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Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence
C Deschamps1, A Bernard, F C Nichols
1Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA. deschamps.claude@mayo.edu
Background:
Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed.
Methods:
All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis.
Results:
Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis.
Conclusions:
Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.
Insights
Post-pneumonectomy empyema and bronchopleural fistula (BPF) are linked to benign disease, lower lung function, and specific surgical techniques. Prophylactic bronchial stump reinforcement may benefit high-risk patients.
Area of Science:
- Thoracic Surgery
- Surgical Oncology
- Pulmonary Medicine
Background:
- Pneumonectomy, a major lung resection, carries risks of serious postoperative complications.
- Empyema and bronchopleural fistula (BPF) are significant morbidities following pneumonectomy.
- Identifying factors influencing these complications is crucial for improving patient outcomes.
Purpose of the Study:
- To analyze factors associated with the incidence of empyema and BPF after pneumonectomy.
- To identify risk factors and potential protective measures for these postoperative complications.
Main Methods:
- Retrospective review of 713 patients undergoing pneumonectomy at the Mayo Clinic (1985-1998).
- Analysis of patient demographics, indications for surgery, and surgical variables.
- Univariate and multivariate statistical analyses to determine factors affecting empyema and BPF incidence.
Main Results:
- Empyema occurred in 7.5% of patients, and BPF in 4.5%.
- Risk factors for empyema included benign disease, lower preoperative FEV1 and DLCO, right pneumonectomy, and completion pneumonectomy.
- Risk factors for BPF included benign disease, lower preoperative FEV1 and DLCO, right pneumonectomy, and bronchial stump reinforcement; staple closure was protective against BPF.
Conclusions:
- Several perioperative factors significantly increase the risk of empyema and BPF after pneumonectomy.
- Prophylactic reinforcement of the bronchial stump with viable tissue is suggested for high-risk patients.
- Further research may refine risk stratification and preventative strategies.