Advanced therapy in thoracic surgery - part 5 pdf

220 / Advanced Therapy in Thoracic Surgery steriods Tracheostomies may be useful in some patients as the only way to secure an airway When possible, they should be placed through the stenosis, preserving the uninvolved trachea for future reconstruction Anesthesia An experienced anesthesiology team working in close cooperation with the surgical team is essential Replacement of spontaneous breathing with positive pressure ventilation can convert a partially obstructing lesion into a complete obstruction When maintenance of the airway is a concern, a breathe down with an inhalation agent is employed and paralytics given once the airway is secured.20 Anesthesia is maintained with total intravenous anesthesia (TIVA) using short-acting agents such as remifentanil and propofol This allows immediate extubation at the completion of the procedure and maintains continuous anesthesia during periods when inhalational agents are interrupted by the procedure When a thoracotomy incision is used, epidural anesthesia significantly decreases thoracotomy pain For lower tracheal and carinal resections, endotracheal intubation is accomplished with an extra-long, armored endotracheal tube Its flexibility allows bronchoscopic placement into one of the main stem bronchi After transecting the airway, the orotracheal tube is pulled back into the trachea and intermittent ventilation is performed with sterile crossfield equipment The orotracheal tube is again advanced once the anastomosis is completed The anesthesiology team should be familiar with the techniques of highfrequency “jet” ventilation Cardiopulmonary bypass is not helpful and only introduces unnecessary risks Simple Tracheal Resection This section describes our technique for uncomplicated resections of the middle and upper trachea Rigid bronchoscopy with dilation is performed at the time of planned resection, and if the lesion appears amenable to surgery, the patient is intubated, positioned, and prepared for incision For most relatively short lesions, the patient is placed supine with an inflatable airbag beneath the shoulders with the neck extended The inflatable bag is important in alleviating tension since it can be deflated to facilitate neck flexion just prior to tying down the anastomosis The head and neck are supported in a foam “doughnut.” The arms are tucked at the sides and only the neck and upper sternum are prepared and draped A low collar incision is adequate for most tracheal resections involving the upper trachea Occasionally, vertical extension with a partial sternal split is required for middle to lower tracheal lesions (Figure 17-8A) Dissection is carried through the platysma, and subplatysmal flaps are elevated superiorly to the level of the cricoid and inferiorly to the level of the sternal notch The strap muscles are separated in the midline, and a plane of dissection is established very close to the tracheal wall to avoid injury to the recurrent laryngeal nerves (Figure 17-8B) The pretracheal plane is dissected to the level of the carina The investing fascia of the innominate artery and the adjacent mediastinal fat is left intact to guard against postoperative tracheoinnominate fistulization The location and extent of the lesion may sometimes be identified by observation of changes in the tracheal wall as seen in the operative field Often, however, these changes are subtle, and the limits of the resection must be delineated by the surgeon transilluminating the trachea above and below the lesion with a flexible bronchoscope while the assistant watches the field and marks the limits of the lesion with fine sutures The trachea is sharply dissected circumferentially at the most distal extent of the lesion, with the dissection plane maintained on the tracheal wall Sterile ventilating tubing is then positioned under the ether screen and fastened to the drapes The endotracheal tube is withdrawn into the upper trachea, the trachea divided at the most distal extent of the lesion, and bilateral 2-0 Vicryl traction sutures placed such that they are anchored around a tracheal ring about cm below the distal transection site A cuffed, armored Tovell tube is promptly passed into the distal tracheal segment and attached to the sterile connecting tubing, and crosstable ventilation commenced (Figure 17-8C) The diseased segment of trachea is sharply dissected from the esophagus and transected at the most proximal extent of the lesion and passed out of the field The patient’s neck is then flexed and the anastomosis tested for tension Using the traction sutures, the proximal and distal segments can be brought towards one another When they come together without tension, the anastomosis can be created If the limits of flexion and safe dissection have been reached and anastomotic tension still exists, then one proceeds with release procedures (see below) It is simplest to anticipate the need for release procedures and perform them prior to dividing the trachea, but this is not always possible When the surgeon is satisfied that the anastomosis will not be under tension, interrupted 4-0 Vicryl anastomotic sutures are placed (but not tied) such that the knots will be on the outside, beginning posteriorly in the midline and proceeding around either side to the front (Figure 17-8D) The sutures are placed to mm from the cut edge of the trachea and mm apart They should encircle a tracheal ring on either side of the anastomosis to help prevent dehiscence Frequently, the Tovell tube 222 / Advanced Therapy in Thoracic Surgery strap muscles In situations where postoperative intubation is thought to be necessary, a small uncuffed endotracheal tube is left in place initially and a stitch placed on the trachea to mark the site for tracheostomy should it become necessary This allows limited dissection and accurate placement in a reoperative field It is best to wait a few days before placing a tracheostomy to allow skin flaps and other tissue layers to seal before exposing them to airway secretions This also allows for postsurgical airway edema to resolve before committing to a tracheostomy tube For tumors, the approach is modified in a number of ways Considerable experience is required to make the judgment of whether a tumor can be safely resected with sufficient tissue to provide a clear margin and yet allow successful primary reconstruction of the airway This can be particularly difficult in patients with adenoid cystic carcinoma in whom frozen sections may show microscopic tumor at grossly clear resection margins When extension of resection to the more distal trachea is required, an upper sternal split may be extended into the right fourth interspace The plane of dissection in tumor cases must be kept away from the involved portion of trachea in order to ensure an adequate radial margin This endangers the recurrent laryngeal nerves more than in resections for benign disease If a recurrent nerve is involved by tumor, the nerve is sacrificed Paratracheal lymph nodes are removed en bloc with the specimen when possible, but extensive lymph node dissection cannot be done for fear of destroying the blood supply to the remaining trachea Postoperative radiation therapy is recommended in all cases of bronchogenic or adenoid cystic carcinoma, unless contraindicated by performance status or anastomotic complications.11 Laryngotracheal Resection In cases where an upper tracheal lesion involves the cricoid, occuring most commonly in idiopathic laryngotracheal stenosis or tumor, a laryngotracheal resection will be necessary In idiopathic laryngotracheal stenosis the lesion typically involves the cricoid on its anterior and lateral luminal surface The operative procedure must be tailored to address the particular anatomical involvement encountered (Figure 17-9) The recurrent laryngeal nerves are protected by bevelling off the cricoid anteriorly and laterally while preserving the posterior plate.21,22 The extent of anterior cricoid resection ranges from complete, with a line of transection through the cricothyroid membrane to none at all, depending on the extent of involvement Tracheal resection depends on the distal extent of lesion (Figure 17-10A and B) The trachea is appropriately tailored so that the proximal trachea coapts well with the cut edge of the lar ynx (Figure 17-10C and D) 2-0 Vicryl “traction sutures” are placed in the midlateral position both proximally and distally Interrupted 4-0 Vicryl sutures were used to fashion the anastomosis The midline of the thyroid cartilage is approximated to the midline of tracheal “prow.” 2-0 Vicryl traction sutures are tied followed by individual 4-0 Vicryl anastomotic sutures (Figure 17-10E and F) This operation is modified in patients in whom the stenosis affects the mucosa overlying the cricoid plate Sparing the posterior cricoid plate preserves the recurrent laryngeal nerves The line of mucosal division is performed high on the posterior cricoid plate to excise involved mucosa and submucosa (Figure 17-11) Mucosal resection stops short of the superior border of the cricoid plate, immediately below the arytenoid cartilages The rostrum or “prow” of the proximal tracheal cartilage is shaped as described above, but posteriorly a broad-based flap of membranous wall is fashioned, which is advanced to resurface the denuded posterior criciod plate The posterior portion of the anastomosis is made with interrupted 4-0 Vicryl sutures placed only through the full thickness of mucosa and submucosa of the posterior wall of the larynx, and then through the full thickness of the membranous wall of the trachea (Figure 17-12), inverted so that the suture knots lay external to the lumen Four sutures are placed through the cartilaginous portion of the inferior margin of the cricoid plate and the outer portion of the membranous wall of the trachea below the proximal edge of the flap in order to fix the membranous wall to the inferior edge of the cricoid plate When the lesion extends proximally toward the conus elasticus, it is necessary to accept some residual narrowing because of the height of the anastomosis Lower Tracheal and Carinal Resections While isolated benign strictures of the lower trachea and carina are seen, the most common lesions requiring surgery are tumors Therefore, the principles of surgical oncology must be strictly applied to most of these resections Patients with bronchogenic carcinoma and N2 disease should be considered to have unresectable disease, and surgery should only be performed in a protocol setting.23–26 Mediastinoscopy is performed on the day of proposed surgery not only to assess nodal status and resectability, but to facilitate the resection and reconstruction by mobilizing the pretracheal plane while visualizing the recurrent laryngeal nerve Scarring of the pretracheal plane from prior mediastinoscopy limits airway mobility, complicates reconstruction, and increases the likelihood of injury to the left recurrent Techniques of Tracheal Resection and Reconstruction / 225 generous caudal displacement of the trachea For this reason, end-to-end anastomosis of trachea to the left main stem with reimplantation of the right into the trachea is more commonly employed A right hilar release maneuver facilitates this procedure More extensive resections require end-to-end anastomosis of trachea to right main stem with reimplantation of left into the bronchus intermedius This obviates the need for extensive left main stem mobility When there is extensive endobronchial involvement, excessive lung destruction, or invasion of hilar vessels, then carinal (sleeve) pneumonectomy is necessary Experienced intraoperative judgment is required to determine the ideal approach The anastamosis is fashioned with interrupted simple 4-0 Vicryl sutures placed with knots tied outside the lumen Once reconstructed, the anastomoses are tested for air tightness to 40 cm of water All suture lines are circumferentially wrapped with pedicled flaps of pericardial fat or a broad-based pleural flap In high-risk patients, especially those who have undergone prior radiotherapy, an intercostal flap stripped of all periosteum or an omentum pedicle is used These flaps not only buttress the anastomoses, but more importantly, separate them from the hilar vessels, helping to prevent bronchovascular fistulas Release Procedures When extensive resections are required the standard methods of mobilization by dissection in the pretracheal plane and flexion of the neck often not allow a tension-free anastomosis In these instances, further mobilization with “release” procedures is required In our experience, this has been necessary in 8.3% of patients undergoing resections for postintubation stenosis and 15% of patients undergoing resections for tumors 18 Certain release maneuvers are more effective for achieving additional mobility of the cervical trachea, whereas others are more effective for freeing the intrathoracic trachea In resection of the upper trachea, additional length may be gained by releasing the lar ynx with a Montgomery suprahyoid release.27 This consists of dividing the muscles that insert on the superior aspect of the central part of the hyoid bone The hyoid itself is then divided just medial to its lesser cornua on either side, and the stylohyoid tendons are divided (Figure 17-13) This provides an additional approximately 1.5 cm of length It is important to realize that laryngeal release maneuvers may predispose patients to postoperative aspiration, especially of liquids In time, however, this problem has resolved in virtually all patients For intrathoracic tracheal or carinal resections, additional length is best achieved by hilar release Mobilization of the right hilum should be done first, along with division of the inferior pulmonary ligament Then, a U-shaped incision is made in the pericardium below the inferior pulmonary vein If required, the pericardium can be incised 360° around the hilus for maximal mobility In this event, the vascular and lymphatic pedicle to the main stem bronchus is left preserved behind the pericardium The left hilum may be similarly mobilized (Figure 17-14) in the unusual case where unilateral mobilization is insufficient However, left-sided hilar release can only be accomplished easily through a median sternotomy by opening the pericardium anteriorly, bilateral thoracotomies, or an extended clamshell incision As with most airway surgery, neck flexion is helpful Laryngeal release has not been shown to produce meaningful mobility at the level of the carina.29 Tracheal Resection in an Irradiated Field In patients who have received radiation therapy prior to coming to surgical resection, the risk of anastomotic dehiscence is increased The detrimental effects of irradiation on tissue and, more specifically, tracheal healing have been amply demonstrated in animals The early Massachusetts General Hospital experience with tracheal resection in patients who had received high doses of radiation, particularly when this occurred remotely in time, confirmed these findings.30 In these patients there was a markedly increased incidence of anastomotic failure When a patient has received either high-dose irradiation (more than 4,500 cGy) or who has undergone irra- FIGURE 17-13 The dotted lines indicate the point where the hyoid bone is divided, separating its body from the greater horn on each side Reprinted with permission from Montgomery ww.27 Techniques of Tracheal Resection and Reconstruction / 227 A collar incision is performed which circumscribes the stoma (Figure 17-16) Dissection identical to that described above for simple tracheal resection is performed up to the point of division of the trachea below the fistula As the posterior wall of the trachea is dissected from inferior to superior, the fistulous connection is isolated circumferentially It is detached from the esophagus with a small rim of normal esophageal tissue and kept attached to the tracheal segment with which it will be removed (Figure 17-17) After removal of the specimen, the esophagus is closed longitudinally with two layers of 4-0 silk (Figure 17-18A and B) The sternohyoid or sternothyroid muscle is sutured into place to buttress the esophageal closure and interpose healthy tissue between the esophageal and tracheal suture lines (Figure 17-19) The end-to-end tracheal anastomosis is then performed as described previously If the fistulous opening is long and the tracheal wall is not circumferentially damaged as far down as the fistula extends, the margin of the tracheal opening may be excised as a V and repaired with a vertical suture line prior to creating the end-to-end tracheal anastomosis In the rare case where there is no significant damage to the trachea associated with the fistula, tracheal resection is unnecessary, and simple esophageal and tracheal repair with muscle buttress is performed Postoperative Issues FIGURE 17-15 Endoscopic view of tracheoesophageal fistula The patient’s postoperative course is largely determined by intraoperative technique The goals of both intraoperative and postoperative care are the maintenance of good pulmonary toilet and the promotion of anastomotic FIGURE 17-16 Exposure for most tracheoesophageal fistulas is through a low collar incision Occasionally, a partial upper sternotomy is required for more distal exposure of the trachea Reprinted with permission from Mathisen DJ et al.31 Techniques of Tracheal Resection and Reconstruction / 229 dure Postoperatively, these include minimizing fluids, elevating the head of the bed and administering racemic epinephrine to help prevent laryngeal edema Rarely, an especially high laryngotracheal resection will cause enough laryngeal edema to necessitate one or two doses of steriods to avoid impending re-intubation and/or tracheostomy Heliox, with its low viscosity, is sometimes useful in these circumstances since it can occasionally gain enough time for the other maneuvers to take effect The patient is cautioned against unnecessary speech during this period, as it can contribute to the laryngeal edema Cervical flexion is maintained with the chin-to-chest suture for to days, after which time the patient is advised not to extend the neck for another week Before removing the chin-to-chest suture, we routinely examine the anastomosis with a flexible bronchoscope or obtain tracheal tomograms to assure normal healing Oral alimentation is begun cautiously, particularly in patients who have undergone a laryngeal release Water is offered initially, since its aspiration is better tolerated and more easily dealt with than more substantial foods Results and Complications Results of tracheal resection have been impressive For simple resections of postintubation stenoses, including our earliest experience and reoperations, of 503 patients there were only 12 deaths and 18 failures.32 Four-hundred and forty (87%) had good and 31(6%) satisfactory results Of 80 patients undergoing laryngotracheal resections for all causes of subglottic stenosis, there was one postoperative death Results were excellent in 18 (22%), good in 52 (65%), and satisfactory in (10%) In only two patients was there failure to achieve a functional airway For primary tumors of the trachea, for which resection and reconstruction was performed, including carinal resections, there were deaths in 132 patients.11 Five of the six were following the more complex carinal procedures Six patients developed significant postoperative restenosis, but all of these underwent successful re-resection The oncologic outcomes of patients with bronchogenic carcinoma has recently been separated out for carinal resections and reported by Mitchell and colleagues.26 In this series of bronchogenic carcinomas, 57% presented with N0 disease, 25% had N1 disease, and 18% had N2 or N3 disease The overall 5-year survival was 42% Lymph node status strongly influenced survival The 5-year survival of N0, N1, and N2 or N3 patients was 51%, 32% and 12%, respectively (see Figure 17-3) Microscopically positive margins did not affect survival Isolated carinal resection resulted in a more favorable prognosis than more extensive resections, with a 5-year survival of 51% The long-term survival data for resected adenoid cystic carcinoma of the trachea and carina have not been as well defined, partly because of the proclivity for late recurrence The published experience of all tracheal adenoid cystic carcinomas, which includes carinal, suggests a much more favorable prognosis than bronchogenic carcinomas Lymph node and margin status not appear to significantly affect survival.11,12,23 Postoperative radiation therapy is recommended in all cases of adenoid cystic or bronchogenic carcinoma, unless contraindicated by performance status or anastomotic complications The role of chemotherapy has not been established Secondary cancers arising in the thyroid and invading the trachea have also been resected with good results Of 27 patients undergoing resection and reconstruction of the trachea for thyroid cancer invading the airway, including patients with both simple and complex laryngotracheal reconstructions, two died in the postoperative period, one had a short segment tracheal necrosis requiring re-resection, and all others were provided with an adequate airway by their initial operation Only two patients experienced an airway recurrence.13 In patients who have received radiation therapy prior to coming to surgical resection, the risk of anastomotic dehiscence is increased Nineteen patients have undergone tracheal resections with vascularized tissue coverage at Massachusetts General Hospital following radiation therapy.30 Fifteen had a pedicied omental flap, a pericardial fat pad flap, an intercostal muscle flap, and a pleural flap Only one of these patients suffered an anastomotic dehiscence, and this resulted in death Another patient required a T-tube Following development of a paratracheal abscess, he ultimately died of recurrent squamous cell carcinoma Two patients developed wound infections that responded to treatment Overall, 15 patients experienced an excellent result without dyspnea, and experienced a good result with dyspnea with moderate exercise Our experience with the repair of tracheoesophageal fistulas involves the performance of 41 operations on 38 patients.31 Simple division and closure of the fistula was done in nine patients Tracheal resection and reconstruction was combined with esophageal repair in the remainder The esophageal defect was closed in two layers and a viable strap muscle interposed between the airway and esophageal suture lines in all cases There were four deaths (11%) Three patients developed recurrent fistulas and one patient suffered a delayed tracheal stenosis All were successfully managed with re-operation Of the 34 survivors, 33 can swallow normally, and 32 breathe without the need for a tracheal appliance 230 / Advanced Therapy in Thoracic Surgery Complications Despite these encouraging outcomes, complications occur They have generally been few for upper tracheal resections Major complications more often have followed carinal or laryngotracheal resections Inability to clear secretions with consequent atalectasis is the most common, though relatively minor, complication and this can be handled as described above This management has limited the number of patients who have suffered pneumonia or respiratory failure after simple tracheal resection Laryngeal edema may occur after procedures involving the larynx, but this generally regresses in approximately one week when treated as described above Unilateral recurrent laryngeal nerve injury rarely occurs as a result of extensive resection, usually in patients with tracheal tumors The most common late complication has been the formation of granulomas at the suture line This is usually manifest as wheezing or minor hemoptysis It has occurred more commonly following resection for inflammatory lesions than for tumor, as residual inflammation may be present in such cases despite efforts to wait out the acute inflammatory phase Granulations can be managed by bronchoscopic removal under light anesthesia Often a suture is found to have migrated into the lumen at the base of the granulation, and in such cases removal of the suture leads to ultimate healing In some cases, however, multiple bronchoscopies are necessary over a period of time The current use of Vicryl rather than nonabsorbable sutures has almost eliminated this once common problem Suture line separation, the most dreaded complication, is almost invariably related to tension on the anastomosis or compromise of its blood supply These problems, which occur most commonly following resection of long segments of trachea and following radiation, are more frequently associated with resection for tumor than for postintubation stenosis Steroid use which has not been discontinued preoperatively has also been associated with anastomotic failure Early, minimal air leakage at the suture line may seal without sequelae and can be managed with closed suction drains True separation, however, is usually heralded by respiratory distress Anastomotic separation in the immediate postoperative period suggests a serious technical error, and reoperation under these conditions is appropriate Early separation that does not appear remediable by resuturing or a local muscle flap can be temporized by placement of a tracheostomy or a Montgomery T-tube, with corrective surgery to be performed months later after regression of the acute inflammatory response Sometimes, with such a tube serving as a stent, the partial restenosis that results may leave a tolerable airway, and this may be improved with endoscopic dilations Stenosis may occur at the anastomotic site after the initial postoperative period, without evidence of a frank separation This can be managed temporarily by rigid bronchoscopic dilation Ultimately, most of these patients will require re-resection This should be done no sooner than months after the initial procedure in order to allow time for regression of inflammation Other rare complications that we have seen include fatal hemorrhage from the pulmonary artery, likely related to erosion from an adjacent tracheobronchial anastomosis, innominate artery hemorrhage, tracheoesophageal fistula, esophagocutaneous fistula, empyema, and quadriplegia, which may have been related to overflexion of the chin to the chest Tracheal Substitutes and Tracheal Transplantation The advancement of techniques in tracheal surgery have allowed up to 50% of the trachea to be resected in favorable patients This has rendered the majority of tracheal lesions requiring surgical treatment correctable with a single-staged resection and reconstruction On rare occasions, the extent of a lesion involves more of the trachea than can be safely reconstructed with a primary end-toend anastomosis These situations have lead investigators to attempt to reconstruct the trachea with prosthetic material Early designs focused on solid tubes anastomosed endto-end with the trachea Neville and colleagues were one of the first to report a small series on human subjects.33 Results were dismal The nonporous silicone tubes failed to become incorporated with tissue and thus became infected and either extruded into the airway or eroded into the surrounding vascular structures To avoid this fate, subsequent designs employed porous cylinders, usually fabricated from metal wire of all different elements and alloys These prosthetic conduits were usually wrapped with an omental or muscle flap and then placed as an interposition graft in the trachea The tissue flap was expected to provide an airtight seal and serve as a source of vascularized tissue in which the prosthesis would become incorporated and protected from the surrounding great vessels Most of the investigations were in animals, and while the prostheses became successfully incorporated, they ultimately failed as the animals became obstructed from granulation tissue 34–37 The lack of an epithelial surface essentially created an open festering wound encouraging granulation tissue to proliferate unchecked, resulting in airway stenosis Small segments of trachea could be successfully replaced in this manner, since respi- Techniques of Tracheal Resection and Reconstruction / 231 ratory epithelium would migrate for to cm from either anastomosis to cover the replaced portion of the airway In larger segments, the respiratory epithelium would either not migrate such a distance or simply could not cover the distance fast enough to outpace and thus quell the exuberant granulation tissue Recent investigators have supplied an epithelial lining by grafting either oral mucosa or splitthickness skin grafts on the inner surface of the porous prosthesis.38 These require a two-staged procedure where the pedicled tissue or prosthesis composite is created and allowed to mature before it is transposed as an interposition tracheal substitute Early results are encouraging, but their complexity and inconsistent results make their clinical application unfeasible at this time The lack of success with prosthetic tracheal replacements has encouraged many investigators to pursue an airway conduit made of all biological tissue, either viable allotransplantation or cryopreserved tracheas Neither approach has achieved meaningful success Tracheal transplantation suffers from several major limitations First, the trachea lacks a single, sizable venous and arterial system Instead, its vascular supply consists of multiple small vessels too fine to anastomose To overcome this limitation, investigators have used the omentum to wrap tracheal transplants to allow for vascular ingrowth.39,40 However, results have been mixed, especially with longer segments Second, unlike most other solid organ transplants, the trachea by virtue of its anatomical location is exposed to a heavy concentration of antigens and microorganisms The result is an ischemic tracheal transplant, heavily contaminated with oropharyngeal microorganisms, in an immunodebilitated patient Finally, many of the conditions which involve the entire trachea are benign processes that are safely managed with Silastic T-tubes and thus not justify the detrimental effects of immunosuppressive therapy In those cases where a malignant tracheal tumor requires resection of the entire trachea, immunosuppressive therapy should be avoided as well In a move to avoid immunosuppressant therapy, investigators have begun to test methods of rendering allogenic tracheal grafts less or nonantigenic The most important transplant antigens involved in graft rejection are expressed by the major histocompatibility complex (MHC) In the trachea, the mucosa and the submucosal glands express MHC-I and MHC-II.41 Cartilage does not express MHC antigens and is an immunologically privileged tissue that has been successfully used in allotransplantation for years without the use of immunosuppressive therapy It is believed that the thick, avascular proteoglycan-collagen matrix that encapsulates the chondrocytes, shields them from recognition by the immune system Moreover, since cartilage has no capil- lary blood supply and survives from diffusion it can survive off the diffusion to and from an omental wrap Investigators have designed methods to process fresh tracheas to remove the tracheal mucosa and submucosal glands while preserving the viability of the cartilage.42,43 In pilot dog studies, these grafts epithelialize and maintain viable cartilage without significant stenosis for up to one year Control animals, which had the same procedure using a fresh unprocessed trachea instead, developed necrosis and stenosis over a few weeks Others have used cryopreservation techniques to achieve similar results since cartilage tends to survive the process and the mucosa and glands not.44,45 The results of these studies are encouraging because they demonstrate that a viable tracheal conduit can be transplanted, integrated, and accepted by the host and re-epithelialized However, these studies were done for small segments of tracheal replacement, where the epithelium can be expected to migrate from the anastomotic ends and resurface the graft Since this form of therapy will be used to treat near total or total tracheal replacement, these methods will need to be tested on longer segments Summary In conclusion, techniques of tracheal resection and reconstruction have advanced to a point where these procedures can be done with the anticipation of good results and an acceptable level of morbidity and mortality Nonsurgical methods such as dilation, ablation, or stenting not currently offer cure of tracheal stenoses, although these may each play a role in palliation or temporization prior to surgery The current standard of care dictates that symptomatic benign tracheal stenoses that can be resected should be resected For primary malignant tumors, squamous cell carcinomas should be resected when complete resection for cure is anticipated, while patients with the more indolent adenoid cystic carcinoma may benefit from even palliative resection with microscopically positive margins Tracheal resection for low-grade thyroid carcinomas invading the airway should also be performed for cure or palliation, sometimes even in the presence of distant metastasis The development of successful techniques of complete tracheal replacement in humans is an area of ongoing research but currently has no clinical applicability References Grillo HC, Bendixon HH, Gephart T Resection of carina and lower trachea Ann Surg 1963;158:889–93 Michelson E, Solomon R, Miura T Experiments in tracheal reconstruction J Thorac Cardiovasc Surg 1961;41:748–59 232 / Advanced Therapy in Thoracic Surgery Mulliken J, Grillo HC The limits of 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outcome J Thorac Cardiovasc Surg 2001;121:465–71 27 Montgomery WW Suprahyoid release for tracheal anastomosis Arch Otolaryngol 1974;99:255–60 28 Newton JR, Grillo HC, Mathisen DJ Main bronchial sleeve resection with pulmonary conservation Ann Thorac Surg 1991;52:1272–80 29 Grillo HC Carinal Neoplasia In: Grillo HC, Austen WG, Wilkins EW, et al editors Current therapy in cardiothoracic surgery Hamilton (ON): B.C Decker Inc.; 1989 p 134 30 Muehrcke DD, Grillo HH, Mathisen DJ Reconstructive airway operation after irradiation Ann Thorac Surg 1995;59:14–8 31 Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD Management of acquired nonmalignant tracheoesophageal fistula Ann Thorac Surg 1991;52:759–65 32 Grillo HC, Donahue DM, Mathisen DJ Postintubation tracheal stenosis: treatment and results J Thorac Cardiovasc Surg 1995;109:486–93 33 Neville We, Bolanowski JP, Kotia GG Clinical experience with the silicone tracheal prosthesis J Thorac Cardiovasc Surg 1990;99:604–12 34 Teramanchi M, Nakamura T, Yamamoto Y Porous-type tracheal prosthesis sealed with collagen sponge Ann Thorac Surg 1997;64:965–9 35 Satoh S, Elstrodt J, Hinrichs WL, Feinjen J Prevention of infection in porous tracheal prosthesis by omental wrapping ASAIO Trans 1990;36:M438–40 19 Mathisen DJ, Grillo HC Endoscopic relief of malignant airway obstruction Ann Thorac Surg 1989;48:469–75 36 Schauwecker HH, Gerlach J, Planck H Isoelastic polyurethane prosthesis for segmental tracheal replacement in beagle dogs Artif Organs 1989;13:216–8 20 Wilson RS Tracheal resection In: Marshall BE, Longnecker DE, Fairley HB, editors Anesthesia for thoracic procedures Boston (MA): Blackwell Scientific; 1988 p 415–32 37 Teramachi M, Kiyontani T, Takimoto Y A new porous tracheal prosthesis sealed with collagen sponge ASAIO Trans 1995;41:M306–10 Techniques of Tracheal Resection and Reconstruction / 233 38 Suh SW, Kim J, Baek CH Development of new tracheal prosthesis: atogenous mucosa-lined prosthesis made from polypropylene mesh Int J Artif Organs 2000;23:261–7 tracheal grafts can be reduced by removing the epithelium and mixed glands from the graft by detergent treatment J Thorac Cardiovasc Surg 2000;120:108–14 39 Li J, Xu P, Chen H Successful tracheal autotransplantation with two-staged approach using greater omentum Ann Thorac Surg 1997;64:199–202 43 Yokomise H, Inui K, Wada H High-dose irradiation prevents rejection of canine tracheal allografts J Thorac Cardiovasc Surg 1994;107:1391–7 40 Park YS, Lee DY, Paik HC The role of omentopexy in tracheal transplantation in dogs Yonsei Med J 1996;37:118–24 44 Mukaida T, Shimizu N, Aoe M Origin of regenerated epithelium in cryopreserved tracheal allotransplantation Ann Thorac Surg 1998;66:205–8 41 Bujia J, Wilmes E, Hammer C Tracheal transplantation: demonstration of HLA class II subregion gene products on human trachea Acta Otolaryngol 1990;110:149–54 45 Mukaida T, Shimizu N, Aoe M Experimental study of tracheal allotransplantation with cryopreserved grafts J Thorac Cardiovasc Surg 1998;116:262–6 42 Liu Y, Nakamura T, Yamamoto Y Immunosuppressant-free allotransplanation of the trachea: the antigenicity of CHAPTER 18 MANAGEMENT OF PULMONARY ARTERIOVENOUS MALFORMATIONS AND SEQUESTRATIONS FRANCIS C NICHOLS, MD MARK S ALLEN, MD Pulmonary Arteriovenous Malformation hemorrhagic telangiectasia (HHT), also known as the Rendu-Osler-Weber syndrome In fact, up to 87% of PAVMs are found in patients with HHT, and approximately 20% of patients with HHT develop PAVMs Although the overwhelming majority of PAVM is congenital in origin, secondary or acquired PAVM can occur The causes of acquired PAVM include trauma, actinomycosis, schistosomiasis, cirrhosis, systemic amyloidosis, mitral stenosis, and metastatic carcinoma.1 Although some patients with PAVM are asymptomatic, most patients are symptomatic Clinical features in a recent Mayo Clinic series are shown in Table 18-1 The most common pulmonary symptom is dyspnea, and this correlates with the degree of shunting Dyspnea can increase with a change in position from supine to upright and with exercise because of increased blood flow to the Pulmonary arteriovenous malformations (PAVMs) are vascular lesions of the lung in which there is an abnormal connection between the pulmonary arterial and venous systems without an intervening capillary bed PAVM has been described under a variety of pseudonyms including benign cavernous hemangioma, pulmonary arteriovenous angiomatosis, hamartomatous angioma of the lung, arteriovenous aneurysm, and arteriovenous fistula.1 The malformation leads to shunting of unoxygenated blood into the systemic circulation and may permit embolic material to pass unfiltered through the lungs PAVMs are classified into simple or complex A simple PAVM has a single feeding vessel, and a complex PAVM has multiple feeding vessels PAVM was first described in 1897 by Churton in a 12year-old child.2 The first surgical intervention was reported by Shenstone who performed a pneumonectomy for a large central lesion.3 Several publications from our institution have focused on the surgical management of PAVM and most recently on the angiographic management.1,4–7 PAVM occurs more commonly than previously thought It occurs with an incidence of in 2,351 to in 39,000 individuals The male-to-female incidence is equal; they are bilateral in to 20% and multiple in 30 to 50% of patients.9 While PAVM can present as isolated pulmonary findings, it is often associated with hereditary TABLE 18-1 Clinical Features in 93 Patients with Pulmonary Arteriovenous Malformation Clinical Feature Dyspnea Cyanosis Clubbing Cerebrovascular event Asymptomatic Hemoptysis Transient ischemic attack Cerebral abscess Seizure Adapted from Swanson KL et al (1999).7 234 Number (%) 53 (57) 27 (29) 18 (19) 17 (18) 15 (16) 14 (15) 11 (12) (5) (5) 256 / Advanced Therapy in Thoracic Surgery In a review of 36 non–HIV-associated immunesuppressed patients eventually having thoracotomy for fungal infections by Temeck and colleagues, most were done on an urgent basis in symptomatic patients without a diagnosis.25 Therapeutic changes were instituted on 23 (64%) of these patients as a result of the intervention Of note, survival was statistically related to the demonstration of angioinvasion in the pathology specimen Other factors were low granulocyte count and the use of chemotherapy and steroids Though 25% of patients had complications from the procedures, patients who succumbed tended to so from the underlying disease or other infective factors treatment of disease Aggressive operative treatment of fungal infections of the lungs combined with antifungal chemotherapy before transplant may offer the best hope of extended survival in patients with localized disease.26,27 In a series by Salerno and colleagues, surgical resection of invasive pulmonary aspergillosis (IPA) cleared the aspergillus infection in 69% of the patients in the perioperative period around bone marrow transplantation 28 In immune-compromised patients with hematologic diseases or liver transplantation with IPA, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear and the disease is localized.29 Surgery may play an important role in IPA complicating treatment in leukemia patients Baron and colleagues in a review of 18 patients observed improved survival in patients diagnosed with IPA.30 Furthermore, the point was made that hemoptysis was common in IPA patients despite antifungal treatment It was also hypothesized that resection would likely reduce the relapse rate Resection may also speed the reintroduction of essential chemotherapy in infected patients Of note, of 36 patients with documented aspergillus infection compiled by Miller and colleagues, the only patient ultimately cured had resection for hemoptysis.17 It would be difficult to determine in a study whether “debulking” or removal of the only known site of fungal lung disease would have a positive impact on cure in cases of general immune suppression A literature review by Wright and colleagues revealed that of 21 diabetic patients in whom mucormycosis occurred without underlying malignancy, only survived.31 Of note, these underwent operation In a review by Tedder and colleagues of 92 patients in whom the diagnosis was made of mucormycosis, patients treated surgically had a significantly lower mortality (9.4% vs 50%, p = 01) than those treated medically.23 Prompt diagnosis of mucormycosis (usually requiring biopsy) is often essential to reduce the mortality rate to allow prompt treatment with amphotericin B and surgical excision of necrotic lung.32 Cryptococcal infections can occur in a variety of circumstances In certain instances the disease is focal and can be encompassed by resection (Figure 20-8) Major Hemoptysis Major hemoptysis may occur from the erosion into a pulmonary vessel by an acute fungal infection It is frequently a terminal event More frequently, recurrent hemoptysis occurs as a complication of a long-standing aspergilloma In these cases the presence of the fungus creates an intense local reaction and the area becomes neovascularized over time Hemoptysis occurs in approximately 50% of patients, and in 10% the hemoptysis is severe and recurrent Superimposed bacterial infection usually accompanies the episodes of hemoptysis, and medical therapy with bed rest, antibiotics, and postural drainage was successful in controlling the hemorrhage in the majority of cases.33 The prognosis of aspergilloma is related primarily to the nature and severity of the underlying disease.34 For intermittent episodes of non–lifethreatening hemoptysis it may be argued that routine surgical excision of aspergilloma is not indicated Where episodes are recurrent or life-threatening, resection of the mycetoma is indicated where possible This will involve careful planning to resect the underlying damaged lung with maximal preservation of overall respiratory function The surgery can be very difficult because of the intense inflammation often surrounding the fungus and obliterating normal tissue planes For nonsurgical cases, FIGURE 20-8 Cryptococcal infection Sixty-eight-year-old female patient with history of central nervous system cryptococcal infection Radiograph shows well-circumscribed cryptococcoma in the right lower lobe of the lung Treated by prolonged course of antifungal chemotherapy Surgery for Fungal and Mycobacterial Diseases / 257 treatment by intracavitary amphotericin B may alleviate hemoptysis with no loss of lung function.35,36 Massive hemoptysis in the course of mucormycosis is a particularly lethal event, and most successful cases involve a combination of surgery and antifungal chemotherapy.37 Chest Wall Invasion or Infection Chest wall infection may occur with actinomyces and sporotrichosis in non–immune-compromised patients In most cases the disease process is an extension of lung pathology Other infection such as aspergillosis can involve the chest wall in the immune compromised host.38 Under ordinary circumstances antifungal therapy should suffice with surgical debridement reserved for severe cases Trachea and Airway Involvement Tracheal involvement by mucormycosis, particularly in diabetics or severe immune compromise, can lead to extensive destruction of the trachea and death.39,40 While treatment with amphotericin B is the mainstay of therapy for pulmonary mucormycosis in diabetics, early aggressive surgical resection of the involved lung tissue may be indicated.41 Pseudomembranous and obstructing casts with aspergillus can lead to varying degrees of airway obstruction with aspergillus in AIDS This manifestation of aspergillus infection appears to be AIDS-specific.17,42 viduals Because of HIV and other factors, it is making a resurgence in many first-world countries The development of drug-resistant strains in certain areas of the Western world appears to be directly linked to treatment of patients with coexistent AIDS and TB The impairment of cellmediated response may make the tuberculin test falsely negative on 50 to 70% of patients with advanced AIDS, leading to diagnostic confusion (Figure 20–9) TABLE 20-1 Indications for Surgery for Tuberculosis Treatment of the disease itself Persistent positive sputum-drug sensitive Persistent positive sputum drug resistant Poorly compliant patient Patient with drug intolerance or allergy Multiple relapses despite good drug response Initial episode but residual cavitation despite good response Totally destroyed lobe/lung Cold Abscess of chest wall Treatment of complications of active tuberculosis Pleural extension Acute hemoptysis Obstructive lymphadenopathy Treatment of sequelae of old tuberculosis Bronchial stenosis Bronchiectasis Cysts and bullae Aspergilloma Mycobacterial Infection TB Resection of affected lung parenchyma for TB became increasingly common in the 1940s; however, thoracoplasty (collapse treatment) remained the most popular treatment of choice until the introduction of effective antituberculous agents With the development of rifampicin in 1966, surgery was seldom needed except for the occasional massive hemoptysis, bronchial stenosis, or bronchopleural fistula or to rule out cancer In most developed countries TB steadily declined until 1985; thereafter there has been a steady increase worldwide with a 50% increase in reported cases in the last decade (World Health Organization statistics) With the rise of drugresistant TB, surgical procedures are again being needed in the primary treatment of mycobacterial disease The general indications for surgery are listed in Table 20-1 The risk of TB infection depends on the concentration of the bacilli in the environment, which in turn is linked to poverty and overcrowding For these and other economic and political reasons, pulmonary TB remains endemic in many parts of the lesser-developed world In Africa, Myobacterium tuberculosis is the most common pathogen in HIV-infected patients The increase in the general disease pool in turn increases the disease amongst non-HIV indi- FIGURE 20-9 Tuberculosis in a patient positive for human immunodeficiency virus (HIV) Young male patient with known HIV presented with massive hemoptysis Sputum was heavily positive for acid-fast bacilli Chest radiograph shows patch consolidation predominantly in the right lower lobe Hemoptysis settled with sedation and antituberculous drug therapy 258 / Advanced Therapy in Thoracic Surgery Indications for Surgery treatment of tb The major indications for surgery of active TB are where patients remain sputum-positive despite adequate sensitivity-directed drug therapy (Figure 20-10) or harbor drug-resistant organisms (Figure 20-11) The objective of surgery will be to ablate areas of gross cavitation and destruction that act as sheltered reservoirs Adequate chemotherapy should cover the patient in the peri- and postoperative period Multidrug-resistant patients may require prolonged courses of treatment to maximize the potential for permanent cure In a series of 62 patients undergoing pulmonary resection for drug-resistant strains of M tuberculosis, 75% who were persistently sputum-positive at the time of operation immediately converted to a negative sputum smear and culture.43 For all patients who were sputumnegative after operation, 80% remain relapse-free by actuarial analysis Other series have reported similar good results.44 For drug-resistant TB, sputum conversion can be achieved in over 75% of patients who had failed with drug therapy alone with a combination of surgery and antituberculous therapy.43 treatment of complications: active pulmonary tb Extension of pulmonary foci through the pleural surface of the lung may lead to tuberculosis effusion, pneumothorax, or combinations thereof Infection of effusions via the bronchi or inappropriate chest drainage may lead to superinfection and the development of a tuberculous empyema In most patients the diagnosis of the effusion is straightforward In a smaller percentage of patients the cause of the effusion may be difficult to identify even with multiple aspirations and pleural biopsy In these patients, the use of diagnostic thoracoscopy may provide the diagnosis in cases refractory to other methods For simple tuberculous effusions, treatment with appropriate antituberculous therapy suffices in most instances Where the volume of effusion is troublesome, then sterile aspiration may provide interim relief One should avoid the use of intercostal drains unless absolutely necessary, for fear of introducing infection For tuberculous-related pneumothorax, intercostal drainage in conjunction with chemotherapy is successful in most cases When the underlying lung is severely damaged, this may lead to poor expansion; however, there is little indication for surgery at this stage The provision of long-term drainage and TB treatment often will suffice (Figure 20-12) The occurrence of life-threatening hemoptysis is a rare but potentially lethal complication of acute pul- FIGURE 20-10 Progression of tuberculosis (TB) despite drug therapy Patient with persistent drug-sensitive TB despite 12-month antituberculous treatment A, Chest radiograph shows persistent opacity in left upper lobe lung Lung resection offered but refused B, Progressive lung destruction over 24 months despite continuation of treatment 260 / Advanced Therapy in Thoracic Surgery The majority of patients respond to this regimen, but some may persist to the extent that surgery is indicated FIGURE 20-13 Posttuberculous bronchiectasis Young female patient with a history of tuberculosis in childhood Presented with chronic cough and copious daily sputum production Chest radiograph shows a bronchiectatic right upper lobe Treated with a right upper lobectomy Tuberculous adenopathy causing airway obstruction is most commonly seen in the pediatric population The pathology is peribronchial nodal compression of the airway by surrounding lymph node groups (Figure 2015) Most cases respond to careful observation with antituberculosis treatment A few will require steroid treatment and even fewer surgical intervention The surgery consists of the emptying of the nodes of their caseating contents as the actual removal of the inflamed node attached to the bronchus may be met with serious airway damage.45 treatment of tb complications Bronchial stenosis may result from endobronchial TB The damage may lead to secretion retention with resultant chronic infection leading to bronchiectasis or abscess formation Partial obstruction may lead to lobar collapse or the development of bullae and hyperinflation (Figure 20-16) As often the distal lung is damaged beyond salvage, resection is often indicated Bronchiectasis (Figure 20-17) may occur as a direct complication of tuberculosis infection or as a result of superimposed, often multiple, bacterial infections The pathology of bronchial dilation, chronic pooling of secre- FIGURE 20-14 Posttuberculous bronchiectasis with massive hemoptysis Young male presented with multiple recurrent episodes of massive hemoptysis He had a history of old tuberculosis and secondary bronchiectasis His lung function precluded resection A, Angiography revealed large bronchial arteries extending from the subclavian artery B, These were embolized with coils with good result 262 / Advanced Therapy in Thoracic Surgery FIGURE 20-19 Nontuberculous mycobacterium infection Young female patient originally treated for presumed drug-resistant tuberculosis Radiograph shows total destruction of the right lung Culture returned as Mycobacterium avium-intracellulare Treated by pneumonectomy plus antituberculous chemotherapy FIGURE 20-18 Rib destruction secondary to tuberculosis Young female patient presented with cough, fever, and left-sided chest pain Chest radiograph shows a pulmonary infiltrate and a lucency in the left seventh rib Sputum was positive for acid-fast bacilli Patient was treated with antituberculous treatment with resolution (Figure 20-19) On occasion, invasive characteristics may be displayed that are unresponsive to chemotherapy In these scenarios treatment is according to similar criteria as for patients with drug-resistant TB Inflammatory Lung Disease Generally few Western centers have a large experience in surgery for inflammatory disease of the lung Conversely, the experience with fungal diseases associated with transplantation and malignancy is higher A contentious issue is the role of surgery in patients with HIV or AIDS In populations with high incidences of HIV, there will be a subset of patients who are merely infected and not severely immune-depressed In these cases the presence of the virus should not strongly influence the decisionmaking process For AIDS patients, few data are available specifically for thoracic surgical operations, but other surgical procedures have supported a pragmatic approach, taking into consideration long- and shortterm prognostic indicators Our own policy is to evaluate each case on its own merits The results for surgery for fungal diseases vary widely on the circumstances and indication for operation Intuitively, operations in situations of healthy patients for the objective of diagnosis will vary tremendously from those conducted for salvage of patients in extremis where no other recourse is possible Technical Approach Resections are often limited by preexisting lung damage.48 Procedures are often a challenge for the surgeon not acquainted with the nuances of resection for inflammatory lung disease The general physical status of the patient and pulmonary function must be considered in selecting the patient for surgery Detailed pulmonary function testing in conjunction with functional assessment of lung performance via quantitative perfusion scans may differentiate the necessity for a pneumonectomy from the need for a lobectomy Preoperative preparation is foremost in importance, along with the timing of intervention Where active infection and sputum production is heavy, antibiotics, postural drainage, and active physiotherapy are indicated Abscess and empyema should be drained and treated prior to resection Tight diabetic control should be instituted Expert anesthetic control is pivotal to successful resection With a standard thoracotomy position, risk of soiling the Surgery for Fungal and Mycobacterial Diseases / 263 dependant lung is a danger We routinely use a double lumen tube and only occasionally resort to bronchial blockers Pre- and postoperative bronchoscopy is helpful with prolific secretions Soiling during induction should result in the deferring of the procedure In Conlan and colleagues49 one-third of deaths were because of spill, in Stevens and colleagues50 100% of deaths resulted from spill, and in Odell and Henderson 51 it was the most common cause of death Pain control in the perioperative period is adequately managed by epidural analgesia, patient-controlled analgesia, or a combination of techniques The aim at the end of a procedure should be the extubation of the patient in the operating room We have never had occasion to electively use a sternotomy for inflammatory lung resection, though some authors advocate it.52 Conlan notes concerns of access to the posterior mediastinum, hilum, and diaphragm, particularly on the left, and risk of sternal and mediastinal sepsis.53 We have not found that resection of ribs as advocated by some authors improves exposure.54 In of 25 of Massard and colleagues’ patients an additional incision was necessary to take down difficult diaphragmatic adhesions.55 We routinely start with a serratus sparing incision and only extend anteriorly if difficulties occur In situations where double lumen control cannot be achieved (typicall in children), the use of the prone position may be advisable.49 In acute infective processes, pleural adhesions are often minimal and easily dissected.30 However, in chronic longstanding cases, intrapleural dissection is usually not achievable, but when possible it may minimize the blood loss.54 Reed and colleagues noted that extrapleural dissection was unhelpful because the inflammatory process extended into the endothoracic fascia.56 In many instances the mediastinum is fortunately spared from severe adhesions, presumably due to the motion of the contents.57,58 In addition Dugan and Samson note the general lack of adhesions to the aorta on the left as well.58 Despite the approach, blood loss can be high, with Regnard and colleagues reporting 71% of patients requiring blood transfusions.48 Use of electrocautery as a dissection tool may lead to excessive tissue thermal damage Paramount to successful resection is control of the hilar vessels Anatomical distortion can occur, as can obliteration of normal planes of dissection Reed noted that most of her surgeons encountered distortion of the hilar vessels.52 Using a stepwise approach, the author has seldom had to resort to intrapericardial dissection Massard and colleagues noted difficult hilar dissection in of 25 patients and resorted to intrapericardial dissection in 6.55 We routinely staple pneumonectomy stumps and sew lesser resections We bury our left stumps and close the right with a pleural flap Reed stapled all stumps and did not cover any.52 Pomerantz and colleagues advocate the routine use of muscle flaps when the sputum is positive for mycobacterium, polymicrobial contamination, and preoperative bronchopleural fistula.59 I agree with Conlan and colleagues, who note that the peribronchial neovascularization will likely enhance the healing potential.49 In his series of 124 patients, 72 were stapled (4 fistulas) and 52 hand-sewn (3 fistulas) I not advocate the routine use of muscle flap as have other authors 60 but rather reserve them for the treatment of complications Frequently, patients with aspergilloma have extensive lung damage and cannot be considered for resection Regnard and colleagues found cavernostomy to be a satisfactor y alternate where resection cannot be tolerated.48 Muscle interposition into the cavity may be a logical extension Intracavitary administration of amphotericin through an indwelling catheter should be considered for any patient who has troublesome sputum production, hemoptysis, or systemic symptoms attributable to an aspergilloma.62 References Faber LP, Jensik RJ, Chawla SK, Kittle CF The surgical implication of broncholithiasis J Thorac Cardiovasc Surg 1975;70:779–89 Trastek VF, Pairolero PC, Ceithaml EL, et al Surgical management of broncholithiasis J Thorac Cardiovasc Surg 1985;90:842–8 Potaris K, Miller DL, Trastek VF, et al Role of surgical resection in broncholithiasis Ann Thorac Surg 2000;70:248–51 Freundlich IM, Israel HL Pulmonary aspergillosis Clin Radiol 1973;24:248–53 Winn RE, Johnson R, Galgiani JN, et al Cavitary coccidioidomycosis with fungus ball formation 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E, Souilamas R, Riquet M, et al Cold abscess of the chest wall: a surgical entity? Ann Thorac Surg 1998;66:1174–8 47 Sarlak AY, Gundes H, Gundes S, Alp M Primary sternal tuberculosis: a rare unhealed case treated by resection and local rotational flap Thorac Cardiovasc Surg 2001;49:58–9 48 Regnard JF, Icard P, Nicolosi M, et al Aspergilloma: a series of 89 surgical cases Ann Thorac Surg 2000;69:898–903 49 Conlan AA, Lukanich JM, Shutz J, Hurwitz SS Elective pneumonectomy for benign lung disease: modern-day mortality and morbidity J Thorac Cardiovasc Surg 1995;110(4 Pt 1):1118–24 50 Stevens MS, de Villiers SJ, Stanton JJ, Steyn FJ Pneumonectomy for severe inflammatory lung disease Results in 64 consecutive cases Eur J Cardiothorac Surg 1988;2:82–6 51 Odell JA, Henderson BJ Pneumonectomy through an empyema J Thorac Cardiovasc Surg 1985;89:423–7 52 Reed CE Pneumonectomy for chronic infection: fraught with danger? Ann Thorac Surg 1995;59:408–11 53 Laros CD, Westermann CJ Dilatation, compensatory growth, or both after pneumonectomy during childhood and adolescence A thirty-year follow-up study J Thorac Cardiovasc Surg 1987;93:570–6 54 Deslauriers J Indications for completion pneumonectomy Ann Thorac Surg 1988;46:133 55 Massard G, Dabbagh A, Wihlm JM, et al Pneumonectomy for chronic infection is a high-risk procedure Ann Thorac Surg 1996;62:1033–8 56 Reed CE, Parker EF, Crawford FA Jr Surgical resection for complications of pulmonary tuberculosis Ann Thorac Surg 1989;48:165–7 57 Sarot IA Extrapleural pneumonectomy and pleurectomy in pulmonary tuberculosis Thorax 1949;4:173–99 58 Dugan DJ, Samson PC Surgical significance of the endothoracic fascia: the anatomic basis for empyemectomy and other extrapleural technics Am J Surg 1975;130:151–8 59 Pomerantz M, Madsen L, Goble M, Iseman M Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections Ann Thorac Surg 1991;52:1108–11 60 Treasure RL, Seaworth BJ Current role of surgery in Mycobacterium tuberculosis Ann Thorac Surg 1995;59:1405–7 61 Ono N, Sato K, Yokomise H, Tamura K Surgical management of pulmonary aspergilloma Role of single-stage cavernostomy with muscle transposition Jpn J Thorac Cardiovasc Surg 2000;48:56–9 62 Jackson M, Flower CD, Shneerson JM Treatment of symptomatic pulmonary aspergillomas with intracavitary instillation of amphotericin B through an indwelling catheter Thorax 1993;48:928–30 CHAPTER 21 SURGICAL TREATMENT OF BRONCHIECTASIS AND BRONCHOLITHIASIS JEAN DESLAURIERS, MD, FRCSC Bronchiectasis ment, and prognosis differ considerably (Table 21-1).3 Localized bronchiectasis is usually the result of childhood pneumonia and often has a benign course characterized by recurrent pulmonary infections always in the same anatomic territory (Figure 21-1) By contrast, diffuse bronchiectasis is often related to immune deficiencies, is bilateral, and may lead to death from respiratory failure This chapter specifically addresses some of the important issues in the pathogenesis, pathology, investigation, and management of true bronchiectasis Bronchiectasis is defined as permanent dilatations of the bronchi with destruction of the bronchial wall This definition differentiates true bronchiectasis from functional bronchiectasis or pseudobronchiectasis, which is expected to return to normal once control of infection has been achieved From the time of Laennec’s description of the disease in 18191 to the discovery of antibiotics, bronchiectasis was considered a morbid disease with a high mortality rate from respiratory failure and cor pulmonale With the advent of specific antibiotics and prompt recognition and effective treatment of pulmonary infection in childhood, the incidence and surgical significance of bronchiectasis has decreased significantly over the last century In developing countries, however, bronchiectasis still constitutes a significant problem.2 In the context of clinical practice, there are two types of bronchiectasis, in which the pathogenesis, manage- History In 1819, Laennec, in his Traité de l’auscultation médiate ou traité du diagnostic des maladies des poumons et du cœur, was the first to describe bronchial dilatations.1 He attributed this condition to accumulation and stagnation of bronchial secretions and emphasized that bronchial dilatations were more likely to occur in the dependent portions of the lung He further proposed to classify TABLE 21-1 Localized and Diffuse Bronchiectasis Localized Bronchiectasis Anatomy Clinical signs Imaging Bronchoscopy Spirometry Management Prognosis Diffuse Bronchiectasis Confined to one site distal to segmental,lobar, or main bronchus Repeated infections characterized by fever, cough, purulent sputum, and sometimes chest pain and hemoptysis Localized pneumonic infiltrate Loss of volume Localized dilatation on computed tomography Must be done to rule out foreign body or tumor Often normal Surgery for repeated infections, hemoptysis Good Multisegmental, multilobar, and often bilateral 266 Repeated infections, daily purulent bronchorrhea, sinusitis Rhonchi always present Clubbing common in advanced disease Diffuse disease predominantly in lung bases Must be done for culture and sensitivity of secretions Mixed obstruction and restriction with decreased Pa02 Surgery seldom indicated Poor with eventual hypoxemia, pulmonary hypertension, and cor pulmonale 268 / Advanced Therapy in Thoracic Surgery Although several anatomic classifications for bronchiectasis have been proposed, the method suggested by Reid in 1950 is certainly the most widely used and easier to correlate with radiologic findings.14 In this morphologic classification, bronchiectasis is divided into (1) a cylindrical variety, in which the dilated bronchi maintain a regular outline until they reach the junction with smaller airways, where there is obstruction by secretions, (2) a varicose pattern, in which dilated bronchi have irregular contours similar to varicose veins (Figure 21-3), and (3) a more severe form of cystic (Figure 21-4) or saccular bronchiectasis, in which there are cystic dilatations in a patent bronchus or air fluid levels are noted Reid has also shown that distal destruction was more severe in the saccular than in the cylindrical variety of bronchiectasis and that the dilated airways are commonly filled with pools of thick and purulent material They can also be occluded by secretions, scar tissue, or distortion In a classic and elegant study of the pathology and pathogenesis of bronchiectasis published in 1952, FIGURE 21-2 A, Standard PA chest radiograph, and B, right bronchogram showing the classic image of Kartagener’s syndrome characterized by dextrocardia and bronchiectasis (cylindrical) in the anatomic left lower lobe (patient’s right side) FIGURE 21-3 A, Standard PA chest radiograph, and B, Computed tomography scan showing varicose bronchiectasis in a 45-year-old asthmatic patient In this case, the bronchiectasis was thought to be secondary to bronchopulmonary aspergillosis 270 / Advanced Therapy in Thoracic Surgery bronchiectasis Aspirated foreign bodies or gastric contents, slow-growing neoplasms, and mucous impaction can all cause local retention of secretions, secondary infection, and bronchiectasis Inhalation of peanuts is specifically dangerous in children, in whom bronchiectasis can develop within a matter of a few days Functional bronchial obstruction can also be a factor in the pathogenesis of diffuse bronchiectasis in cases of chronic bronchitis or allergic bronchopulmonary aspergillosis Perhaps the most common extrinsic factor related to the development of bronchiectasis is the bronchial aspiration of infected mucus from the nasal accessory sinuses Host factors per se are uncommon causes of bronchiectasis, although it is likely that in many cases, immunodeficiency cannot be adequately documented by laboratory testing To date, the strongest association is that with primary ciliary dyskinesia (PCD) (Figure 21-5) and cystic fibrosis (CF) In congenital ciliary defects, including the Kartagener syndrome, the defect, which is an autosomal recessive disorder, is a structure abnormality of the dyneic arm of the cilia causing impaired ciliary function and poor clearance of secretions.19–21 Due to this impaired mucociliary transport, bronchopulmonary infections occur and these may be important causes of bronchiectasis Patients with Kartagener syndrome present with sinusitis, situs inversus, bronchiectasis, decreased serum levels of immunoglobulin (Ig) A (IgA), and abnormal ciliary motility due to dyneic arm abnormalities, which result in failure of the cilia to beat.22,23 It is worth noting that most male patients with ciliary defects are also infertile because of dysfunction in spermatozoid movements (Table 21-3) In CF, the sol layer is affected by the disease According to Boucher, alveolar secretion of water appears deficient, and sodium and water reabsorption in the airways is increased.19 Thus, the sol layer is constricted, and the mucous layer impacts on the cilia, interferes with their beating, and slows clearance Because of that, mucous plugging and lobar collapse are common occurrences in CF Bronchiectasis associated with CF tends to involve primarily the upper lobes Immunoglobulin deficiencies can also lead to bronchiectasis by predisposing to recurrent and severe FIGURE 21-5 Bronchogram showing cylindrical bronchiectasis (arrow) in the left lower lobe in a 51-year-old man with congenital ciliary defects bronchopulmonary infection, and often these infections are caused by organisms of relatively low virulence, such as Pneumocystis carinii or cytomegalovirus In patients with immunoglobulin deficiencies, the incidence of bronchiectasis is in the range of 10%, and most patients have a mixed deficiency of IgA and IgG Bronchiectasis is also prevalent in patients with human immunodeficiency virus (HIV) infection and in the transplant population Other rare congenital disorders that are associated with bronchiectasis include (1) Williams-Campbell syndrome,24 characterized by congenital absence of cartilage beyond segmental bronchi, (2) Young’s syndrome (see Table 21-3), characterized by sinopulmonary infections and epididymal disease causing infertility, and (3) Mounier-Kuhn syndrome,25 which consists of dilatation of the trachea and main bronchi secondary to abnormalities of the connective tissue of the airways Alpha-1- TABLE 21-3 Congenital Ciliary Defects and Bronchiectasis Syndrome Bronchiectasis Cilia Epididymal Disease Spermogram Sweat Test Ciliary defects Yes Abnormal No Normal Cystic fibrosis Young’s syndrome Yes Yes Normal Normal Yes Yes Immobile spermatozoids Azoospermy Azoospermy Abnormal Normal Surgical Treatment of Bronchiectasis and Broncholithiasis / 271 antitrypsin deficiencies usually lead to panacinar emphysema, but in some cases, it has been reported to be associated with bronchiectasis.26 There remains a group of patients in whom no acquired or host factors can be positively identified but yet who develop bronchiectasis These patients often have diffuse bronchiectasis and sinusitis, and it is likely that most have some degree of immunologic deficiency, even though it may not be measurable Diagnosis clinical presentation The clinical presentation of patients with bronchiectasis is variable and depends on the etiology of bronchiectasis and on whether the condition is localized or diffuse (see Table 21-1) However, the hallmark of this pathology consists of chronic cough, bronchial suppuration, and purulent bronchorrhea, which in some cases can amount to 500 mL daily In the past, some bronchiectasis has been described as being nonproductive or “dry,” although in retrospect these were mostly cases of post-tuberculous bronchiectasis located in the upper lobes Patients with bronchiectasis typically present with a history of recurrent febrile episodes, and indeed the diagnosis of bronchiectasis is often made at the time of an acute infectious exacerbation Repeated infections can lead to the occurrence of hemoptysis of variable amounts but usually not massive or life threatening In the series by Brooke Nicotra and colleagues, cough was the most important symptom affecting 90% of the cohort (Table 21-4).18 Hemoptysis occurred in 51% of patients, with the episodes tending to recur A history of recurrent episodes of fever frequently accompanied by pleuritic chest pain was also present in most patients, as was dyspnea Physical examination is often nonspecific, with clubbing being present in less than 5% of cases Occasionally, TABLE 21-4 Symptoms and Signs of Bronchiectasis Symptoms Cough Daily sputum Hemoptysis Recurrent fever Recurrent pleurisy Dyspnea Signs Crackles Wheezing Squeaks (rhonchi) Clubbing No (%) of Patients with Finding 111 (90.2) 93 (75.6) 63 (51.2) 86 (69.9) 57 (46.3) 88 (71.5) No (%) of Patients with Finding 86 (69.9) 42 (34.1) 64 (43.9) (3.2) From Brooke Nicotra M, et al Clinical, pathophysiologic, and microbiologic characterization of bronchiectasis in an aging cohort Chest 1995; 108:955–61 nasal polyps associated with chronic sinusitis will be seen Crepitation, wheezing, and coarse expiratory rhonchi may be heard over the lung bases, whereas clinical signs of cor pulmonale and denutrition are uncommon and indicate advanced disease Routine clinical assessment should include a careful recording of personal and familial history, which may indicate an inherited disorder Complaints of sinus problems, repeated infections at other sites, infertility, or a family history of similar problems may all be important in selecting the proper management strategy imaging Standard chest radiographs are usually the first examinations done, and although the changes noted are nonspecific, they may indicate the need for further investigation Recognizable signs include linear markings due to peribronchial fibrosis and retained secretions, patchy or confluent pulmonary shadows, or evidence of lobe collapse Occasionally, a dilated bronchus will be seen as an image of bronchocele Computed tomography (CT) scanning is currently the best technique to establish the presence, severity, and distribution of bronchiectasis,27–29 replacing Lipiodol bronchography, which is considered more invasive and more unpleasant to the patient as well as being occasionally associated with complications such as alveolitis or allergy to the local anesthetic agent or contrast medium In addition, there can be considerable disagreement between experienced radiologists and clinicians in the interpretation of bronchograms For accurate assessment of bronchiectasis, both bronchography and CT scanning should be done at least to weeks after the end of an acute infectious episode The CT scan has a sensitivity of 66% and specificity of 92% with 10 mm thick sections30 but a sensitivity of 84% and specificity of 92% with thin sections of 1.5 mm.31 False-negative images are essentially found in territories adjacent to cardiac cavities but this limitation has decreased with the use of high-resolution and spiral CT Another advantage of CT scanning over bronchography is the better imaging of peribronchial inflammation and parenchymal disease The nature of CT scan images depends on the number, size, type, and contents of bronchial dilatations as well as on the axis of the pathologic bronchi versus the axis of the CT scan cut Perfusion isotopic scans are considered important in the preoperative evaluation of patients with bronchiectasis because they may demonstrate abnormal territories considered normal on CT scans but representing potential areas of bronchial dilatations This is explained by bronchial artery hyperplasia creating flow reversal through systemic to pulmonary artery shunting, thus causing areas of defective perfusion on the isotopic scan 272 / Advanced Therapy in Thoracic Surgery Such amputations may not only indicate more extensive disease than assessed by CT scan, but their presence may also influence the choice of therapy By contrast, normal perfusion indicates that there is no significant bronchiectasis, for which surgery is not indicated,16,17 and is also seen with complete segmental or lobar atelectasis and replacement of the anatomic territory by adjacent normal lung (false-negative) other investigations Other tests that should be done in cases of bronchiectasis include bronchoscopy to rule out a foreign body or tumor, bacteriological examination of bronchial secretions for culture and sensitivity, a sweat test for CF, radiographs or CT scanning of the sinuses, and a simple immunologic work-up consisting of measurements of serum levels of immunoglobulin (B lymphocytes), lymphocyte count and cutaneous tests (T lymphocytes), white blood cell count and differential (phagocytes), and assays of individual components of complement (CH50, C3, C4).32 Pulmonary function studies are usually normal in patients with localized bronchiectasis In patients with diffuse bronchiectasis, several authors have found evidence of airway obstruction similar to that observed in chronic bronchitis.33 In patients with severe bronchiectasis, a mixed obstructive and restrictive pattern with hypoxemia has been observed Other examinations that may be done if necessary include bronchial arteriography to document the origin of hemoptysis, esophageal studies if gastroesophageal reflux is suspected, and ultrastructural examination of cilia from biopsy of the nasal respiratory epithelium if ciliary dyskinesia is suspected Medical Management The initial treatment strategy for nearly all patients with bronchiectasis should be conservative (Table 21-5) This includes infection control, bronchodilation, and active physical therapy In general, antibiotics tend to reduce the daily amount of sputum, its purulence, and the number of hospital days Long-term administration of antibiotics may also be helpful in some individuals Bronchodilators, usually administered by nebulizer, tend to reduce mucosal edema and associated bronchospasm Physical TABLE 21-5 Objectives of Conservative Treatment Elimination of underlying cause (if reversible) Treatment of associated and contributing conditions (eg, sinusitis or gastroesophageal reflux) Control of infection (antibiotics) Improved clearance of secretions (physical therapy and postural drainage) Reversal of air-flow limitation (bronchodilators) therapy is most important in patients with multisegmental disease, and it includes postural drainage34 with clapping done several times daily, breathing exercises, and the teaching of principles of respiratory hygiene Other measures that are part of the medical management of bronchiectasis include the use of humidity to increase mucous fluidity, mucolytic and expectorant drugs, and the reduction of exposure to irritants such as tobacco smoke and industrial products Perhaps the most important aspect of medical management is the aggressive treatment of associated conditions such as sinusitis, gastroesophageal reflux, or immunoglobulin deficiencies, and the elimination of reversible underlying causes (eg, endobronchial tumors or foreign bodies) Immunizations against pertussis or measles and influenza vaccine given yearly are also helpful Surgical Treatment and Results According to Hodder and colleagues, patients who are candidates for surgical resection must fulfill the following criteria35: (1) have localized bronchiectasis adequately documented preoperatively by bronchography or CT scanning, (2) have adequate cardiopulmonary reserve to tolerate the proposed resection, (3) have an irreversible process and not an early radically treatable condition, (4) have significant symptoms with a continued chronic productive cough, repeated or significant hemoptysis, or recurring major episodes of pneumonia, and (5) have failed an adequate trial of medical management If these conditions are fulfilled, complete resection of all dilated segments is usually possible, and the results of surgery are excellent In all patients undergoing pulmonary resection, it is imperative to clearly determine preoperatively the extent of resection to be done because at surgery it may be difficult to judge with great accuracy the segments that are involved Indirect signs that may be helpful during operation are the poor expansion of involved segments or lobes, the actual palpation of ectatic bronchi, and the lack of anthracotic pigment over the abnormal lung, indicating lack of function All patients undergoing surgery must also be adequately prepared by specific antibiotics given for at least 48 hours prior to operation and by active physical therapy with clapping and postural drainage Every type of resection is possible for bronchiectasis, the purpose of surgery being to remove all involved segments while preserving maximum function Technically, the surgery of bronchiectasis can be either very easy or extremely difficult, and a double-lumen tube should always be used to avoid possible intraoperative contamination of contralateral lobes Technical difficulties may arise with dense adhesions, hyperplastic lymph nodes around the pulmonary artery and its branches, Surgical Treatment of Bronchiectasis and Broncholithiasis / 273 and incomplete fissures Bronchial artery hyperplasia around the bronchus may be finally the source of intraor postoperative bleeding if these vessels are not carefully identified and ligated It is worth noting that because of bronchial artery hyperplasia and good vascular supply to the bronchus, patients with bronchiectasis undergoing lobectomy are expected to have a lower incidence of postoperative bronchopleural fistula than similar patients undergoing lobectomy for lung cancer Although the results of surgery are excellent in patients with limited and localized disease, these results are less predictable in patients with diffuse and multisegmental disease, and operation should generally be avoided in these individuals In this group, patients who may benefit from surgery have the following indications: (1) disease that is symptomatic, unresponsive to medical treatment, and can be completely resected; (2) hemoptysis that cannot be controlled or recurs after bronchial artery embolization, and (3) the need for palliative surgery in which the most involved lobe or segments are resected to improve symptoms In select individuals, limited resections of targeted segments may achieve lasting symptomatic improvement In one series from France, total disappearance or regression of preoperative symptoms occurred in 75% of such patients.36 Surgical resection of bronchiectasis in patients with CF or in patients with PCD is more controversial and very few patients with these conditions will benefit from operation In one small series from the Netherlands, 11 of 13 patients who underwent surgical resection of bronchiectasis associated with PCD felt better after the operation.21 Patients with CF are even less likely to benefit from surgery because their condition is compounded by nutritional deficiencies, colonization of sinuses and airways with resistant organisms, and systemic comorbidities including hepatic and pancreatic dysfunctions.37 Although many authors have presented the results of surgery for bronchiectasis, the past and current literature is difficult to interpret because of the nonhomogeneity of inclusion criteria, methods of diagnosis, and treatment strategies For the purpose of clarity, I have chosen to review only three series,2,3,38 all of which present similar results, although there is a 35-year interval between these three publications (Table 21-6) In the series by Sealy and colleagues, 140 patients underwent resection of bronchiectasis between 1954 and 1963, and of these, 70 had localized disease and 70 had diffuse multisegmental bronchiectasis considered to be part of a panrespiratory tract involvement.3 Of the 70 patients with localized disease, 42 could relate the onset to an episode of pneumonia (n = 37) or aspiration of a foreign body (n = 5), whereas only 19 of the 70 patients with multisegmental bronchiectasis could trace the onset to a previous episode of pneumonia One hundred and five patients complained of a persistent productive cough, and “the more extensive the disease, the greater the sputum volume.” Hemoptysis occurred in 75 patients and varied from blood streaking to brisk hemorrhage In that series, postoperative complications were uncommon, and the operative mortality was of 157 operations (1.3%) For 95% of patients, the operation was considered beneficial, and a greater number of good results was obtained in those patients with localized disease Fifteen patients had bilateral resections and 13 of 15 were considered to have a good result or were improved, while in 13 of 22 patients with bilateral disease, a second operation was never required because of good outcome after resection of the more involved side In the series by Agasthian and colleagues from the Mayo Clinic, 134 patients underwent pulmonary resection for bronchiectasis between 1976 and 1993.38 The mean duration of symptoms was years and included a productive cough (n = 104), recurrent infections (n = 81), and hemoptysis (n = 56) In that series, the operative mortality was 2.2% and the morbidity rate was 24% Overall, 61 patients (59.2%) became asymptomatic during follow-up, and symptoms were improved in an additional 30 patients (29.1%) In a more recent series from Turkey, 166 patients underwent surgery for bronchiectasis, mostly because of chronic infection and daily significant bronchorrhea.2 At follow-up (mean of 4.2 years), 75% of patients were asymptomatic and an additional 20% had improved symptoms and quality of life Although several prognostic factors for good results after surgery have been described, Fujimoto and colleagues were able to extract only three significant prognostic factors by logistic regression,40 and these were cylindrical type of bronchiectasis, absence of sinusitis, and complete resection of the diseased parenchyma From personal experience41 and a review of the literature, it is clear that surgery for bronchiectasis can be TABLE 21-6 Results of Surgery for Bronchiectasis Author Sealy et al (1966)3 Agasthian et al (1996)38 Kutlay et al (2002)2 Year 1954–1963 1976–1993 1990–2000 Number of Patients Operative Mortality 140 134 166 1% 2% 2% Morbidity — 25% 11% Asymptomatic 58% 59% 75% Asymptomatic and Improved 95% 88% 96% 274 / Advanced Therapy in Thoracic Surgery done with minimal complications and that it improves symptoms and quality of life, mostly in younger patients with localized disease Broncholithiasis Broncholithiasis is a condition in which a calcified mass is found within, or has eroded into, the lumen of a bronchus According to Faber and colleagues, the first description of lithoptysis or the “spitting of stones” is that of Aristotle in the year 300 BC.42 In the year 1600, Shenk and Groftenberg reported 17 patients with lithoptysis,43 and in 1744, Boerhaave described the expectoration of 400 broncholiths by the botanist Vallentius.43 A number of clinical reports have documented that the usual causes of broncholithiasis are tuberculosis and histoplasmosis Pathogenesis and Bacteriology The source of broncholithiasis is usually a lymph node that has undergone calcification through precipitation of calcium salts following an acute infectious lymphadenitis Because of the constant respiratory movements of the bronchi, this now calcified node eventually causes a bronchial stricture with distal infection and bronchiectasis or a complete bronchial obstruction with distal atelectasis These nodes can also erode into adjacent vascular structures, usually the pulmonary artery, or into the esophagus, creating a bronchoesophageal fistula In many cases of nodal histoplasmosis, this process of erosion is helped by the morphology of bronchioliths, which have a sharp and narrow ossified rim.44 Most cases of broncholithiasis occur on the right side because of the greater number and particular anatomy of nodes on that side Although the original infective organisms may be difficult to isolate from resected specimens, most cases of broncholithiasis are believed to be caused by either tuberculosis or nodal infection by Histoplasma capsulatum Other organisms possibly involved include Coccidioides immitis, Cryptococcus neoformans, and Blastomyces dermatitidis In the report of Cole and colleagues, the offending organism was isolated in only 15 of 42 cases (36%),43 while in the series by Faber and colleagues, the organism was found in only of 43 patients (5%).42 Rare causes of broncholithiasis include renal stone erosion, silicosis,43 and sarcoidosis Diagnosis Most patients with broncholithiasis are symptomatic, and only a handful will actually spit stones The most common symptom is that of protracted and severe cough, often present for years and unresponsive to the usual treatment.45 This cough, which is due to mechanical irritation of the bronchial mucosa, may be accompanied by purulent bronchorrhea if there is associated lung infection Hemoptysis may result from direct vascular erosion or from granulation tissue that has formed over the site of bronchial erosion Of the 43 patients with broncholithiasis presented by Faber and colleagues, hemoptysis was a major complaint in 16 patients, and in 11 of the 16, it was recurrent.42 It is important to remember that unlike what is seen with bronchiectasis, hemoptysis associated with broncholithiasis can be life threatening Other symptoms include wheezing, if the broncholithiasis is obstructive of a bronchus, and chronic suppuration The diagnosis of broncholithiasis can be suspected from standard radiographs showing extensive hilar or multiple areas of calcification with distal atelectasis or parenchymal consolidation.42 One interesting radiologic feature is the migration of calcified foci identified on previous radiographs The definitive diagnosis of broncholithiasis is usually made by a combination of CT scanning46 and bronchoscopy, which may show the actual broncholith or other nonspecific abnormalities, such as granulation tissue, edema, or extrinsic compression with stenotic bronchi Management Options Three treatment modalities are available for the management of patients with broncholithiasis,47,48 and these are surgical intervention, endoscopic removal, and observation Indications for surgery include recurrent hemoptysis, intractable cough, bronchiectasis and suppurative lung disease, bronchial stenosis, and, less often, bronchoesophageal or bronchovascular fistulas In 2000, Potaris and colleagues from the Mayo Clinic reported on 47 patients with broncholithiasis who underwent operation.48 Indications for surgery were hemoptysis in 20 patients, recurrent pneumonia in 11, and other reasons in 16 patients As a rule, resection should aim at preserving as much normal lung as possible, but at the same time, it should be extensive enough to remove both the broncholith and distal bronchiectatic lung.42 Whenever possible, sleeve lobectomies or sleeve bronchial resections should be done instead of pneumonectomies During surgery, dissection of individual blood vessels may be dangerous, and it is recommended that proximal control of the pulmonary artery be attained before dissection is begun more distally.42 In the surgical group of 47 patients reported by Potaris and colleagues, both pulmonary resection and broncholithectomy were performed in 30 patients while broncholithectomy without pulmonary resection was done in patients.48 In that series, intraoperative complications occurred in six patients, but none were fatal These included lacerations ... procedures in hydatid disease of the lung in children Surgery 1970;68:379–82 14 Slim MS, Akel SR Hydatidosis in children Prog Pediatr Surg 1982; 15: 119–29  250 / Advanced Therapy in Thoracic Surgery 15. .. Thorac Cardiovasc Surg 1978; 75: 680–7 264 / Advanced Therapy in Thoracic Surgery 11 Stansell JD Pulmonary fungal infections in HIV-infected persons Semin Respir Infect 1993;8:116–23 12 Cendan... Semin Med Bs As 1924;31:271 29 King C Echinococcosis In: Principles and practice of infectious disease 4th ed New York: Churchill & Livingstone; 19 95 p 255 0–1 30 World Health Organization Echinococcosis,