Adult Chest Surgery

Chapter 81. Bronchoplasty 

Although bronchoplasty for malignant lung lesions is common, bronchoplasty for benign lung lesions is relatively rare. In most instances, these lesions are published as individual case reports, and various approaches and procedures have been performed. In this chapter, selected case reports of bronchoplasty for benign lung lesions are used to illustrate each disease entity. We begin with a description of the endobronchial Watanabe spigot, a newly developed instrument that is used to occlude the bronchus. Specific entities discussed in this chapter include bronchoplasty for tracheobronchomalacia, tuberculous bronchial lesions, endobronchial benign tumors, endobronchial inflammatory polyps, bronchial stenosis after bronchial anastomosis, and bronchial disruption.

TRACHEOBRONCHOMALACIA

Tracheobronchomalacia is characterized by weakness of the tracheobronchial wall and supporting cartilage. Collapsing airways owing to tracheobronchomalacia have been stabilized with a variety of external splints; for example, autologous rib and various types of prostheses have been used. A new technique in which a ringed polytetrafluoroethylene (PTFE) graft splint was placed for serious tracheobronchomalacia has been reported.The patient was 55-year-old man with grade 3 tracheobronchomalacia (Johnson's classification).Chest CT scan showed a crescent deformity of the trachea (Fig. 81-1A ). Bronchoscopy revealed crescent-type stenosis (see Fig. 81-1B ). Matsuoka and colleaguescut the 12-mm-diameter ringed PTFE graft to a length of 2.5 cm (Fig. 81-2A ). The prosthesis was divided longitudinally and spread. The rings were cut at various points to fit the membranous portion of the trachea and bronchi (see Fig. 81-2B ), after which the prosthesis was sutured to the cartilage and membranous portion with 4–0 PDS-II sutures (see Fig. 81-2C ). This process was repeated from the trachea to the bilateral bronchi. The patient's symptoms were markedly improved after surgery. Postoperative chest CT scan showed that the caliber of the trachea was well preserved (Fig. 81-3).

Figure 81-1.

 
 

A. Chest CT scan revealed a crescent deformity of the trachea. (Used with permission from Matsuoka H, Nishio W, Sakamoto T, et al: Use of span plasty with ringed PTFE for serious tracheobronchomalacia. Jpn J Chest Surg 16:602, 2002.)B. Bronchofiberscopic findings revealing a slitlike stenosis of crescent type. (Used with permission from Matsuoka H, Nishio W, Sakamoto T, et al: Use of span plasty with ringed PTFE for serious tracheobronchomalacia. Jpn J Chest Surg 16:602, 2002.)

 

Figure 81-2.

 

A. A ringed PTFE with a diameter of 12 mm is cut to a length of 2.5 cm. B. After dividing the prosthesis longitudinally, it is spread. The rings are cut in various portions to fit the membranous portion of the trachea and bronchi. C. The reinforcement is first sutured to the edge of the cartilaginous rings with 4-0 PDS-II. It is then sutured in a similar fashion at the proximal, distal, and central points of the membranous portion.

 

Figure 81-3.

 

Postoperatively, the caliber of the trachea was well preserved. (Used with permission from Matsuoka H, Nishio W, Sakamoto T, et al: Use of span plasty with ringed PTFE for serious tracheobronchomalacia. Jpn J Chest Surg 16:602, 2002.)

TUBERCULOUS BRONCHIAL LESION

Endobronchial tuberculosis is often associated with significant tracheobronchial stenosis. The incidence of strictures in females is remarkably higher than in males.3,4 The left main bronchus is affected most often.3,4 If the stricture is an active tuberculous lesion and the patient has symptoms owing to the stenosis, antituberculosis medication should be given, and laser ablation, balloon dilation, and/or stenting should be performed.3–5 Surgical bronchoplasty is indicated for nonactive tuberculous lesions with symptoms and/or repeated infections.3–5 Case reports of sleeve resection of the left main bronchus, sleeve left upper lobectomy, balloon dilation, and Dumon stent placement have been published.6–8

Sleeve Resection of Left Main Bronchus

A 31-year-old woman came to the hospital with left chest pain and dyspnea after medication therapy for pulmonary tuberculosis.Chest x-ray showed atelectasis of the left lower lobe and mediastinal deviation to the left (Fig. 81-4). Bronchoscopy revealed a cicatricial obstruction of the left main bronchial orifice. By MRI, it was concluded that the left upper lobe and lower lobe bronchi were patent. Sleeve resection of the left mainstem bronchus was performed from the carina to the left second carina. The anastomosis was done by interrupted 4–0 absorbable suture, and it was reinforced by two mattress stitches of 4–0 nonabsorbable suture. Virtual CT endoscopy showed no anastomotic stenosis 1 year and 9 months after the operation (Fig. 81-5).

Figure 81-4.

 
 

Chest x-ray showed atelectasis of the left lower lobe and mediastinal deviation to the left. (Adapted with permission from Hoshi E, Aoyama K, Murai K, et al: A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion. Kyobu Geka 52:152, 1999.)B. Bronchoscopy revealed cicatricial obstruction of the left main stem bronchial orifice (arrow). (Adapted with permission from Hoshi E, Aoyama K, Murai K, et al: A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion. Kyobu Geka 52:152, 1999.)

 

Figure 81-5.

 

Virtual CT endoscopy showed no anastomotic stenosis 1 year and 9 months after the operation. (Adapted with permission from Hoshi E, Aoyama K, Murai K, et al: A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion. Kyobu Geka 52:152, 1999.)

Sleeve Left Upper Lobectomy

A 33-year-old man presented with a past medical history of pulmonary tuberculosis.He developed left pneumonia, and chest X-ray showed left atelectasis (Fig. 81-6). Stenosis of the left mainstem bronchus could be seen at bronchoscopy, and balloon dilation was performed twice. However, stenosis and pneumonia recurred frequently. Therefore, he was admitted for surgery. Chest x-ray showed patchy and granular shadows owing to the repeated pneumonia. Chest tomogram showed a 15-mm obstruction of the left mainstem bronchus, and the left upper lobe bronchus was not seen. Stenosis of the left mainstem bronchus was clearly observed by three-dimensional CT scan (Fig. 81-7). Bronchoscopy revealed occlusion of the left mainstem bronchus two rings from the carina At the fourth intercostal thoracotomy, the left upper lobe was found to be damaged by the tuberculosis. Therefore, a left upper sleeve lobectomy was performed. The total left mainstem bronchus was resected, and the carina and the left lower lobe bronchus were anastomosed with 4–0 PDS interrupted sutures. Postoperative bronchoscopy revealed an excellent anastomosis.

Figure 81-6.

 
 
 

A. Chest x-ray showed left atelectasis. B. Chest x-ray showed patchy and granular shadows owing to the repeated pneumonia. C. Chest tomogram revealed a 15-mm obstruction of the left mainstem bronchus (arrow), and the left upper lobe bronchus was not seen. (Adapted with permission from Toyama K, Tsubota N, Yoshimura Y, et al: Sleeve lobectomy for tuberculous bronchial stenosis: A case report. Kyobu Geka 50:1140, 1997.)

 

Figure 81-7.

 
 
 

A. Three-dimensional CT scan revealed the left main stem bronchial stenosis (arrow). B. Bronchoscopy revealed occlusion of the left mainstem bronchus two rings from the carina. C. Postoperative bronchoscopy revealed excellent anastomosis. (Adapted with permission from Toyama K, Tsubota N, Yoshimura Y, et al: Sleeve lobectomy for tuberculous bronchial stenosis: A case report. Kyobu Geka 50:1140, 1997.)

Balloon Dilation and Dumon Stent

Kobayashi and colleaguesreported that balloon dilation alone for tuberculous bronchial stenosis resulted in dilation failure and recommended implantation of a Dumon stent instead. Figure 81-8A illustrates severe stenosis of the left mainstem bronchus before balloon dilation. Nine months after the seventh balloon dilation, the stenosis still remained. Figure 81-8C shows the condition of the left mainstem bronchus 6 months after the placement of 10-mm-diameter Dumon stent (Novatech, Grasse, France). Because granulation formation was seen at the distal edge of the stent, it was removed. Nineteen months after stent removal, the granulation disappeared completely, and the lumen was reestablished without further need for dilations.

Figure 81-8.

 
 
 
 

A. Bronchoscopy showed severe stenosis of the left mainstem bronchus (arrow) before balloon dilation. B. The stenosis of the left mainstem bronchus still remained 9 months after the seventh balloon dilation. C.Bronchoscopy showed the Dumon stent, which was placed in the left mainstem bronchus 6 months ago. The distal edge of the stent became stenotic owing to granulation tissue. D. The granulation tissue regressed 19 months after the stent removal. (Adapted with permission from Kobayashi M, Matsui K, Masuda N, et al: Treatment of tuberculous bronchial stenosis. JJSRE23:381, 2001.)

ENDOBRONCHIAL BENIGN TUMOR

Benign tumors of the airways are much less common than those with malignant potential. In particular, benign endobronchial tumors are extremely rare. Benign neoplasms may cause serious or fatal conditions as a consequence of airway obstruction and therefore cannot be left untreated. Less invasive treatment modalities should be chosen, and these tumors generally are removed by bronchoscopy or by bronchoplasty. Resection of the lung parenchyma usually can be avoided. In this section, cases of endobronchial mucous gland adenoma, lipoma, and hamartoma are reported.

Endobronchial Mucous Gland Adenoma

Bronchial mucous gland adenoma is a rare disease that arises from bronchial glands of the mucous type. A 77-year-old man presented with bloody sputum and cough.Chest tomogram (Fig. 81-9A ) and CT scan (Fig. 81-9B ) showed a tumor in the left mainstem bronchus. Bronchoscopy revealed a polypoid tumor in the left mainstem bronchus. The diagnosis of mucous gland adenoma was made by biopsy. Circumferential resection of the left mainstem bronchus was performed, and the tumor was removed. The anastomosis was made by interrupted 3–0 absorbable suture. The tumor was diagnosed histologically as bronchial mucous gland adenoma.

Figure 81-9.

 
 
 
 

A. Chest tomogram showed the tumor in the left mainstem bronchus (arrow). B. CT scan showed the tumor in the left mainstem bronchus (arrow). C. Macroscopic findings of the resected bronchus and tumor. D.Microscopic findings of the tumor. The tumor is diagnosed histologically as bronchial mucous gland adenoma. (Used with permission from Okabe K, Aoe M, Nakata M, et al: A case of bronchial mucous gland adenoma with cancer in adenoma. JJSRE13:82, 1991.)

Endobronchial Lipoma

Bronchial lipoma is rare and makes up approximately 0.1% of all pulmonary tumors.10 A 72-year-old man was found by bronchoscopy to have an endobronchial lipoma in the bronchus of the lingula accompanied by squamous cell carcinoma in the lower lobe bronchus.11 Figure 81-10A shows a yellowish polypoid tumor with smooth surface at the orifice of the bronchus of the lingula. A left lower lobectomy was done for the squamous cell carcinoma. Sleeve resection of the bronchus of the lingula with telescoping bronchial anastomosis was performed for the lipoma. The length of the resected bronchus was 10 mm from the bifurcation of the upper and lingual division. Histologic examination showed mature adipose tissue diagnosed as a benign endobronchial lipoma.

Figure 81-10.

 
 

A. A bronchoscopic examination revealed a yellowish polypoid tumor with a smooth surface at the orifice of the bronchus of the lingula. B. Histologic examination showing mature adipose tissue diagnosed as a benign endobronchial lipoma. (Adapted with permission from Kamiyoshihara M, Sakata K, Otani Y, et al: Endobronchial lipoma accompanied with primary lung cancer. Surg Today 32:402, 2002.)

Endobronchial Hamartoma

Although hamartoma is the most common form of benign lung tumor, endobronchial hamartoma is rare, and only 1.4% of hamartomas are located in the bronchus.12 A 46-year-old man was admitted to the hospital with fever and productive cough.13 Chest x-ray and CT scan (Fig. 81-11A ) showed partial atelectasis of the left lung. A 20 x 17 mm mass in the left mainstem bronchus was observed by CT scan. Bronchoscopy demonstrated complete obstruction of the left mainstem bronchus by a hard tumor with a smooth surface. The tumor was too hard to get a good biopsy specimen for definitive diagnosis. By thoracotomy and bronchotomy, the tumor, which obstructed the left upper lobe bronchus and left mainstem bronchus, was removed partially to preserve the left upper lobe. The remainder was resected completely by transbronchial electrosurgery snare and neodymium:yttrium-aluminum-garnet laser 2 weeks after the thoracotomy. The tumor was 35 x 15 x 15 mm in diameter and was diagnosed as a hamartoma. No finding of recurrence was seen by bronchoscopy for 3 years after the resection.

Figure 81-11.

 
 
 

A. CT scan of the chest revealed an endobronchial tumor (arrow) and atelectasis of the left lung. B. Bronchoscopy demonstrated complete obstruction of the left mainstem bronchus by the tumor. C. Resected specimen showing the tumor. It was elastic, hard, and 35 x 15 x 15 mm in diameter and was diagnosed as hamartoma. (Adapted with permission from Ishibashi H, Akamatsu H, Kikuchi M, et al: Resection of endobronchial hamartoma by bronchoplasty and transbronchial endoscopic surgery. Ann Thorac Surg 75:1300, 2003.)

ENDOBRONCHIAL INFLAMMATORY POLYP

Inflammatory bronchial polyp is a rare, benign, and nontumorous lesion similar to inflammatory polyps of the nasal cavities. It is composed of inflammatory granulation tissue. It can be treated bronchoscopically and/or surgically. Resection with a forceps, hot snare, and neodymium:yttrium-aluminum-garnet laser is available using a bronchoscope. A case of sleeve bronchial resection for an inflammatory polyp is reported here.14 A 60-year-old man was referred because cancer was suspected by sputum cytology. Chest CT scan (Fig. 81-12A ) revealed a polypoid lesion in the bronchus of the lingula. Bronchoscopy revealed a smooth-surfaced polypoid lesion at the lingular orifice. The biopsy revealed squamous metaplasia with moderate atypia histologically. Sleeve resection of the bronchus of the lingula was performed, and the lesion was resected. The superior bronchus and inferior bronchus of the lingular division were anastomosed, respectively, to the upper lobe bronchus by interrupted 5-0 absorbable sutures. The pathologic diagnosis of the resected specimen was inflammatory bronchial polyp.

Figure 81-12.

 
 
 
 

A. Chest CT scan on admission showed a polypoid shadow (arrow) in the bronchus of the lingula. B. The bronchoscopic findings showed a smooth-surfaced polypoid lesion in the bronchus of the lingula. C. The resected specimen showing the polypoid mass arising from the bronchus of the lingula. D. Microscopic findings of the polyp showing fibrous connective tissue covered by columnar ciliated epithelium and inflammatory infiltration of neutrophils. (Used with permission from Mizobuchi T, Iwai N, Nomoto Y, et al: A case of bronchial reconstruction for inflammatory bronchial polyp. JJSRE22:505, 2000.)

BRONCHIAL STENOSIS AFTER BRONCHIAL ANASTOMOSIS

Bronchial stenosis may occur after bronchial wedge resections, sleeve resection, or lung transplantation. Treatments include surgical resection and reanastomosis, debridement by forceps, laser resection, balloon dilation, and stent placement. A case of debridement by forceps, laser resection, and stent placement for anastomotic stenosis after right upper wedge lobectomy is reported here.15 A 71-year-old man underwent right upper wedge lobectomy for squamous cell lung cancer. The bronchial anastomosis was performed with interrupted 3–0 absorbable sutures, and it was wrapped with an intercostal muscle flap. A few weeks after the surgery, bronchoscopy revealed local infection at the anastomotic site. Necrotic tissue at the anastomotic site was removed by biopsy forceps. Methicillin-resistant Staphylococcus aureus was detected in the bronchial lavage fluid, and vancomycin was given. Six months after surgery, bronchoscopy was done because of increased breathing difficulty, and severe anastomotic stricture was found. Figure 81-13A shows the stenosis of 2 mm and inflammatory granulation tissue. Three-dimensional CT scan revealed a serious anastomotic stenosis (Fig. 81-13B ). Therefore, neodymium:yttrium-aluminum-garnet laser resection for the inflammatory granulation was performed, and a self-expanding metallic stent (Ultraflex stent, Boston Scientific, Natick, MA) was placed successfully. Figure 81-13C,D shows the placed stent and widely opened anastomosis.

Figure 81-13.

 
 
 
 

A. Bronchoscopy revealed severe stenosis and inflammatory granuloma at the anastomotic lesion. B. Chest three-dimensional CT scan revealed a severe anastomotic stenosis. C. Bronchoscopy showed the inserted stent and the improved bronchial mucosa. D. CT scan revealed good position and dilation of the inserted stent. (Adapted with permission from Inoue S, Fujino S, Sawai S, et al: Experience with self-expanding metallic stents (SEMS, Ultraflex stent) for postoperative bronchial stenosis. JJSRE23:454, 2001.)

BRONCHIAL DISRUPTION

Bronchial disruption secondary to blunt trauma is unusual. The prognosis is poor, and greater than half the patients die before arriving at a hospital.16 It is important to suspect the condition by clinical and radiographic findings. Early bronchoscopy is strongly recommended to get a definitive diagnosis. More than 80% of tracheobronchial disruptions are within 2.5 cm of the carina.16 If bronchial disruption is found, immediate surgical repair should be performed. A case of complete transection of the left mainstem bronchus owing to blunt chest trauma is reported here.11,17 A 62-year-old man was hit by a car and brought to an emergency center. Severe subcutaneous emphysema was present in the neck and chest. Breath sounds were reduced in the left chest. Chest x-ray (Fig. 81-14) after bilateral chest tube placements showed bilateral pneumothoraces, subcutaneous emphysema, pneumomediastinum, multiple rib fractures, and tracheal shift to the right. Chest CT scan (Fig. 81-15) revealed bilateral lung contusion in addition to the chest x-ray findings. Because of a massive air leak from the left chest tube, bronchoscopy was done. It demonstrated complete transection of the left mainstem bronchus at two rings from the carina. Emergency thoracotomy was performed, and an end-to-end anastomosis was carried out with interrupted 4–0 absorbable sutures. The anastomosis was wrapped with a fifth intercostal muscle flap.

Figure 81-14.

 

Chest x-ray after bilateral chest tube placements showed bilateral pneumothoraces, subcutaneous emphysema, pneumomediastinum, multiple rib fractures, and tracheal shift to the right. (Adapted with permission from Kamiyoshihara M, Ishikawa S, Ihara N, et al: Complete transection of the left main bronchus due to a blunt chest trauma: Report of a case. Kyobu Geka 54:603, 2001.)

 

Figure 81-15.

 

Chest CT scan revealed bilateral lung contusions in addition to the chest x-ray findings. (Adapted with permission from Kamiyoshihara M, Ishikawa S, Ihara N, et al: Complete transection of the left main bronchus due to a blunt chest trauma: Report of a case. Kyobu Geka 54:603, 2001.)

EDITOR'S COMMENT

Although rare, endobronchial narrowing secondary to benign disease is a vexing problem. Without treatment, the lesion may grow, resulting in an extensive lung resection down the road that could have been avoided. In general, these lesions are not managed successfully with the newer expandable stents, since they may cause significant ingrowth of granulation tissue and become permanently lodged in the airway. Other options include the old-fashioned Dumon stent or the new Watanabe spigot. When all else fails, the surgeon should be comfortable proceeding with a sleeve resection with muscle flap coverage for these problematic lesions.

–MJK

REFERENCES

1. Matsuoka H, Nishio W, Sakamoto T: Use of span plasty with ringed PTFE for serious tracheobronchomalacia. Jpn J Chest Surg 16:692, 2002. 

2. Johnson T, Mikita J, Wilson R: Acquired tracheomalacia. Radiology 109:577, 1973. 

3. Kawamura M, Watanabe M, Kobayashi K: Surgical treatment for tuberculous tracheobronchial stenosis. Kekkaku 74:891, 1999. [PubMed: 10655696]

4. Nakajima Y, Shiraishi Y: Surgical treatment and endobronchial stent placement for tuberculous tracheobronchial strictures. Kekkaku 74:897, 1999. [PubMed: 10655697]

5. Yamamoto H, Kanzaki M, Obara T: Treatment for tuberculous bronchial stricture. JJSRE 23:375, 2001. 

6. Hoshi E, Aoyama K, Murai K: A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion. Kyobu Geka 52:152, 1999. [PubMed: 10036878]

7. Toyama K, Tsubota N, Yoshimura Y: Sleeve lobectomy for tuberculous bronchial stenosis: A case report. Kyobu Geka 50:1140, 1997. [PubMed: 9404118]

8. Kobayashi M, Matsui K, Masuda N: Treatment of tuberculous bronchial stenosis. JJSRE 23:381, 2001. 

9. Okabe K, Aoe M, Nakata M: A case of bronchial mucous gland adenoma with cancer in adenoma. JJSRE 13:82, 1991. 

10. Schraufnagel D, Morin J, Wang N: Endobronchial lipoma. Chest 75:97, 1979. [PubMed: 421539]

11. Kamiyoshihara M, Sakata K, Otani Y: Endobronchial lipoma accompanied with primary lung cancer. Surg Today 32:402, 2002. [PubMed: 12061688]

12. Gjevre J, Myers J, Prakash U: Pulmonary hamartomas. Mayo Clin Proc 71:14, 1996. [PubMed: 8538225]

13. Ishibashi H, Akamatsu H, Kikuchi M: Resection of endobronchial hamartoma by bronchoplasty and transbronchial endoscopic surgery. Ann Thorac Surg 75:1300, 2003. [PubMed: 12683579]

14. Mizobuchi T, Iwai N, Nomoto Y: A case of bronchial reconstruction for inflammatory bronchial polyp. JJSRE 22:505, 2000. 

15. Inoue S, Fujino S, Sawai S: Experience with self-expanding metallic stents (SEMS, Ultraflex Stent) for postoperative bronchial stenosis. JJSRE 23:454, 2001. 

16. Mills S, Johnston F, Hudspeth A: Clinical spectrum of blunt tracheobronchial disruption illustrated by seven cases. J Thorac Cardiovasc Surg 84:49, 1982. [PubMed: 7087541]

17. Kamiyoshihara M, Ishikawa S, Ihara N: Complete transection of the left main bronchus due to a blunt chest trauma: Report of a case. Kyobu Geka 54:603, 2001. [PubMed: 11452534]



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