Use of the Posterior Pericardium to Cover the Bronchial Stump After Right Extrapleural Pneumonectomy
2013; Elsevier BV; Volume: 96; Issue: 2 Linguagem: Inglês
10.1016/j.athoracsur.2013.02.048
ISSN1552-6259
Autores Tópico(s)Trauma Management and Diagnosis
ResumoLimited tissue is available to cover the bronchial stump after right extrapleural pneumonectomy for malignant pleural mesothelioma. After completing the resection, the pericardial reflection can be freed from the superior vena cava, the right pulmonary artery and veins, and the posterior wall of the pericardial sac between the transverse and oblique pericardial sinuses. The length and mobility from the posterior pericardium can then provide excellent coverage for the right bronchial stump. This technique has the advantage of being easy to perform and requiring limited time and dissection. Limited tissue is available to cover the bronchial stump after right extrapleural pneumonectomy for malignant pleural mesothelioma. After completing the resection, the pericardial reflection can be freed from the superior vena cava, the right pulmonary artery and veins, and the posterior wall of the pericardial sac between the transverse and oblique pericardial sinuses. The length and mobility from the posterior pericardium can then provide excellent coverage for the right bronchial stump. This technique has the advantage of being easy to perform and requiring limited time and dissection. Extrapleural pneumonectomy (EPP) requires resection of the parietal pleura, pericardium, diaphragm, and lung. Although the surgery can be performed with limited mortality, the complication rate remains high [1Sugarbaker D.J. Jaklitsch M.T. Bueno R. et al.Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies.J Thorac Cardiovasc Surg. 2004; 128: 138-146Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar]. Bronchopleural fistula (BPF) is one of the most dreaded complications after EPP. It occurs predominantly on the right side because of the limited amount of tissue available to cover the bronchial stump at the end of the surgery [2Opitz I. Kestenholz P. Lardinois D. et al.Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.Eur J Cardiothorac Surg. 2006; 29: 579-584Crossref PubMed Scopus (71) Google Scholar, 3de Perrot M. McRae K. Anraku M. et al.Risk factors for major complications after extrapleural pneumonectomy for malignant pleural mesothelioma.Ann Thorac Surg. 2008; 85: 1206-1210Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. Several techniques can be used to cover the bronchial stump after EPP. These techniques generally require the harvesting of an intercostal muscle flap, transposition of an extrathoracic muscle such as the anterior serratus muscle, or mobilization of a pericardial, azygos vein, or thymic or omental flap [4Wolf A.S. Daniel J. Sugarbaker D.J. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication.Semin Thorac Cardiovasc Surg. 2009; 21: 132-148Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 5Beshay M. Carboni G. Hoksch B. Reymond M.A. Schmid R.A. The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients.Interact Cardiovasc Thorac Surg. 2008; 7: 621-624Crossref PubMed Scopus (8) Google Scholar, 6Hamad A.M. Marulli G. Sartori F. Rea F. Pericardial flap for bronchial stump coverage after extrapleural pneumonectomy; is it feasible?.Eur J Cardiothorac Surg. 2008; 34: 1255-1256Crossref PubMed Scopus (4) Google Scholar]. During the past 4 years, I have used the posterior pericardium to cover the right main bronchus in the vast majority of patients with malignant pleural mesothelioma undergoing right-sided EPP. After freeing the pericardial reflection along the posterior wall of the pericardial sac, the posterior pericardium provided excellent coverage of the right bronchial stump. This technique has the advantage of being easy to perform and requiring limited time and dissection.TechniqueAfter right posterolateral thoracotomy, the parietal pleura and diaphragm are dissected en bloc with the lung exposing the pericardium in the anterior mediastinum and posterior mediastinum below the subcarinal space. The pericardium is then opened anteriorly in front of the superior vena cava (SVC) and posteriorly behind the right inferior pulmonary vein, and sharply dissected down to the diaphragm. The inferior vena cava (IVC) is identified below the diaphragm and is sharply dissected toward the right atrium. The right and left inferior phrenic veins are ligated along the IVC. The pericardial reflection extending between the IVC and the right inferior pulmonary vein is freed with cautery (Fig 1). The right inferior pulmonary vein, right superior pulmonary vein, and right pulmonary artery are stapled and sectioned intrapericardially. The right main bronchus is trimmed proximally to approximately 1 cm from the carina and stapled. After resection of the parietal pleura, diaphragm, pericardium, and right lung, the edge of the posterior pericardium is exposed up to the right inferior pulmonary vein. The pericardial reflection can then be freed with sharp dissection in the pulmonary venous recess and postcaval recess. After complete dissection of the posterior pericardium around the right pulmonary veins, the right pulmonary artery, and the SVC, the pericardial reflection is dissected toward the left pulmonary veins between the oblique sinus and the transverse sinus to gain enough mobility (Fig 2). Care should be taken during that stage to cauterize the collateral branches selectively from the bronchial arteries that communicate with the coronary circulation. Complete dissection of the pericardial reflection from the posterior wall of the pericardial sac provides enough mobility to the posterior pericardium to cover the right bronchial stump and be attached with interrupted stitches to peribronchial structures, such as the right vagus nerve, the muscular wall of the esophagus, and the azygos vein (Fig 3). Because no additional pericardium is removed and no pericardial flap is raised, the pericardial mesh can be fixed to the anterior and posterior pericardial edge in a standard fashion.Fig 2(A) Exposure of the right hilum obtained through a right posterolateral thoracotomy after completing the EPP. The right main bronchus (RMB) is stapled. The pericardial reflection is dissected off the right pulmonary veins (RPV), the right pulmonary artery (RPA), and the superior vena cava. The edge of the posterior pericardium (PP) is then exposed up to the transverse sinus in front of the esophagus (Eso). After freeing the pericardial reflection between the transverse sinus and the oblique sinus (number 4), the posterior pericardium gains length and mobility to cover the right bronchial stump (#). The number 4 correlates with the identification given in Figure 1.View Large Image Figure ViewerDownload (PPT)Fig 3The bronchial stump is entirely covered and mediastinalized. The pericardial mesh is fixed to the anterior and posterior edges of the pericardium in a standard fashion because no additional pericardium is removed or raised to create a flap.View Large Image Figure ViewerDownload (PPT)I have used this technique in 28 consecutive patients undergoing right EPP, including 21 patients after induction hemithoracic radiation as part of a prospective trial approved by our institutional research ethics board. In four patients, the posterior pericardium did not provide enough tissue and the bronchial stump was covered with a thymic flap (n = 2), a pericardial flap (n = 1), or an omental flap (n = 1). The bronchial stump from the remaining 24 patients undergoing right EPP was covered by the posterior pericardium alone. One patient (4%) who had received preoperative chemotherapy died from pneumonia within 30 days after surgery. No BPF was observed clinically and on bronchoscopy. None of the remaining patients developed BPF after a median follow-up of 14 months (range, 1 to 48 months).CommentThe use of the posterior pericardium to cover the right bronchial stump is easily applicable and can be used in the majority of patients undergoing right EPP. The mobilization of the posterior pericardium does not require any additional dissection other than simply freeing the pericardial reflection along the posterior wall of the pericardial sac. In addition, no extra pericardium is removed than what is needed to resect the tumor. Therefore, the pericardial mesh can be attached to the anterior and posterior pericardial edges in a standard fashion, thus limiting the risk of problem related to the pericardial patch. This technique appears to be a safe option to cover the bronchial stump after right EPP, even in patients who undergo induction hemithoracic radiation therapy. Extrapleural pneumonectomy (EPP) requires resection of the parietal pleura, pericardium, diaphragm, and lung. Although the surgery can be performed with limited mortality, the complication rate remains high [1Sugarbaker D.J. Jaklitsch M.T. Bueno R. et al.Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies.J Thorac Cardiovasc Surg. 2004; 128: 138-146Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar]. Bronchopleural fistula (BPF) is one of the most dreaded complications after EPP. It occurs predominantly on the right side because of the limited amount of tissue available to cover the bronchial stump at the end of the surgery [2Opitz I. Kestenholz P. Lardinois D. et al.Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.Eur J Cardiothorac Surg. 2006; 29: 579-584Crossref PubMed Scopus (71) Google Scholar, 3de Perrot M. McRae K. Anraku M. et al.Risk factors for major complications after extrapleural pneumonectomy for malignant pleural mesothelioma.Ann Thorac Surg. 2008; 85: 1206-1210Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. Several techniques can be used to cover the bronchial stump after EPP. These techniques generally require the harvesting of an intercostal muscle flap, transposition of an extrathoracic muscle such as the anterior serratus muscle, or mobilization of a pericardial, azygos vein, or thymic or omental flap [4Wolf A.S. Daniel J. Sugarbaker D.J. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication.Semin Thorac Cardiovasc Surg. 2009; 21: 132-148Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 5Beshay M. Carboni G. Hoksch B. Reymond M.A. Schmid R.A. The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients.Interact Cardiovasc Thorac Surg. 2008; 7: 621-624Crossref PubMed Scopus (8) Google Scholar, 6Hamad A.M. Marulli G. Sartori F. Rea F. Pericardial flap for bronchial stump coverage after extrapleural pneumonectomy; is it feasible?.Eur J Cardiothorac Surg. 2008; 34: 1255-1256Crossref PubMed Scopus (4) Google Scholar]. During the past 4 years, I have used the posterior pericardium to cover the right main bronchus in the vast majority of patients with malignant pleural mesothelioma undergoing right-sided EPP. After freeing the pericardial reflection along the posterior wall of the pericardial sac, the posterior pericardium provided excellent coverage of the right bronchial stump. This technique has the advantage of being easy to perform and requiring limited time and dissection. TechniqueAfter right posterolateral thoracotomy, the parietal pleura and diaphragm are dissected en bloc with the lung exposing the pericardium in the anterior mediastinum and posterior mediastinum below the subcarinal space. The pericardium is then opened anteriorly in front of the superior vena cava (SVC) and posteriorly behind the right inferior pulmonary vein, and sharply dissected down to the diaphragm. The inferior vena cava (IVC) is identified below the diaphragm and is sharply dissected toward the right atrium. The right and left inferior phrenic veins are ligated along the IVC. The pericardial reflection extending between the IVC and the right inferior pulmonary vein is freed with cautery (Fig 1). The right inferior pulmonary vein, right superior pulmonary vein, and right pulmonary artery are stapled and sectioned intrapericardially. The right main bronchus is trimmed proximally to approximately 1 cm from the carina and stapled. After resection of the parietal pleura, diaphragm, pericardium, and right lung, the edge of the posterior pericardium is exposed up to the right inferior pulmonary vein. The pericardial reflection can then be freed with sharp dissection in the pulmonary venous recess and postcaval recess. After complete dissection of the posterior pericardium around the right pulmonary veins, the right pulmonary artery, and the SVC, the pericardial reflection is dissected toward the left pulmonary veins between the oblique sinus and the transverse sinus to gain enough mobility (Fig 2). Care should be taken during that stage to cauterize the collateral branches selectively from the bronchial arteries that communicate with the coronary circulation. Complete dissection of the pericardial reflection from the posterior wall of the pericardial sac provides enough mobility to the posterior pericardium to cover the right bronchial stump and be attached with interrupted stitches to peribronchial structures, such as the right vagus nerve, the muscular wall of the esophagus, and the azygos vein (Fig 3). Because no additional pericardium is removed and no pericardial flap is raised, the pericardial mesh can be fixed to the anterior and posterior pericardial edge in a standard fashion.Fig 3The bronchial stump is entirely covered and mediastinalized. The pericardial mesh is fixed to the anterior and posterior edges of the pericardium in a standard fashion because no additional pericardium is removed or raised to create a flap.View Large Image Figure ViewerDownload (PPT)I have used this technique in 28 consecutive patients undergoing right EPP, including 21 patients after induction hemithoracic radiation as part of a prospective trial approved by our institutional research ethics board. In four patients, the posterior pericardium did not provide enough tissue and the bronchial stump was covered with a thymic flap (n = 2), a pericardial flap (n = 1), or an omental flap (n = 1). The bronchial stump from the remaining 24 patients undergoing right EPP was covered by the posterior pericardium alone. One patient (4%) who had received preoperative chemotherapy died from pneumonia within 30 days after surgery. No BPF was observed clinically and on bronchoscopy. None of the remaining patients developed BPF after a median follow-up of 14 months (range, 1 to 48 months). After right posterolateral thoracotomy, the parietal pleura and diaphragm are dissected en bloc with the lung exposing the pericardium in the anterior mediastinum and posterior mediastinum below the subcarinal space. The pericardium is then opened anteriorly in front of the superior vena cava (SVC) and posteriorly behind the right inferior pulmonary vein, and sharply dissected down to the diaphragm. The inferior vena cava (IVC) is identified below the diaphragm and is sharply dissected toward the right atrium. The right and left inferior phrenic veins are ligated along the IVC. The pericardial reflection extending between the IVC and the right inferior pulmonary vein is freed with cautery (Fig 1). The right inferior pulmonary vein, right superior pulmonary vein, and right pulmonary artery are stapled and sectioned intrapericardially. The right main bronchus is trimmed proximally to approximately 1 cm from the carina and stapled. After resection of the parietal pleura, diaphragm, pericardium, and right lung, the edge of the posterior pericardium is exposed up to the right inferior pulmonary vein. The pericardial reflection can then be freed with sharp dissection in the pulmonary venous recess and postcaval recess. After complete dissection of the posterior pericardium around the right pulmonary veins, the right pulmonary artery, and the SVC, the pericardial reflection is dissected toward the left pulmonary veins between the oblique sinus and the transverse sinus to gain enough mobility (Fig 2). Care should be taken during that stage to cauterize the collateral branches selectively from the bronchial arteries that communicate with the coronary circulation. Complete dissection of the pericardial reflection from the posterior wall of the pericardial sac provides enough mobility to the posterior pericardium to cover the right bronchial stump and be attached with interrupted stitches to peribronchial structures, such as the right vagus nerve, the muscular wall of the esophagus, and the azygos vein (Fig 3). Because no additional pericardium is removed and no pericardial flap is raised, the pericardial mesh can be fixed to the anterior and posterior pericardial edge in a standard fashion. I have used this technique in 28 consecutive patients undergoing right EPP, including 21 patients after induction hemithoracic radiation as part of a prospective trial approved by our institutional research ethics board. In four patients, the posterior pericardium did not provide enough tissue and the bronchial stump was covered with a thymic flap (n = 2), a pericardial flap (n = 1), or an omental flap (n = 1). The bronchial stump from the remaining 24 patients undergoing right EPP was covered by the posterior pericardium alone. One patient (4%) who had received preoperative chemotherapy died from pneumonia within 30 days after surgery. No BPF was observed clinically and on bronchoscopy. None of the remaining patients developed BPF after a median follow-up of 14 months (range, 1 to 48 months). CommentThe use of the posterior pericardium to cover the right bronchial stump is easily applicable and can be used in the majority of patients undergoing right EPP. The mobilization of the posterior pericardium does not require any additional dissection other than simply freeing the pericardial reflection along the posterior wall of the pericardial sac. In addition, no extra pericardium is removed than what is needed to resect the tumor. Therefore, the pericardial mesh can be attached to the anterior and posterior pericardial edges in a standard fashion, thus limiting the risk of problem related to the pericardial patch. This technique appears to be a safe option to cover the bronchial stump after right EPP, even in patients who undergo induction hemithoracic radiation therapy. The use of the posterior pericardium to cover the right bronchial stump is easily applicable and can be used in the majority of patients undergoing right EPP. The mobilization of the posterior pericardium does not require any additional dissection other than simply freeing the pericardial reflection along the posterior wall of the pericardial sac. In addition, no extra pericardium is removed than what is needed to resect the tumor. Therefore, the pericardial mesh can be attached to the anterior and posterior pericardial edges in a standard fashion, thus limiting the risk of problem related to the pericardial patch. This technique appears to be a safe option to cover the bronchial stump after right EPP, even in patients who undergo induction hemithoracic radiation therapy. Pericardial Coverage of the Bronchial StumpThe Annals of Thoracic SurgeryVol. 97Issue 5PreviewI read with interest the article by de Perrot, “The use of posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy” [1]. His approach uses the well-proven technique of covering the bronchial stump with a small posterior flap of pericardium, which, as stated, “has the advantage of being easy to perform and requiring limited time and dissection.” My question to the author is why does he limit this approach to extrapleural pneumonectomies; especially, why only on the right side? The maneuver of bronchial coverage with the posterior pericardial flap could be performed in the course of intrapleural pneumonectomies as well and on the left side, even more easily than on the right [2] (Fig 1). Full-Text PDF
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