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Clinical Cases

Videomediastinoscopic transcervical approach of postpneumonectomy left main bronchial fistula

Andrei Cristian Bobocea1, Cristian Paleru1, 2, Ciprian Lovin3, Olga Danaila1, Ciprian Bolca1, Radu Stoica4, Ioan Cordos1, 2 Contact: Andrei Cristian Bobocea,
1. Clinica Chirurgie Toracica I, Institutul de Pneumologie „Marius Nasta“, Bucuresti; 2. UMF „Carol Davila“, Bucuresti; 3. Departamentul de Chirurgie Toracica, Spitalul „Sfantul Apostol Andrei“, Galati; 4. Sectia A.T.I., Institutul de Pneumologie „Marius Nasta“, Bucuresti


Bronchopleural fistulas and empyema are the most devastating complications after lung resection. The optimal management remains a major subject of controversy for thoracic surgeons over the wide variety of therapeutic approaches, none suitable for all patients. In 1996 Azorin et al. Reported the first successful mediastinoscopic reclosure by stapling of an insufficient bronchial stump after left pneumonectomy using video-assisted mediastinoscopy. The authors report the first national case of left-sided bronchopleural fistula closure using video-assisted mediastinoscopy, describing their experiencewith this technique. A 40 years old woman presented to our unit with left thorax empyema after having undergone left pneumonectomy for TB destructed lung with aspergillosis in another hospital. Bronchoscopy revealed a 15 mm long bronchial stump with insufficiency. Despite all advances made over the last decades in perioperative management, bronchopleural fistula after pneumonectomy remains a significant problem in thoracic surgery. Video-mediastinoscopy is an alternative to the open methods as it allows approaching the bronchial stump via the mediastinum. The dissection of thetrachea through its natural route enables bronchial mobilization. Positive factors influencing our decision were the virgin mediastinum with no surgical dissection and no radiation therapy applied. The mediastinoscopic approach for bronchial stump closure after pneumonectomy is a novel option inhighly selected patients. This is our choice for a long (at least 10 mm) bronchial stump because its morbidity is minimal compared with transpericardial sternotomy or a transthoracic approach. It warrants minimal surgical trauma; however, skilled surgeons with experience in mediastinoscopy haveto be prepared to convert to an open technique immediately.

Keywords: Azorin, bronchopleural fistula, video-assisted mediastinoscopy, pneumonectomy