. 1994, the lung was found to be extensively scarred and to contain multiple adhesions throughout the right hemithorax. In our opinion this operation would have been technically more difficult through a traditional thoracotomy approach. The patient had no operative or postoperative complications. She was discharged on April 29, 1994 (postoperative day 9) and was doing well at 3.75 years. Comment The median sternotomy incision was popularized with the advent of open heart surgery, and its indications for general thoracic operations have broadened. Through a sternotomy, as proposed by Urschel and Razzuk [1], the thoracic surgeon gains exposure of both lung fields and the ability to safely identify important hilar vessels and bronchi. This advantage is important when attempting to obtain proximal control of these structures in patients with areas of sepsis, scarring, and adhesions within the thoracic cavity. Postoperative pain and therefore pulmonary dysfunction is potentially decreased in median sternotomy patients. Another advantage of the median sternotomy approach is the ability to perform synchronous bilateral pulmonary procedures. This can prevent staged bilateral thoracotomies in patients with contralateral disease. Cooper and coworkers [2] showed that both the median sternotomy and lateral thoracotomy result in marked loss of measured lung function, but recovery occurs sooner after median sternotomy. At 4 and 7 days postoperatively, the differences in peak flow and vital capacities were statistically significant between the two procedures. At 1 week, peak flow returned to 80% of the preoperative value for sternotomy patients, compared with 64% for thoracotomy patients. Hayward and coworkers [3] noted less postoperative pain, less atelectasis, and shorter operative times (89% of time required for a standard thoracotomy) in median sternotomy patients. Beltrami [4] reported 10 patients with postpneumonectomy bronchopleural fistulas treated with transsternal division of the affected main stem bronchus (Abruzzini operation). Sternal wound infection can be a disastrous complication of the median sternotomy incision. Some surgeons may avoid a median sternotomy in patients with tuberculosis for fear of a Mycobacterium tuberculosis sternal wound infection. Arsan and colleagues [5] reported 105 patients who underwent transsternal pericardiectomy for the treatment of pericarditis. A total of 40 patients had associated tuberculosis. The authors documented mediastinitis and septicemia in one patient. However, there were no reported cases of sternal wound infection or osteomyelitis in their series. Reed and colleagues [6] reported 24 patients treated surgically for pulmonary complications of tuberculosis. Their main indications for surgical intervention included hemoptysis, drug resistance, bronchiectasis, and possible neoplasm. All operations were performed through a standard posterolateral thoracotomy. The authors noted

5 Ann Thorac Surg CONNERY ET AL 2003;75: STERNOTOMY FOR PNEUMONECTOMY IN TUBERCULOSIS 1617 a total major and minor complication rate of 46%. Surgical therapy usually required lobectomy, which sometimes resulted in substantial blood loss. The authors reported good long-term prognosis after successful resection. Treasure and Seaworth [7] reported 59 patients with pulmonary tuberculosis treated surgically via thoracotomy incisions. The author asserted (in the closing comments) that treating tuberculosis patients through a median sternotomy incision would be difficult because of inadequate exposure and poor access caused by dense adhesions. Our group, however, has achieved excellent exposure of the right lung and upper left lung through a sternotomy approach without complication. It is recognized that thoracotomy can be an effective method to treat lungs destroyed by tuberculosis. Brown and Pomerantz [8] reported their series of 62 pneumonectomies for tuberculosis with only one operative death and one postpneumonectomy stump breakdown. They reported using an extrapleural approach. Intrapericardial left pneumonectomy through sternotomy has been used in our practice for some selected patients with central left-sided tumors. We have not used the sternotomy approach in patients in whom we expect to find left lower lobe scarring or extensive diffuse adhesions because of the difficulty in mobilizing these without hemodynamically significant displacement of the heart. (During the period of the study no patients underwent left pneumonectomy for tuberculosis.) We used several indications for a median sternotomy approach for pulmonary resection in patients with pulmonary complications of tuberculosis. These included severe scarring and adhesions from previous surgeries and chronic tuberculosis, persistent areas of chronic sepsis from tuberculosis, and poor pulmonary function tests. Median sternotomy access permitted performance of the operation in planes uncontaminated by chronic sepsis, which is often seen in patients with pulmonary complications of tuberculosis. In cases of bronchopleural fistulas, the median sternotomy approach permitted access to the proximal bronchi and hilar vessels for control of these structures in clean, unscarred planes. Poor preoperative PFTs can preclude a thoracotomy approach because of the anticipated postoperative pulmonary dysfunction. We believe that the median sternotomy approach allowed us to perform surgery in 2 patients for this indication. One limitation of the sternotomy approach identified in our experience was the difficulty of delivering a serratus anterior or pectoralis major muscle flap for closure of a bronchopleural fistula. In these cases, a flap of pericardial tissue can be used. An alternative would be use of an omental flap. The median sternotomy approach has created excellent access for pneumonectomy in our 5 patients with pulmonary complications of tuberculosis. There were no sternal wound infections or bronchopleural fistulas in this small series. This approach allows bilateral exploration and performance of most pulmonary procedures. Complications were few and postoperative ventilatory impairment is minimized. We therefore recommend the median sternotomy as an alternative operative approach in selected patients with pulmonary complications of tuberculosis. References 1. Urschel HC, Razzuk MA. Median sternotomy as a standard approach for pulmonary resection. Ann Thorac Surg 1986;41: Cooper JD, Nelems JM, Pearson FG. Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 1978;26: Hayward RH, Knight WL, Baisden CE, Korompai FL. Access to the thorax by incision. J Am Coll Surgeons 1994;179: Beltrami V. Surgical transsternal treatment of bronchopleural fistula postpneumonectomy. Chest 1989;95: Arsan S, Mercan S, Sarigul A, et al. Long-term experience with pericardiectomy: analysis of 105 consecutive patients. Thorac Cardiovasc Surg 1994;42: Reed CE, Parker EF, Crawford FA Jr. Surgical resection for complications of pulmonary tuberculosis. Ann Thorac Surg 1989;48: Treasure RL, Seaworth BJ. Current role of surgery in mycobacterium tuberculosis. Ann Thorac Surg 1995;59: Brown J, Pomerantz. Extrapleural pneumonectomy for tuberculosis. Chest Surg Clin North Am 1995;5: