再次开胸瘘修补术治疗肺切除术后早期支气管胸膜瘘

Surgical repair of early bronchopleural fistula after pulmonary resection

目的总结采用再次手术瘘修补结合自体带蒂肌瓣组织包盖残端的方法治疗23例肺切除术后早期支气管胸膜瘘（BPF）（9例伴有胸腔感染）的经验，并对治疗选择进行探讨。方法23例中第一次手术方式全肺切除13例，肺叶切除10例。BPF发生时间为术后5-40天，平均21天。BPF确诊后，立即行胸腔闭式引流术并考虑行二次开胸瘘修补术。4例采用直接缝合修补瘘口，10例重新切除残端至正常组织后再次缝合，7例切除残端后行支气管成形或隆凸成形术，2例将带蒂肌瓣缝合到瘘口边缘达到封闭；瘘修补后残端后包埋的肌瓣包括肋间肌瓣5例，肋背阔肌瓣10例、前锯肌瓣6例、骶棘肌2例。瘘修补术后常规给予胸腔冲冼。结果无术中及术后近期死亡。术后并发严重并发症4例，均对症治疗后痊愈。21例瘘口修补成功，失败2例，成功率为91．3％。1例修补后2年因残端复发致BPF伴脓胸，其余均无BPF复发。结论肺切除术后早期BPF，即使有胸腔感染，如果预期可耐受手术，应尽早积极手术修补瘘口并以带蒂胸壁肌瓣包盖，结合术后胸腔持续冲洗，可获得良好效果。

Objective Bronchopleural fistula （BPF） is a common but potentially lethal complication after pulmonary re- section. Currently, there is still controversy over the appropriate management strategy for BPF, especially when pleural space contamination develops. The purpose of this study was to evaluate the efficacy and safety of surgical repair fistulas combined with pedieled muscle flaps coverage in patients with early BPF after pulmonary resection based on our experience with 23 cases. Methods The clinical data for 23 patients who underwent surgical repair of early BPF from January 1999 to December 2010 at our hospital were reviewed. Thirteen patients had undergone a prior pneumonectomy and 10 patients had undergone a prior lo- bectomy. BPF occurred from postoperative day 5 to 40 （ mean postoperative day 21 ）. Nine patients had a contaminated pleural space. After BPF was clearly diagnosed, prompt closed pleural drainage was instituted, followed by surgical repair of BPF. Four patients underwent a direct suture repair of fistula, ten patients underwent stump revision and suture closure, seven pa- tients underwent stump revision and bronchoplasty or carina plasty, and a pedicled muscle flap was sewn to the edges of the fis- tula in two patients. The stump was covered with various muscle flaps, including intercostal muscle flap in five cases, latissi- mus dorsi muscle flap in ten eases, serratus anterior muscle flap in six cases, and erector spinae muscle flap in two cases. Post- operatively, the pleural space was routinely irrigated and drained. Results No intraoperative or early postoperative death oc- curred. Four patients developed severe complications, including respiratory failure in two cases, pulmonary embolism in one case, and empyema in one case. All four eases recovered well after treatment. The mean duration of hospitalization was 33 days （ range 8 - 120 days）. Surgical repair of BPF was successful in 21 cases （91.3%） but failed for 2 patients.. BPF recurrence developed in only one patient two years postoperatively due to stump recurrence. He died of extensive metastatic disease 2 years after BPF recurrence. Conclusion Excellent results can be achieved by early surgical repair combined with stump pedicled muscle flaps coverage in patients with BPF who can tolerate reoperation, even if they have a contaminated pleural space.