Adult Chest Surgery

Chapter 83. Surgery for Bronchiectasis 

Bronchiectasis is a considerable cause of respiratory illness (Fig. 83-1). It is defined by the permanent dilatation of the bronchi1 and caused by a recurrent process of transmural infection and inflammation. Repeated pulmonary infections, a progressive decline in respiratory function despite prolonged antibiotic treatment, and occasional life-threatening hemoptysis are typical once the disease is entrenched. Patients with either focal or diffuse patterns of bronchiectasis may be eligible for surgical intervention; the diffuse form of the disease is best treated with bilateral lung transplantation and will not be discussed extensively in this chapter.

Figure 83-1.

 

The three basic forms of bronchiectasis are depicted. Cylindrical or tubular bronchiectasis gives rise to tapered airways. Varicose bronchiectasis is characterized by areas of dilatation and narrowing. Saccular or cystic bronchiectasis causes progressively dilated airways that end in saclike cystic structures that resemble clusters of grapes.

GENERAL PRINCIPLES AND PATIENT SELECTION

The disease process is characterized by the pathologic or radiographic appearance of the airways. Cylindrical or tubular bronchiectasis results in dilated, slightly tapered airways. Varicose bronchiectasis (Fig. 83-2) resembles the chronic venous state of the same name, with areas of dilatation and narrowing. Saccular or cystic bronchiectasis is characterized by progressive dilatation of the airways that can end in saclike cystic structures that resemble a cluster of grapes (Fig. 83-3). The cylindrical narrowing is often seen with tuberculosis infections, whereas the saccular or cystic type is more common after obstruction or bacterial infection. Thick mucoid secretions are often seen pooled in the dilated airways and cause a chronic inflammatory state involving the airway walls. The lung parenchyma distal to the dilated, ectatic airways is often damaged as well, with fibrosis and emphysematous changes present. The accompanying bronchial arteries and lymph nodes also may be engorged and hypertrophied. The usual area of involvement is the left lower lobe, followed by the lingula and right middle lobe.

Figure 83-2.

 

CT appearance of varicose bronchiectasis.

 

Figure 83-3.

 

CT appearance of saccular or cystic bronchiectasis. Note the saclike cystic structures that resemble a cluster of grapes.

A number of congenital and acquired diseases lead to the development of bronchiectasis. The common pathway for each of these disorders is recurrent transmural infection of the bronchial wall. Bacterial infections, particularly those involving potentially necrotizing agents such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, and various anaerobes, remain important causes of bronchiectasis, particularly when there is a delay in treatment or other factors that prevent eradication of the infection. Bronchiectasis in patients with allergic bronchopulmonary aspergillosis is caused by an immune reaction to the fungal organ, with production of inflammatory mediators and subsequent direct airway invasion by the fungus. Viral infections can lead to bronchiectatic airways both through direct infection and through a reduction in host defenses. This latter theme is common when considering the pathophysiology of bronchiectasis. Primary ciliary dyskinesia and various immune deficiencies such as hypogammaglobulinemia are examples of congenital disorders where there is impairment in host defense mechanisms. Cystic fibrosis is another important cause of bronchiectasis, with predilection for the upper lobes. Occasionally, the appearance of bronchiectasis in middle age is the presenting symptom in patients with milder forms of cystic fibrosis. Several autoimmune disorders, such as rheumatoid arthritis and inflammatory bowel disease, have been linked to the presence of recurrent pulmonary infections and the development of bronchiectasis.

Both focal and diffuse forms of bronchiectasis are seen. The focal variety is often associated with an isolated abnormality causing relative or complete bronchial obstruction. An aspirated foreign body, a slowly growing tumor, and broncholith are examples. Rarely, bronchial compression (as seen with middle lobe syndrome) or angulation of the bronchus (after surgical lobectomy) produces obstruction leading to recurrent infection and the development of localized disease. The process of infection, bronchial inflammation and dilatation, and parenchymal scarring tends to be self-renewing once established, leading to further damage. Bronchiectasis arising from postinfectious causes is more likely to be localized, whereas disease owing to congenital deficiencies is more likely to be diffuse.

Therapy for bronchiectasis involves treatment of the underlying disorder (if possible), suppression of the bacterial load through appropriate use of antibiotics, encouragement of proper pulmonary hygiene (including the routine use of bronchodilators, mucolytic agents, and postural drainage), and surgery in selected patients. The role of surgery is threefold. First, patients with focal areas of disease that cause unremitting symptoms, associated with localized lung parenchymal destruction, are candidates for resection therapy, usually by means of segmentectomy or lobectomy. Second, the rare patient who presents with massive hemoptysis should be considered for surgical therapy if less invasive maneuvers such as bronchial artery embolization are unsuccessful. Finally, some patients with end-stage bronchiectasis may be candidates for lung transplantation. As with other patients with end-stage suppurative lung disease, sequential double-lung transplantation is indicated to avoid contamination of the new lung grafts.

Several features or characteristics make a patient with focal bronchiectasis an ideal candidate for resectional therapy. First, the disease should be truly localized and amenable to anatomic lung resection. Nonanatomic or wedge resections should be avoided because they leave behind more proximal dilated bronchi with pooled secretions that, over time, serve to further contaminate adjacent lung parenchyma. Second, adequate pulmonary reserve for the planned resection should be present. This is usually not a major issue because the heavily diseased lung segments tend to contribute little to the patient's overall lung function. Finally, it is preferable tominimize the bacterial load present within the bronchi and lung tissue at the time of surgery with appropriate antimicrobial therapy, often initiated months in advance. This is particularly true in the setting of mycobacterial disease to minimize the risk of subsequent bronchopleural fistula formation.

PREOPERATIVE ASSESSMENT AND PREPARATION

Patients with bronchiectasis present with recurrent pulmonary infections characterized by dyspnea and an unremitting chronic cough productive of thick, tenacious purulent sputum. Hemoptysis is common and rarely can be massive when there is erosion into the enlarged bronchial vessels. Occasionally, patients with bronchiectasis will describe a nonproductive cough, indicative of upper lobe involvement. Auscultation reveals crackles, wheezes, or rhonchi in most patients.

The radiographic findings in bronchiectasis are understandably important in establishing the diagnosis. Standard radiographs are abnormal in most cases, demonstrating focal areas of consolidation, atelectasis, evidence of thickened bronchi (best noted as ring shadows when seen on end), and in advanced cases, delineation of the dilated cystic changes in the airway. Bronchography using contrast medium, once the standard for establishing the diagnosis of bronchiectasis, has been replaced by CT scanning as the diagnostic procedure of choice. CT scanning, particularly high-resolution imaging, is more sensitive and specific for the diagnosis of bronchiectasis. Evidence of airway dilatation, changes consistent with saccules or varicosities of the airway, and lack of airway tapering toward the periphery are all consistent with bronchiectasis. Evidence of cavitary disease also may be seen. The severity of bronchial wall thickening on CT scan has been linked to the degree of lung impairment and subsequent functional decline.2,3 Upper lobe involvement suggests the diagnosis of cystic fibrosis or allergic bronchopulmonary aspergillosis. Middle lobe and lingular disease is more typical of nontuberculous (environmental) mycobacterial infection such as Mycobacterial avium complex, and lower lobe predominance suggests bacterial involvement.

As mentioned earlier, initiation of targeted antimicrobial therapy before the planned surgical date is crucial to the success of the procedure. This is particularly true in the setting of mycobacterial disease, such as M. tuberculosis and the various environmental mycobacterial species now more common in the United States. For example, patients at our institution with focal bronchiectasis and M. avium complex infection typically are started on a three-or four-drug regimen for 2–3 months before surgery based on in vitro susceptibility testing of the isolated organism. The regimen is continued through the hospital stay and for several months thereafter, often to a total of 24 months.4 The preoperative antibiotic treatment, of course, will vary considerably depending on the offending organisms; routine bacterial pathogens do not require the preoperative treatment duration typical in mycobacterial disease. It is important in most cases to reimage the patient before surgery because effective antimicrobial therapy may improve areas of parenchymal and cavitary disease, particularly in those with normal (non cystic fibrosis) genotypes.5

Most patients with chronic suppurative disease of the lungs are malnourished, often to a considerable degree, as a result of the long-standing catabolic state these patients experience. If malnutrition is present, an aggressive preoperative regimen of nutritional supplementation is advised. In many cases, nutritional augmentation may require use of a nasojejunal feeding tube or a percutaneous gastrostomy. In our experience, preoperative improvement in nutritional status in these debilitated patients may lessen the morbidity of the subsequent procedure.6

SURGICAL TECHNIQUE

Anesthesia

A standard anesthetic technique typical for thoracic surgical procedures is used. Single-lung ventilation is achieved with placement of a double-lumen tube. A thoracic epidural catheter is employed when an open (thoracotomy) approach is planned based on the extent of resection and if muscle or omental transposition is anticipated. In patients in whom a thoracoscopic lobectomy or segmentectomy is performed, the epidural is omitted. An arterial line and urinary catheter are placed. Fluid administration is limited, as with other forms of major lung resection. Extubation at the end of the operation is planned.

Bronchoscopy

Preoperative bronchoscopic examination of the airway is essential. Bronchial obstruction owing to tumor or an aspirated foreign body should be ruled out. If severe inflammation of the airway mucosa is found, it may be best to defer definitive resection until better infection control is obtained. Finally, normal variations in bronchial anatomy make preoperative bronchoscopy by the surgeon advisable, particularly if a segmental resection is planned.

Surgical Approach

Most major lung resections for bronchiectasis (e.g., lobectomy or segmentectomy) are amenable to a video-assisted thoracoscopic (VATS) approach. A standard VATS technique is used, with two 10-mm ports and a 5-cm utility incision based over a rib space in the anterior axillary line (Fig. 83-4). No rib spreading is used. Typically, the initial two ports are placed—one in the seventh intercostal space, anterior axillary line, and the other just posterior to the scapular tip—and the safety and feasibility of a VATS approach are confirmed. The utility incision then can be made, centered over an interspace (usually fourth or fifth) to allow easy access to the area of dissection. The serratus muscle fibers are separated along the axis of the utility incision. The exact placement of the ports and the utility incision depends in part on the planned resection.

Figure 83-4.

 

Target port placement for a standard VATS approach. Initially, two 10-mm ports are placed, one in the seventh intercostal space along the anterior axillary line and the second posterior to the scapular tip. A 5-cm utility incision is placed over the area of dissection, which is usually at the fourth or fifth interspace.

For patients in whom extensive extrapleural dissection is needed, or if muscle transposition is planned, an open approach is used. A lateral thoracotomy affords excellent exposure to all planned resections, with the possible exception of completion pneumonectomy, where a posterolateral incision is preferred. If possible, the latissimus dorsi and serratus muscles should be spared for possible transposition later, if needed.

Extent of Resection

After access is achieved, the anatomic resection is completed in a standard fashion, with individual ligation of the vessels and bronchus to the target lobe or segment. The resection technique is the same whether the approach is VATS or open, although stapling devices are usually mandatory when a VATS approach is used. Situations in which there is concern regarding the bronchial closure, particularly pneumonectomy, may suggest the need for an open approach to facilitate a tailored suture closure of the bronchus and tissue transposition. The diseased segment or lobe often has considerable pleural adhesions that are lysed with cautery, taking care to avoid the usually adjacent phrenic nerve (Fig. 83-5). There is usually considerable bronchial artery hypertrophy and lymphadenopathy surrounding the involved pulmonary hilum, consistent with the chronic infectious state. It is important to achieve complete resection of the diseased bronchi and associated lung tissue, if possible. We prefer in these patients to divide the lung parenchyma (e.g., along the fissures), erring on the side of the uninvolved lobe and thus ensuring complete removal of diseased tissue. An Endocatch bag (Autosuture, Norwalk, CT) or similar device is used to retrieve the specimen through the utility incision if VATS is used. As with resections for lung cancer, this latter technique is imperative; certain nontuberculous mycobacterial organisms such as M. abscessus can cause devastating chest wall infections if a careless method is adopted.

Figure 83-5.

 

Dense pleural adhesions are lysed to facilitate bronchial closure during an open pneumonectomy, with care to avoid the phrenic nerve.

Once the specimen is removed from the field, it is divided on the back table for appropriate cultures to guide subsequent antimicrobial therapy. We typically "double culture" specimens at two different laboratories to minimize sampling or contamination error. The intrathoracic space typically is drained with one or two 28F thoracostomy tubes.

Use of Tissue Flaps

Tissue transposition is indicated if there is risk of potential breakdown of the bronchial stump or when a significant intrathoracic "space" is present after resection. Postoperative bronchopleural fistulas (BPFs) are more common in the setting of certain poorly controlled infections, such as multi-drug-resistant M. tuberculosis, or after certain resections, such as right pneumonectomy. We favor use of either a latissimus dorsi or intercostal muscle flap for bronchial stump coverage in routine circumstances and use of omentum after pneumonectomy, particularly after a right-sided resection.6 Use of the serratus anterior muscle is often problematic because of winged scapula-related problems of wound healing and skin necrosis in these chronically malnourished patients. Mobilization of the latissimus dorsi muscle is completed at the initiation of the procedure, and the muscle is transposed into the chest through the second or third intercostal space after resection. The omentum is mobilized before thoracotomy through a limited midline abdominal incision, based on the right gastroepiploic artery and vein, and tacked to the undersurface of the right hemidiaphragm for retrieval later after lung resection.

The presence of a significant intrathoracic "space" appears to be more common after major lung resection for infectious lung disease such as bronchiectasis compared with other indications for surgery. The use of transposed muscle such as latissimus dorsi minimizes the potential complications in this setting, including postresection empyema or prolonged air leak.

POSTOPERATIVE MANAGEMENT

With few exceptions, patient management after lung resection for bronchiectasis is routine. Appropriate antimicrobial coverage is continued in the postoperative period and often for several months afterwards, as described earlier, depending on the isolated organisms. Special emphasis is placed on pulmonary toilet, chest physiotherapy, early postoperative mobilization, and nutritional supplementation. In patients in whom focal areas of bronchiectasis remain (e.g., on the contralateral side in staged resections), postoperative bronchoscopy may be needed to aid secretion clearance. Chest tube management is typical of other indications for lung resection. Most patients after VATS resection are ready for discharge by the second or third postoperative day, whereas patients undergoing more extensive resections by means of open thoracotomy may require hospitalization for 5–7 days.

COMPLICATIONS

Bronchopleural Fistula

In our practice, development of BPF after segmental or lobar resection is rare. It remains a considerable source of morbidity after pneumonectomy, particularly after right or completion pneumonectomy or in the setting of persistently smear-positive patients with organisms such as multi-drug-resistant M. tuberculosis. In these patients, prevention is the key: Appropriate antimicrobial coverage before surgery, a tailored handsewn bronchial closure, and use of muscle or (preferably) omental coverage of the bronchial stump may avoid this disastrous complication.

When it occurs, a BPF will present in a manner similar to those seen after lung resection for other indications. Fever, cough productive of serous followed by purulent sputum, contralateral lung infiltrates, and a dropping air-fluid level on chest radiograph are typical findings. Drainage of the infected space is a key initial step to limit damage to the remaining lung. BPFs noted very early after the initial resection may be treated with primary reclosure and rebuttressing of the stump; later BPFs usually require rib resection and creation of an Eloesser flap, followed by BPF closure (usually with omental transposition, if not used previously) and subsequent Clagett procedure, for successful treatment (see Chap. 72).

Space Problems and Empyema

As mentioned previously, space problems are somewhat more common after lung resection for infectious lung disease than after resection for lung carcinoma. This is due to the relative inability of the remaining lung to fully expand to minimize the residual space, perhaps because of chronic granulomatous changes in the other lobes. In most cases, the space is well tolerated and does not cause problems if the residual lung is fully expanded. However, in difficult resections in which significant pleural soilage or parenchymal injury is observed, the space may lead to a prolonged air leak or, worse, an empyema. Again, prevention is the key: Significant space problems should be anticipated, with liberal use of muscle flaps or a pleural tent to minimize postoperative complications.

RESULTS

Recent studies of resectional therapy for bronchiectasis have been encouraging, with reported operative mortality rates of 0–2.2%.7–13 Mortality after completion pneumonectomy, however, continues to be formidable.6,7Failure of medical therapy (recurrent infections despite repeated courses of antibiotics) is the predominant indication for surgical intervention, with only a small percentage of patients presenting with significant hemoptysis or lung abscess. A minority of patients had bilateral disease. All authors stressed the importance of localized disease, early surgical referral and intervention, and complete resection as the keys to successful surgical therapy.

SUMMARY

Surgical treatment of bronchiectasis is usually successful and can be accomplished with minimal morbidity or mortality. Keys to successful surgical intervention are (1) presence of localized disease, (2) relatively early intervention to minimize development of resistant organisms and soilage of adjacent lung segments, (3) successful identification of the predominant organisms involved, with targeted antimicrobial therapy based on in vitro sensitivities initiated prior to surgery and continued postoperatively, (4) assessment of preoperative nutritional status and nutritional supplementation where indicated, (5) complete resection of the involved segments of lung containing bronchiectatic airway, and (6) anticipation of potential complications and alteration of the operative plan to minimize subsequent morbidity.

CASE HISTORY

A 62-year-old-woman with a long history of pulmonary infections, bronchiectasis, and mycobacterial superinfection was referred for further evaluation and treatment. Previous sputum cultures had yielded M. avium complex and M. abscessus. At the time of her initial M. avium complex diagnosis, she had been treated with a three-drug regimen (i.e., clarithromycin, ethambutol, and ciprofloxacin) for 18 months. At the time of presentation, she complained of chronic fatigue and dyspnea on exertion and a variably productive cough. Her past medical history included a remote diagnosis of asthma and prior augmentation mammoplasty. Born in New York, she resided for the past decade in Florida. She was a nonsmoker, had no pets, and did not have either a hot tub or a pool. Her family history was notable for a sister also with bronchiectasis and M. avium complex infection, who died of respiratory complications the year before.

Sputum cultures obtained at presentation grew M. abscessus. Thin-cut CT scan of the chest demonstrated partial atelectasis and coarse bronchiectasis of the right middle lobe and lingula (Fig. 83-6). Her pulmonary function tests revealed an FEV1 of 77% and an FVC of 86% of predicted. Her DLCO was preserved. Her room-air oxygen saturation was 95%. Although the patient was thin, initial studies did not suggest malnutrition.

Figure 83-6.

 

Patient with family history of bronchiectasis with culture positive for M. abscessus. Thin-cut CT scan of the chest demonstrates partial atelectasis and coarse bronchiectasis of the right middle lobe and lingula.

The patient was placed on a three-drug outpatient regimen based on in vitro drug sensitivities, which was intensified with the addition of intravenous amikacin 2 weeks before surgery. She underwent an uncomplicated VATS lingulectomy, with discharge on the third postoperative day. Six weeks later, she was readmitted and underwent VATS right middle lobectomy. Her antibiotics were continued through both hospitalizations. Both surgical specimens demonstrated severe bronchiectasis and chronic granulomatous inflammation consistent with her history of environmental mycobacterial disease. Her antimicrobial coverage was adjusted based on intraoperative cultures obtained at both procedures and was maintained for 18 additional months. She remains alive and well and is essentially asymptomatic with respect to her pulmonary disease.

EDITOR'S COMMENT

Bronchiectasis is becoming a rare disease, but one that is still causing significant morbidity. The authors describe a modern approach to the diagnosis of bronchiectasis. Again, a lung-sparing procedure, especially using VATS, is the preferred operative technique. For larger more central lesions, use of muscle flaps with concomitant resection is helpful. Patients with bronchiectasis should not be considered candidates for lung volume reduction surgery.

–MJK

REFERENCES

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4. Iseman MD: Medical management of pulmonary disease caused by Mycobacterium avium complex. Clin Chest Med 23:633–41, 2002.[PubMed: 12370999]

5. Kim JS, Tanaka N, Newell JD, et al: Nontuberculous mycobacterial infection: CT scan findings, genotype, and treatment responsiveness. Chest 128:3863–9, 2005.[PubMed: 16354855]

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7. Agasthian T, Deschamps C, Trastek VF, et al: Surgical management of bronchiectasis. Ann Thorac Surg 62:976–8; discussion 979–80, 1996. 

8. Balkanli K, Genc O, Dakak M, et al: Surgical management of bronchiectasis: Analysis and short-term results in 238 patients. Eur J Cardiothorac Surg 24:699–702, 2003.[PubMed: 14583301]

9. Fujimoto T, Hillejan L, Stamatis G: Current strategy for surgical management of bronchiectasis. Ann Thorac Surg 72:1711–5, 2001.[PubMed: 11722069]

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