Martini et al4 reported the overall incidence of recurrence in patients with resected stage I NSCLC was 27% (local or regional 7%, systemic 20%). In the study by Harpole et al,5 the initial location of recurrence of stage I NSCLC after surgical resection was at a distant site in 19%, within the ipsilateral hemithorax in 11% or at both locations in 6% of patients. Distant recurrence rates between 14% to 23% in stage I NSCLC after surgical resection have also been reported in the literature.6-8 Our studies11,12 demonstrated that overall incidence of recurrence was 31.0% (distant only in 17.8%, local only in 7.9%, local and distant in 5.3%) in stage I NSCLC after surgical resection. The patterns of local recurrence included local only in 60.2%, local with distant in 15.4%, local before distant in 19.5% and distant before local in 4.9% of patients. Approximately 78% of patients with local recurrence occurred within the first 2 years after operation. We also showed that approximately 84% of patients with distant metastases occurred within the first 2 years after operation. A major proportion of patients (62%) died within one year after distant metastasis.

Most distant metastases appear as multiple foci in multiple organs after treatment of original cancer.30 Martini et al4 reported that the most common site of distant metastasis in patients with resected stage I NSCLC was the brain. Yoshino et al31 demonstrated that pulmonary metastasis was most common in NSCLC patients with recurrence at distant organs, followed by bone metastasis. Our study12 revealed that bone (32.1%) was the most common site of single organ metastasis in patients with resected stage I NSCLC, followed by the brain (29.2%). We further demonstrated that the patterns of distant metastasis included single and multiple organ metastases in approximately 64% and 36% of patients, respectively.

The recurrence-free rate of stage I NSCLC (TNM 7) has also been reported in the literature.28,32,33 Maeda et al32,33 reported that the 5-year recurrence-free rate in patients with stage IA NSCLC (TNM 7) ranges between 84 to 87%. In another article by Maeda et al,28 they reported that 5-year recurrence-free rate in patients with stage I NSCLC (TNM 7) was 84.2%.

## **4. Predictors of recurrence**

286 Topics in Thoracic Surgery

The prognostic factors of stage I NSCLC (TNM 6) have been widely reported in the literature.4-6,18,19 Martini et al4 reported that T2 status and sublobar resection were the prognostic factors for poor overall survival in resected stage I NSCLC. Harpole et all5 reported that presence of symptoms, vascular invasion, visceral pleural invasion and tumor size greater than 3 cm were the factors affecting overall survival in resected stage I NSCLC. Sawyer et al18 reported that factors predicting poor overall survival included fewer than 15 lymph nodes dissected and tumor size greater than 3 cm. Varlotto et al19 also reported that lymphadenectomy was associated with improved overall survival and disease-free survival in resected stage I NSCLC. Many other reports also demonstrated the prognostic value of tumor size in stage I NSCLC.6,20 The number of mediastinal lymph nodes dissected/sampled alternatively represents the quality of lymphadenectomy and affects the survival rate for patients with resected stage I NSCLC.19,21 Our previous studies21,22 also showed that number of mediastinal lymph nodes dissected/sampled was a predictor of survival in stage I NSCLC. Cigarette smoking has been shown to be another prognostic factor in patients with NSCLC in the literature.23-26 Hanagiri et al23 reported that smoking was a significant postoperative prognostic factor in patients with NSCLC. Bryant et al24 reported that 5-year survival rate was significantly better for never smokers compared to

Only few studies reported the prognostic factors of stage I NSCLC (TNM 7).25-28 In the report by Maeda et al, 27 5-year overall survival rates for stage IA and IB (TNM 7) were 89.9% and 72.3%, respectively. They also demonstrated that older age, intratumoral vascular invasion, and visceral pleural invasion were poor prognostic factors in stage IB NSCLC.27 In the report by Maeda et al,27 5-year disease-specific survival rates for stage IA and IB NSCLC (TNM 7) were 93.1% and 72.3%, respectively. They also demonstrated that intratumoral vascular invasion and visceral pleural invasion were poor prognostic factors for cancerspecific survival in stage IB NSCLC.27 Maeda et al25 reported that overall survival and recurrence-free survival in never smokers were significant better than those of ever smokers in patients with stage I NSCLC (TNM 7). Maeda et al26 also discovered that a greater smoking extent was associated with the presence of solid components in stage I lung adenocarcinoma, which may have more aggressive biological features resulting in poorer

For stage I NSCLC (TNM 6), Martini et al4 reported that the 2- and 5-year recurrence-free rates were 84% and 76%, respectively. Sixty percent of patients developed recurrence within the first 2 years after operation. Sawyer et al18 reported that 5-year of local recurrence-free and distant metastasis-free rates were 85% and 83%, respectively, in patients with resected stage I NSCLC. In the study by Varlotto et al 29 regarding tumor recurrence in patients with resected NSCLC (including 82% of patients with stage I NSCLC), the 2- and 5-year local recurrence-free rates were 84% and 68%, respectively. The 2- and 5-year distant metastasis-

Martini et al4 reported the overall incidence of recurrence in patients with resected stage I NSCLC was 27% (local or regional 7%, systemic 20%). In the study by Harpole et al,5 the

**2. Prognostic factors for stage I NSCLC**

smokers in stage I NSCLC (TNM 6).

outcomes.

**3. Recurrence patterns**

free rates were 87% and 79%, respectively.

The predictors for recurrence in resected stage I NSCLC (TNM 6) has been well demonstrated in the literature.4,5,18,29 In the report by Martini et al,4 the factors having adverse effects on recurrence in resected stage I NSCLC included lesser resection than lobectomy, no lymph node dissection, T2 tumor, and greater tumor size. In the study by Harpole et al,5 the factors affecting early recurrence in resected stage I NSCLC included presence of symptoms, vascular invasion, visceral pleural invasion, and tumor size greater than 3 cm. Although both Martini et al4 and Harpole et al5 performed elegant analysis demonstrating the factors influencing tumor recurrence in resected stage I NSCLC, they did not analyze local recurrence and distant metastasis as separate end-points. Only few studies evaluated the risk factors for local recurrence and distant metastasis separately. Varlotto et al29 reported that local recurrence in resected NSCLC was associated with lymphatic or vascular invasion, the use of chemotherapy, and diabetes. Distant metastasis in resected NSCLC was significantly higher in patients with non-squamous cell histology, those undergoing pneumonectomy and those with more advanced TNM stage.29 In the report by Sawyer et al,18 the factors independently predicting local recurrence in resected stage I NSCLC included fewer than 15 lymph nodes dissected and T2 tumor. Tumor size greater than 5 cm and non-squamous histology independently predicted a poor distant metastasisfree rate in resected stage I NSCLC.18

Stage I Non-Small Cell Lung Cancer: Recurrence Patterns, Prognostic Factors and Survival 289

pulmonary resection. If the two patients were excluded, patients undergoing re-operation had significantly better post-recurrence survival than those receiving chemotherapy and/or radiotherapy (*P* = 0.021). The differences of therapeutic effects of surgery and chemotherapy

Disease-free interval has also been shown to be a significant prognostic factor of postrecurrence survival in NSCLC. Longer disease-free interval was associated as with better post-recurrence survival in NSCLC after complete pulmonary resection.10,34,36 Walsh et al34 reported that disease-free interval greater than 12 months was a favorable predictor of postrecurrence survival in NSCLC after complete resection. Our study12 showed that diseasefree interval > 16 months was a significant predictor for better post-recurrence survival in

Although some reports in the literature had tried to figure out the impact of specific distant metastatic organ sites on post-recurrence survival in resected NSCLC, small cohorts or mixtures with local and distant metastasis made it difficult to acquire definite results. Sugimura et al10 reported that initial recurrence confined to the lung was associated with better post-recurrence survival in resected NSCLC. Yoshino et al31 demonstrated that intra-pulmonary metastasis was a favorable factor for postrecurrence survival of resected NSCLC, while bone metastasis was a marginally unfavorable factor. Liver metastasis has also been reported as a worse prognostic factor in NSCLC after recurrence.7,36 In our study, patients with distant metastases confined within the contralateral lung have significantly better post-recurrence survival than those with distant metastases outside the contralateral lung. We further showed that for patients with distant metastases outside the contralateral lung, those with bone metastasis had

Treatment for initial recurrence is a prognostic predictor for post-recurrence survival in resected stage I NSCLC with local recurrence. Longer disease-free interval and treatment for distant metastasis are indicators for better post-recurrence survival in resected stage I NSCLC with single organ metastasis. Complete surgical resection should be considered in selected candidates with resectable local recurrent disease. Aggressive treatment for distant metastasis in selected patients with longer disease-free interval may prolong the post-

[1] Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med.

[2] Scott WJ, Howington J, Feigenberg S, et al. Treatment of Non-small Cell Lung Cancer

[3] Mountain CF. Revisions in the international system for staging lung cancer. Chest.

Stage I and Stage II: ACCP Evidence-Based Clinical Practice Guidelines (2nd

and/or radiotherapy need larger series for further investigation.

patients with stage I NSCLC after distant metastasis.

significantly worse post-recurrence survival.

**6. Conclusion**

recurrence survival.

2004;350:379-392.

1997;111:1710-1717.

Edition). Chest. 2007;132:234S-242S.

**7. References**

The predictors for recurrence in resected stage I NSCLC (TNM 7) has not been widely investigated in the literature. In the reports by Maeda et al,28,33 they demonstrated that histologic differentiation, intratumoral vascular invasion, and visceral of pleural invasion were significant predictors for recurrence in stage I NSCLC (TNM 7).

## **5. Postrecurrence survival**

In our previous study,11 the 1- and 2-year post-recurrence survival rates for resected stage I NSCLC patients with local only recurrence were 48.7% and 17.6%, respectively. Tumor size and treatment for initial recurrence were significant predictors for post-recurrence survival in patients with local only recurrence in univariate analyses. The hazard of death was greater in patients with larger tumor size. Treatment for initial recurrence was still significant prognostic indicator in multivariate analysis. Patients underwent re-operation after local recurrence survived longer than those with chemotherapy or/and radiotherapy and those without treatment.

For patients with single organ metastasis, the 1- and 2-year post-recurrence survival rates were 30.2% and 15.1%, respectively.12 The most common site of single organ metastasis was the bone, followed by the brain. Disease-free interval > 16 months and treatment for distant metastasis (including re-operation, chemotherapy and/or radiotherapy) were significant predictors of better post-recurrence survival in resected stage I NSCLC with single organ metastasis. Post-recurrence survival was not significantly different between single and multiple organ metastases groups of patients. Multiplicity of metastatic organ sites is not a significant prognostic factor in these patients. Yoshino and coworkers31 reported that the 2 year survival rate of NSCLC patients with postoperative recurrence at distant organs was 15.7 %. Their result is similar to that in our study.

Surgical resection offers a good chance of cure for patients with stage I NSCLC.3,5,20 However, the outcome of surgical treatment in resected stage I NSCLC after local recurrence have rarely been reported. Walsh et al34 reported that complete surgical resection or highdose radiotherapy with curative intent significantly prolonged post-recurrence survival in NSCLC. Sugimura et al10 demonstrated that whether surgery or combination chemotherapy with radiation significantly improved post-recurrence survival over both no treatment and radiation alone in resected NSCLC after local recurrence. Voltolini et al35 reported that 5 year survival after re-operation for locally recurrent bronchogenic carcinoma was 15.5%. The 5-year post-recurrence survival in our patients undergoing re-operation after local recurrence was 15%.

Treatment for recurrent NSCLC significantly prolongs overall survival and post-recurrence survival.10,34 Yoshino et al31 reported that patients who underwent metastatectomy for recurrence in distant organs had significantly longer survival while those with chemotherapy had marginally prolonged survival. Nakagawa et al7 reported that treatment for the initial recurrence prolonged survival in stage I NSCLC after recurrence. In our study,12 treatment for distant metastasis (including surgery and chemotherapy and/or radiotherapy) had a favorable survival in resected stage I NSCLC after distant metastasis than without treatment. There was no significant difference in post-recurrence survival between patients undergoing re-operation and those treated with chemotherapy and/or radiotherapy. However, there were two postoperative deaths due to respiratory failure after pulmonary resection. If the two patients were excluded, patients undergoing re-operation had significantly better post-recurrence survival than those receiving chemotherapy and/or radiotherapy (*P* = 0.021). The differences of therapeutic effects of surgery and chemotherapy and/or radiotherapy need larger series for further investigation.

Disease-free interval has also been shown to be a significant prognostic factor of postrecurrence survival in NSCLC. Longer disease-free interval was associated as with better post-recurrence survival in NSCLC after complete pulmonary resection.10,34,36 Walsh et al34 reported that disease-free interval greater than 12 months was a favorable predictor of postrecurrence survival in NSCLC after complete resection. Our study12 showed that diseasefree interval > 16 months was a significant predictor for better post-recurrence survival in patients with stage I NSCLC after distant metastasis.

Although some reports in the literature had tried to figure out the impact of specific distant metastatic organ sites on post-recurrence survival in resected NSCLC, small cohorts or mixtures with local and distant metastasis made it difficult to acquire definite results. Sugimura et al10 reported that initial recurrence confined to the lung was associated with better post-recurrence survival in resected NSCLC. Yoshino et al31 demonstrated that intra-pulmonary metastasis was a favorable factor for postrecurrence survival of resected NSCLC, while bone metastasis was a marginally unfavorable factor. Liver metastasis has also been reported as a worse prognostic factor in NSCLC after recurrence.7,36 In our study, patients with distant metastases confined within the contralateral lung have significantly better post-recurrence survival than those with distant metastases outside the contralateral lung. We further showed that for patients with distant metastases outside the contralateral lung, those with bone metastasis had significantly worse post-recurrence survival.

## **6. Conclusion**

288 Topics in Thoracic Surgery

The predictors for recurrence in resected stage I NSCLC (TNM 7) has not been widely investigated in the literature. In the reports by Maeda et al,28,33 they demonstrated that histologic differentiation, intratumoral vascular invasion, and visceral of pleural invasion

In our previous study,11 the 1- and 2-year post-recurrence survival rates for resected stage I NSCLC patients with local only recurrence were 48.7% and 17.6%, respectively. Tumor size and treatment for initial recurrence were significant predictors for post-recurrence survival in patients with local only recurrence in univariate analyses. The hazard of death was greater in patients with larger tumor size. Treatment for initial recurrence was still significant prognostic indicator in multivariate analysis. Patients underwent re-operation after local recurrence survived longer than those with chemotherapy or/and radiotherapy

For patients with single organ metastasis, the 1- and 2-year post-recurrence survival rates were 30.2% and 15.1%, respectively.12 The most common site of single organ metastasis was the bone, followed by the brain. Disease-free interval > 16 months and treatment for distant metastasis (including re-operation, chemotherapy and/or radiotherapy) were significant predictors of better post-recurrence survival in resected stage I NSCLC with single organ metastasis. Post-recurrence survival was not significantly different between single and multiple organ metastases groups of patients. Multiplicity of metastatic organ sites is not a significant prognostic factor in these patients. Yoshino and coworkers31 reported that the 2 year survival rate of NSCLC patients with postoperative recurrence at distant organs was

Surgical resection offers a good chance of cure for patients with stage I NSCLC.3,5,20 However, the outcome of surgical treatment in resected stage I NSCLC after local recurrence have rarely been reported. Walsh et al34 reported that complete surgical resection or highdose radiotherapy with curative intent significantly prolonged post-recurrence survival in NSCLC. Sugimura et al10 demonstrated that whether surgery or combination chemotherapy with radiation significantly improved post-recurrence survival over both no treatment and radiation alone in resected NSCLC after local recurrence. Voltolini et al35 reported that 5 year survival after re-operation for locally recurrent bronchogenic carcinoma was 15.5%. The 5-year post-recurrence survival in our patients undergoing re-operation after local

Treatment for recurrent NSCLC significantly prolongs overall survival and post-recurrence survival.10,34 Yoshino et al31 reported that patients who underwent metastatectomy for recurrence in distant organs had significantly longer survival while those with chemotherapy had marginally prolonged survival. Nakagawa et al7 reported that treatment for the initial recurrence prolonged survival in stage I NSCLC after recurrence. In our study,12 treatment for distant metastasis (including surgery and chemotherapy and/or radiotherapy) had a favorable survival in resected stage I NSCLC after distant metastasis than without treatment. There was no significant difference in post-recurrence survival between patients undergoing re-operation and those treated with chemotherapy and/or radiotherapy. However, there were two postoperative deaths due to respiratory failure after

were significant predictors for recurrence in stage I NSCLC (TNM 7).

**5. Postrecurrence survival**

and those without treatment.

recurrence was 15%.

15.7 %. Their result is similar to that in our study.

Treatment for initial recurrence is a prognostic predictor for post-recurrence survival in resected stage I NSCLC with local recurrence. Longer disease-free interval and treatment for distant metastasis are indicators for better post-recurrence survival in resected stage I NSCLC with single organ metastasis. Complete surgical resection should be considered in selected candidates with resectable local recurrent disease. Aggressive treatment for distant metastasis in selected patients with longer disease-free interval may prolong the postrecurrence survival.

## **7. References**

Stage I Non-Small Cell Lung Cancer: Recurrence Patterns, Prognostic Factors and Survival 291

[22] Hung JJ, Jeng WJ, Hsu WH, et al. Prognostic factors in pathological stage IB non-small

[23] Hanagiri T, Sugio K, Mizukami M, et al. Significance of smoking as a postoperative

[24] Bryant A, Cerfolio RJ. Differences in epidemiology, histology, and survival between

[25] Maeda R, Yoshida J, Ishii G, et al. The Prognostic Impact of Cigarette Smoking on Patients with Non-small Cell Lung Cancer. J Thorac Oncol 2011;6:735-742. [26] Maeda R, Ishii G, Yoshida J, et al. Influence of cigarette smoking on histological subtypes of stage I lung adenocarcinoma. J Thorac Oncol 2011;6:743-750. [27] Maeda R, Yoshida J, Ishii G, et al. Poor prognostic factors in patients with stage IB non-

[28] Maeda R, Yoshida J, Ishii G, et al. Risk factors for tumor recurrence in patients with

[29] Varlotto JM, Recht A, Flickinger JC, et al. Factors associated with local and distant

[30] Cady B. Fundamentals of contemporary surgical oncology: biologic principles and the

[31] Yoshino I, Yohena T, Kitajima M, et al. Survival of non-small cell lung cancer patients

[32] Maeda R, Yoshida J, Ishii G, et al. Long-term outcome and late recurrence in patients

[33] Maeda R, Yoshida J, Ishii G, et al. Long-term survival and risk factors for recurrence in

[34] Walsh GL, O'Connor M, Willis KM, et al. Is follow-up of lung cancer patients after

[35] Voltolini L, Paladini P, Luzzi L, et al. Iterative surgical resections for local recurrent

cell lung cancer greater than 3 cm. Eur Respir J 2010;36:1355-1361.

643.

2008;3:1127–1132.

2011;139:855-861.

2009;115:1059-1069.

2001;7:204-209.

2010;5:1246-1250.

2000;18:529-534.

dimension. Chest 2010;138:357-362.

792.

1570.

May 26. [Epub ahead of print]

Chest 2007;132:185–192.

influence overall and disease-free survival. J Thorac Cardiovasc Surg. 2007;134:638-

prognostic factor in patients with non-small cell lung cancer. J Thorac Oncol

cigarette smokers and never-smokers who develop non-small cell lung cancer.

small cell lung cancer according to the seventh edition TNM classification. Chest

early-stage (stage I and II) non-small cell lung cancer: Patient selection criteria for adjuvant chemotherapy according to the 7th edition TNM classification. Chest 2011

recurrence and survival in patients with resected nonsmall cell lung cancer. Cancer

threshold concept govern treatment and outcomes. J Am Coll Surg 2001;192:777-

with postoperative recurrence at distant organs. Ann Thorac Cardiovasc Surg

with completely resected stage IA non-small cell lung cancer. J Thorac Oncol

stage I non-small cell lung cancer patients with tumors up to 3 cm in maximum

resection medically indicated and cost-effective? Ann Thorac Surg 1995;60:1563-

and second primary bronchogenic carcinoma. Eur J Cardiothorac Surg

[4] Martini N, Bains MS, Burt ME, et al. Incidence of local recurrence and second primary

[5] Harpole DH Jr, Herndon JE II, Young WG Jr, et al. Stage I non-small cell lung cancer.

[6] Jones DR, Daniel TM, Denlinger CE, et al. Stage IB nonsmall cell lung cancers: are they all

[7] Nakagawa T, Okumura N, Ohata K, et al. Postrecurrence survival in patients with stage I non-small cell lung cancer. Eur J Cardiothorac Surg 2008;34:499-504. [8] Al-Kattan K, Sepsas E, Fountain SW, et al. Disease recurrence after resection for stage I

[9] Martin J, Ginsberg RJ, Venkatraman ES, et al. Long-term results of combined-modality therapy in resectable non-small-cell lung cancer. J Clin Oncol 2002;20:1989-1995. [10] Sugimura H, Nichols FC, Yang P, et al. Survival after recurrent nonsmall-cell lung cancer after complete pulmonary resection. Ann Thorac Surg 2007;83:409-418. [11] Hung JJ, Hsu WH, Hsieh CC, et al. Post-recurrence survival in completely resected stage I non-small cell lung cancer with local recurrence. Thorax. 2009;64:192-196. [12] Hung JJ, Jeng WJ, Hsu WH, et al. Prognostic factors of post-recurrence survival in

[13] Sobin L, Wittekind Ch, eds. TNM Classification of Malignant Tumors, Sixth Edition.

[14] American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. New York:

[15] International Union Against Cancer. TNM Classification of Malignant Tumours. 7th ed.

[16] Rami-Porta R, Ball D, Crowley J, et al. The IASLC Lung Cancer Staging Project:

[18] Sawyer TE, Bonner JA, Gould PM, et al. Patients with stage I non-small cell lung

[19] Varlotto JM, Recht A, Nikolov M, et al. Extent of lymphadenectomy and outcome for patients with stage I nonsmall cell lung cancer. Cancer. 2009;115:851-858. [20] Nesbitt JC, Putnam JB Jr, Walsh GL, et al. Survival in early-stage non-small cell lung

[21] Hung JJ, Wang CY, Huang MH, et al. Prognostic factors in resected stage I non-small

of the TNM classification for lung cancer. J Thorac Oncol 2007;2:593-602. [17] Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project:

proposals for the revision of the T descriptors in the forthcoming (seventh) edition

proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2007;2:706-

carcinoma at postoperative risk for local recurrence, distant metastasis, and death: implications related to the design of clinical trials. Int J Radiat Oncol Biol Phys.

cell lung cancer with a diameter of 3 cm or less: visceral pleural invasion did not

completely resected stage I non-small cell lung cancer with distant metastasis.

129.

Cancer. 1995;76:787-796.

Thorax. 2009;65:241-245.

Springer; 2010.

1999;45:315-321.

714.

New York: Wiley-Liss, 2002: 99-103.

Oxford, UK: Wiley-Blackwell; 2009.

cancer. Ann Thorac Surg 1995;60:466-472.

the same? Ann Thorac Surg. 2006;81:1958-1962.

lung cancer. Eur J Cardiothorac Surg 1997;12:380-384.

tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg. 1995;109:120-

influence overall and disease-free survival. J Thorac Cardiovasc Surg. 2007;134:638- 643.

**17**

*Turkey*

Hidir Esme and Sevval Eren *Konya Education and Researc Hospital, Dicle University, School of Medicine,*

**Surgical Treatment of Bronchiectasis**

Bronchiectasis is pathologically defined as a condition in which there are abnormal and permanent dilatations of proximal bronchi with predominance at the level of the second to the sixth bronchial division. This definition differentiates true bronchiectasis from functional bronchiectasis or pseudobronchiectasis, which is expected to return to normal once control of infection has been achieved (Deslauriers et al., 1998). Bronchiectasis was first described by Laenec in 1819 and, before the antibiotic era, was considered a morbid disease with a high mortality rate from respiratory failure and cor pulmonale (Balkanli et al., 2003). With the development of antibiotics in the 1940s, this entity began to be seen less frequently, but, with the emergence of drug-resistant microorganisms and the increasing frequency of drugresistant tuberculosis, an increased incidence of postinfectious bronchiectasis is being noted (Miller, 2000). The current increase in tuberculosis rates is directly related to insufficient and irregular medication. Additionally, irregular and inadequate treatment, the cessation of medication shortly after symptom improvement, and a lack of check-ups after treatment are factors accelerating recurrent pulmonary infection in developing countries. As the disease progresses, physical activities become increasingly limited, patients fail to thrive, and ultimately they suffer from social deprivation, intrinsic depression, and respiratory failure (Al-Kattan et al., 2005). Therefore, bronchiectasis is still a major cause of morbidity and

Reid categorized bronchiectasis as having three main phenotypes: 1) tubular characterized by smooth dilation of the bronchi; 2) varicose in which the bronchi are dilated with multiple indentations; and 3) cystic in which dilated bronchi terminate in blind ending sacs (Reid, 1950). The current major form seen on High resolution computed tomography scanning (HRCT) is the tubular form of bronchiectasis. The most definitive study of the pathology of bronchiectasis was performed by Whitwell (Whitwell, 1952). Whitwell suggested that bronchiectasis should be divided into (1) follicular bronchiectasis, characterized by excessive formation of lymphoid tissue both in the walls of dilated bronchi and in enlarged lymph nodes and thought to be sequelae of whooping cough, measles, or bronchopneumonia, (2) saccular bronchiectasis, characterized by loss of bronchial structures in the sacculi and of alveoli around them, and (3) atelectatic bronchiectasis, in which lung collapse leads to

**1. Introduction**

mortality in developing countries.

**2. Pathophysiology**

[36] Williams BA, Sugimura H, Endo C, et al. Predicting postrecurrence survival among completely resected nonsmall-cell lung cancer patients. Ann Thorac Surg 2006;81:1021-1027.

## **Surgical Treatment of Bronchiectasis**

## Hidir Esme and Sevval Eren

*Konya Education and Researc Hospital, Dicle University, School of Medicine, Turkey*

#### **1. Introduction**

292 Topics in Thoracic Surgery

[36] Williams BA, Sugimura H, Endo C, et al. Predicting postrecurrence survival among

2006;81:1021-1027.

completely resected nonsmall-cell lung cancer patients. Ann Thorac Surg

Bronchiectasis is pathologically defined as a condition in which there are abnormal and permanent dilatations of proximal bronchi with predominance at the level of the second to the sixth bronchial division. This definition differentiates true bronchiectasis from functional bronchiectasis or pseudobronchiectasis, which is expected to return to normal once control of infection has been achieved (Deslauriers et al., 1998). Bronchiectasis was first described by Laenec in 1819 and, before the antibiotic era, was considered a morbid disease with a high mortality rate from respiratory failure and cor pulmonale (Balkanli et al., 2003). With the development of antibiotics in the 1940s, this entity began to be seen less frequently, but, with the emergence of drug-resistant microorganisms and the increasing frequency of drugresistant tuberculosis, an increased incidence of postinfectious bronchiectasis is being noted (Miller, 2000). The current increase in tuberculosis rates is directly related to insufficient and irregular medication. Additionally, irregular and inadequate treatment, the cessation of medication shortly after symptom improvement, and a lack of check-ups after treatment are factors accelerating recurrent pulmonary infection in developing countries. As the disease progresses, physical activities become increasingly limited, patients fail to thrive, and ultimately they suffer from social deprivation, intrinsic depression, and respiratory failure (Al-Kattan et al., 2005). Therefore, bronchiectasis is still a major cause of morbidity and mortality in developing countries.

## **2. Pathophysiology**

Reid categorized bronchiectasis as having three main phenotypes: 1) tubular characterized by smooth dilation of the bronchi; 2) varicose in which the bronchi are dilated with multiple indentations; and 3) cystic in which dilated bronchi terminate in blind ending sacs (Reid, 1950). The current major form seen on High resolution computed tomography scanning (HRCT) is the tubular form of bronchiectasis. The most definitive study of the pathology of bronchiectasis was performed by Whitwell (Whitwell, 1952). Whitwell suggested that bronchiectasis should be divided into (1) follicular bronchiectasis, characterized by excessive formation of lymphoid tissue both in the walls of dilated bronchi and in enlarged lymph nodes and thought to be sequelae of whooping cough, measles, or bronchopneumonia, (2) saccular bronchiectasis, characterized by loss of bronchial structures in the sacculi and of alveoli around them, and (3) atelectatic bronchiectasis, in which lung collapse leads to

Surgical Treatment of Bronchiectasis 295

The middle lobe syndrome consists of a small atelectatic lobe, often owing to extrinsic bronchial compression secondary to enlarged peribronchial nodes (Deslauriers et al., 1998). The right middle lobe bronchus is long, often bends sharply at its bifurcation and is of relatively small caliber. A collar of lymph nodes also surrounds the proximal bronchus and any condition that causes a prolonged enlargement of these nodes may lead to obstruction and secondary bronchiectasis. This may also occur in malignancy and in nontuberculous

mycobacterial infection (Figure 2) (Bertelsen et al., 1980; Levin, 2002).

Fig. 2. Chest CT scan showing the bronchiectasis in the right middle lobe

There have been a large number of factors that have been described as causative for bronchiectasis. A list of etiologic factors in different studies is given in Table 1. Recurrent pulmonary infection during childhood is an important factor in the etiology. Most of patients had recurrent infections in their histories and insufficient medication for pulmonary infection (Prieto et al., 2001; Agasthian et al., 1996; Fujimoto et al., 2001). The insufficient and inadequate use of medications for pulmonary infections and tuberculosis in patients, and the lack of follow-up over time, create a background for lung destruction (Figure 3). Bronchiectasis should not be mistaken with pseudo-bronchiectasis, temporary (up to 6 months) cylindrical dilatation of the bronchi accompanying lung infection in children (Sirmali et al., 2006). In developing countries, tuberculosis is still one of the most important causes of bronchiectasis. Bronchiectasis commonly develops between 1 and 3 months after the initial infection and usually in the same pulmonary region (Karakoc et al., 2001;

Deficiencies in immune function, especially in humoral immunity, cause children to be at risk for recurrent sinopulmonary infections, which can lead to the development of bronchiectasis. This includes both primary immunodeficiency and secondary, or acquired, disease states (Boren et al., 2008). Cystic fibrosis is the most common cause of bronchiectasis among Caucasians of North America and Europe. Muco-ciliary clearance is a key defence mechanism against pulmonary infection. Its compromise is important in the development of the vicious cycle of bronchiectasis. The most prominent cilial disorder is primary ciliary dyskinesia which combines upper and lower respiratory tract infection, male infertility and in approximately 50%, situs inversus (King, 2009). Bronchial obstruction from either endobronchial pathology or external compression can also be an acquired factor predisposing to the development of bronchiectasis. Aspirated foreign bodies or gastric contents, slow-growing neoplasms, and mucous impaction can all cause local retention of

secretions, secondary infection, and bronchiectasis (Deslauriers et al., 1998).

**3. Etiology**

Haciibrahimoglu et al., 2004).

bronchiectasis. Follicular bronchiectasis was the dominant form and this corresponded to tubular bronchiectasis. In his study, he demonstrated marked inflammation of the bronchial wall, principally in the smaller airways. Bronchial dilation was characterized by deficiency/loss of elastin and more advance disease by destruction of muscle and cartilage. There was variable bronchial wall fibrosis, atelectasis and peribronchial pneumonic change (King, 2009).

Follicular bronchiectasis was characterized by the presence of lymphoid follicles in the bronchial wall. The inflammatory process commenced in the small airway. This small airway inflammation caused the release of mediators such as proteases which damaged the large airways causing loss of elastin and other components such as muscle and cartilage which resulted in bronchial dilation. With progression of the disease lymphoid follicles enlarged in size and caused airflow obstruction to the small airways. The final event was spread of the inflammation beyond the airways to cause interstitial pneumonia (King, 2009). The dominant cell types involved in the inflammatory process in bronchiectasis are neutrophils, lymphocytes, and macrophages. Neutrophils are the most prominent cell type in the bronchial lumen (Loukide et al., 2002; Khair et al., 1996) and release mediators, particularly proteases/elastase which cause bronchial dilation (Khair et al., 1996; Zheng et al., 2000). The infiltrate in the cell wall is predominantly composed of macrophages and lymphocytes (Loukide et al., 2002; Lapa a Silva et al., 1989)

Bronchiectasis can occur as focal or localized disease, or in a diffuse manner. 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. By contrast, diffuse bronchiectasis is often related to immune deficiencies, is bilateral, and may lead to death from respiratory failure (Deslauriers et al., 1998). Karadag et al. found that bronchiectasis most commonly involved the lower lobes. Only one lobe was found to be diseased in 46%, bilobar involvement in 28.1%, and multilobar involvement in 31.9% (Karadag et al., 2005). Karakoc et al. found bronchiectasis affecting the left lower lobe in 30.4%, and multilobar involvement in 56.5% (Karakoc et al., 2001). Dogru et al. found the most common lobe affected by bronchiectasis was the left-lower lobe in the 204 children they evaluated (Dogru et al., 2005). Isolated upper lobe bronchiectasis generally relates to prior tuberculosis, bronchopulmonary aspergillosis, or bronchial obstruction. Overall, onethird of cases of bronchiectasis are unilateral and affect a single lobe, one-third are unilateral but affect more than one lobe, and one-third are bilateral (Figure 1) (Deslauriers et al., 1998).

Fig. 1. Chest CT scan showing bilateral cystic bronchiectasis in the lower lobes.

bronchiectasis. Follicular bronchiectasis was the dominant form and this corresponded to tubular bronchiectasis. In his study, he demonstrated marked inflammation of the bronchial wall, principally in the smaller airways. Bronchial dilation was characterized by deficiency/loss of elastin and more advance disease by destruction of muscle and cartilage. There was variable bronchial wall fibrosis, atelectasis and peribronchial pneumonic change

Follicular bronchiectasis was characterized by the presence of lymphoid follicles in the bronchial wall. The inflammatory process commenced in the small airway. This small airway inflammation caused the release of mediators such as proteases which damaged the large airways causing loss of elastin and other components such as muscle and cartilage which resulted in bronchial dilation. With progression of the disease lymphoid follicles enlarged in size and caused airflow obstruction to the small airways. The final event was spread of the inflammation beyond the airways to cause interstitial pneumonia (King, 2009). The dominant cell types involved in the inflammatory process in bronchiectasis are neutrophils, lymphocytes, and macrophages. Neutrophils are the most prominent cell type in the bronchial lumen (Loukide et al., 2002; Khair et al., 1996) and release mediators, particularly proteases/elastase which cause bronchial dilation (Khair et al., 1996; Zheng et al., 2000). The infiltrate in the cell wall is predominantly composed of macrophages and

Bronchiectasis can occur as focal or localized disease, or in a diffuse manner. 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. By contrast, diffuse bronchiectasis is often related to immune deficiencies, is bilateral, and may lead to death from respiratory failure (Deslauriers et al., 1998). Karadag et al. found that bronchiectasis most commonly involved the lower lobes. Only one lobe was found to be diseased in 46%, bilobar involvement in 28.1%, and multilobar involvement in 31.9% (Karadag et al., 2005). Karakoc et al. found bronchiectasis affecting the left lower lobe in 30.4%, and multilobar involvement in 56.5% (Karakoc et al., 2001). Dogru et al. found the most common lobe affected by bronchiectasis was the left-lower lobe in the 204 children they evaluated (Dogru et al., 2005). Isolated upper lobe bronchiectasis generally relates to prior tuberculosis, bronchopulmonary aspergillosis, or bronchial obstruction. Overall, onethird of cases of bronchiectasis are unilateral and affect a single lobe, one-third are unilateral but affect more than one lobe, and one-third are bilateral (Figure 1) (Deslauriers et al., 1998).

Fig. 1. Chest CT scan showing bilateral cystic bronchiectasis in the lower lobes.

lymphocytes (Loukide et al., 2002; Lapa a Silva et al., 1989)

(King, 2009).

The middle lobe syndrome consists of a small atelectatic lobe, often owing to extrinsic bronchial compression secondary to enlarged peribronchial nodes (Deslauriers et al., 1998). The right middle lobe bronchus is long, often bends sharply at its bifurcation and is of relatively small caliber. A collar of lymph nodes also surrounds the proximal bronchus and any condition that causes a prolonged enlargement of these nodes may lead to obstruction and secondary bronchiectasis. This may also occur in malignancy and in nontuberculous mycobacterial infection (Figure 2) (Bertelsen et al., 1980; Levin, 2002).

Fig. 2. Chest CT scan showing the bronchiectasis in the right middle lobe

## **3. Etiology**

There have been a large number of factors that have been described as causative for bronchiectasis. A list of etiologic factors in different studies is given in Table 1. Recurrent pulmonary infection during childhood is an important factor in the etiology. Most of patients had recurrent infections in their histories and insufficient medication for pulmonary infection (Prieto et al., 2001; Agasthian et al., 1996; Fujimoto et al., 2001). The insufficient and inadequate use of medications for pulmonary infections and tuberculosis in patients, and the lack of follow-up over time, create a background for lung destruction (Figure 3). Bronchiectasis should not be mistaken with pseudo-bronchiectasis, temporary (up to 6 months) cylindrical dilatation of the bronchi accompanying lung infection in children (Sirmali et al., 2006). In developing countries, tuberculosis is still one of the most important causes of bronchiectasis. Bronchiectasis commonly develops between 1 and 3 months after the initial infection and usually in the same pulmonary region (Karakoc et al., 2001; Haciibrahimoglu et al., 2004).

Deficiencies in immune function, especially in humoral immunity, cause children to be at risk for recurrent sinopulmonary infections, which can lead to the development of bronchiectasis. This includes both primary immunodeficiency and secondary, or acquired, disease states (Boren et al., 2008). Cystic fibrosis is the most common cause of bronchiectasis among Caucasians of North America and Europe. Muco-ciliary clearance is a key defence mechanism against pulmonary infection. Its compromise is important in the development of the vicious cycle of bronchiectasis. The most prominent cilial disorder is primary ciliary dyskinesia which combines upper and lower respiratory tract infection, male infertility and in approximately 50%, situs inversus (King, 2009). Bronchial obstruction from either endobronchial pathology or external compression can also be an acquired factor predisposing to the development of bronchiectasis. Aspirated foreign bodies or gastric contents, slow-growing neoplasms, and mucous impaction can all cause local retention of secretions, secondary infection, and bronchiectasis (Deslauriers et al., 1998).

Surgical Treatment of Bronchiectasis 297

Symptoms may be mild (eg, unproductive cough) or even absent if the disease is restricted to the upper lobes. Patients may also present with symptoms of the underlying disease that has led to the development of bronchiectasis (Zhang et al., 2010). Acute exacerbations of bronchiectasis are defined by symptomatic changes, including increased thick sputum production with change in color, shortness of breath, pleuritic chest pain, and generalized malaise. Chest roentgenograph (CXR) rarely shows new infiltrates, and the patient may lack

> Zhang n, %

Productive cough 133 (55.8) 94 (65.7) 671 (85) 167 (94.9) 48 (77.4) 32 (91.4)

pulmonary infection 84 (35.2) 69 (48.2) - - 41 (66.1) 33 (94.2) Fetid sputum 116 (48.7) 72 (50.3) 277 (35) 139 (79) 27 (43.5) 28 (80) Hemoptysis 39 (12.1) 21 (14.6) 411 (52) 78 (44.3) 7 (11.3) 4 (11.4) Chest pain - 12 (8.3) 56 (7.1) - 7 (11.3) - Fatigue - - - - 17 (27.4) - Dyspnea - - - - 34 (54.8) - Growth retardation - - - 34 (19.3) - - Asymptomatic 10 (4.2) 2 (2.0) 25 (3.2) - 10 (16.1) -

Physical examination is often nonspecific. 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

Pulmonary function testing can help determine the degree of lung damage because of bronchiectasis. Bronchiectasis typically results in obstructive lung function changes as the disease progresses. Typical obstructive changes on lung function testing include a reduced forced vital capacity (FVC), reduced forced expiratory volume in 1 s (FEV1), and reduced FEV1 to FVC ratio. Airway hyperresponsiveness with reversibility after the administration

Diagnosis of bronchiectasis is based on clinical history and imaging. CXR findings that are suggestive but nondiagnostic of bronchiectasis include stranding, cystic lesions, volume loss with crowding of vessels, air-fluid levels and honeycombing, and areas of infiltrates and atelectasis (Agasthian et al., 1996). Computed tomography scanning is currently the best technique to establish the presence, severity, and distribution of bronchiectasis, 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. HRCT has replaced this procedure in the diagnosis of bronchiectasis, with only a 2% false negative and a 1% false positive rate (Young et al., 1991). The detailed images demonstrate bronchial dilatation, peribronchial

of inhaled bronchodilator should also be evaluated (Boren et al., 2008).

Sirmali n, %

Cobanoglu n, %

Haciibrahimoglu n, %

fever and chills (Boren et al., 2008).

Symptoms Balkanli

Table 2. Semptoms of the patients

inherited disorder (Deslauriers et al., 1998).

inflammation, and parenchymal disease.

Recurrence of

**5. Imaging**

n, %

Eren n, %

Table 1. Etiologic factors of bronchiectasis

Fig. 3. Standart PA chest radigraph and Chest CT scan of a 4-year-old boy shows a destroyed left lung.

## **4. 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 of diffuse. Semptoms of the patients in different studies were presented in Table 2. The primary clinical symptom of bronchiectasis is a recurrent or permanent cough with ample sputum production. The sputum is frequently purulent and is often accompanied by hemoptysis in advanced stages of the disease (Nicotra et al., 1995). In the past, some bronchiectasis has been described as being nonproductive or "dry", although in retrospect these were mostly cases of posttuberculous bronchiectasis located in the upper lobes (Deslauriers et al., 1998). Severe and life-threatening bleeding may result from erosions of the hypertrophic bronchial arteries or lesions in abnormal anastomoses between the pulmonary and bronchial arterial circulations.

Pneumonia 86 (36.1) 22 (15.3) 109 (61.9) 18 (29.0) 10 (22.2)

Srmali n, %

Cobanoglu n, %

Giovannetti n, %

Eren n; %

Childhood infection 63 (26.4) 19 (13.2) - 7 (11.3) -

foreign body 1 (0.4) 4 (2.7) 23 (13) 1 (1.6) -

sequestration 4 (1.6) 2 (1.4) - 4 (6.4) -

pneumonitis - 34 (23.7) - 2 (3.2) - Measles - - - 4 (6.4) - Pertussis - - - 3 (4.8) 4 (8.8) Tuberculosis - 22 (15.3) 44 (25) 11 (17.7) 6 (13.3)

(IgG, IgA) - - - 1 (1.6) - Cystic fibrosis - - - 2 (3.2) - Unknown etiology 84 (35.2) 40 (27.9) - 4 (6.4) 25 (55%)

Fig. 3. Standart PA chest radigraph and Chest CT scan of a 4-year-old boy shows a

The clinical presentation of patients with bronchiectasis is variable and depends on the etiology of bronchiectasis and on whether the condition is localized of diffuse. Semptoms of the patients in different studies were presented in Table 2. The primary clinical symptom of bronchiectasis is a recurrent or permanent cough with ample sputum production. The sputum is frequently purulent and is often accompanied by hemoptysis in advanced stages of the disease (Nicotra et al., 1995). In the past, some bronchiectasis has been described as being nonproductive or "dry", although in retrospect these were mostly cases of posttuberculous bronchiectasis located in the upper lobes (Deslauriers et al., 1998). Severe and life-threatening bleeding may result from erosions of the hypertrophic bronchial arteries or lesions in abnormal anastomoses between the pulmonary and bronchial arterial circulations.

Etiolgic factor Balkanli

Obstruction due to

Pulmonary

Postobstructive

Immunodeficiency

destroyed left lung.

**4. Clinical presentation**

Table 1. Etiologic factors of bronchiectasis

n, %

Symptoms may be mild (eg, unproductive cough) or even absent if the disease is restricted to the upper lobes. Patients may also present with symptoms of the underlying disease that has led to the development of bronchiectasis (Zhang et al., 2010). Acute exacerbations of bronchiectasis are defined by symptomatic changes, including increased thick sputum production with change in color, shortness of breath, pleuritic chest pain, and generalized malaise. Chest roentgenograph (CXR) rarely shows new infiltrates, and the patient may lack fever and chills (Boren et al., 2008).

Table 2. Semptoms of the patients

Physical examination is often nonspecific. 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 (Deslauriers et al., 1998).

Pulmonary function testing can help determine the degree of lung damage because of bronchiectasis. Bronchiectasis typically results in obstructive lung function changes as the disease progresses. Typical obstructive changes on lung function testing include a reduced forced vital capacity (FVC), reduced forced expiratory volume in 1 s (FEV1), and reduced FEV1 to FVC ratio. Airway hyperresponsiveness with reversibility after the administration of inhaled bronchodilator should also be evaluated (Boren et al., 2008).

#### **5. Imaging**

Diagnosis of bronchiectasis is based on clinical history and imaging. CXR findings that are suggestive but nondiagnostic of bronchiectasis include stranding, cystic lesions, volume loss with crowding of vessels, air-fluid levels and honeycombing, and areas of infiltrates and atelectasis (Agasthian et al., 1996). Computed tomography scanning is currently the best technique to establish the presence, severity, and distribution of bronchiectasis, 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. HRCT has replaced this procedure in the diagnosis of bronchiectasis, with only a 2% false negative and a 1% false positive rate (Young et al., 1991). The detailed images demonstrate bronchial dilatation, peribronchial inflammation, and parenchymal disease.

Surgical Treatment of Bronchiectasis 299

Fig. 4. Computed tomography scan showing the classic image of Kartagener's syndrome caharacterized by dextrocardia and cylindrical bronchiectasis in the right upper lobe

Careful preoperative preparations are of the utmost importance to reduce operation-related morbidity and mortality. The preoperative treatment should include reducing airway obstruction and elimination of microorganisms from the lower respiratory tract, which consists of antimicrobial therapy, postural physiotherapy, bronchodilators, and corticosteroids (Agasthian et al., 1996). Patients should be well prepared during the preoperative period with regard to infection to minimize postoperative complications. Bacterial infections, particularly those involving potentially necrotizing agents such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumonia, and various anaerobes, remain important causes of bronchiectasis, particularly when there is a delay in treatment or other factors that prevent eradication of the infection (Deslauriers et al., 1998). Antimicrobial therapy is particularly true in the setting of mycobacterial disease, such as M. tuberculosis and various environmental mycobacterial species. Patients with focal bronchiectasis and M. avium complex infection typically are started on a three-or four-drug regimen for 2-3 months before surgery based on in vitro susceptibility testing of the isolated organism.  Preoperative bronchoscopic examinations were performed in 117 (81.8%) of our patients as an adjuvant diagnostic method, to rule out benign or malignant bronchial obstruction, and for localization, collection of samples for microbiology, and bronchial toilet. We consider it essential in the preoperative evaluation and tracheobronchial cleaning of all

(patient's left side).

**7. Preoperative preparation**

thereafter, often to a total of 24 months (Kim et al., 2005).

Perfusion isotopic lung scans using 99m Tc albumin particles in microspheres 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. Bronchial arteriography may be done 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 may be done (Deslauriers et al., 1998).

#### **6. Therapy for bronchiectasis**

Treatment options for the management of bronchiectasis include pharmacologic agents such as antibiotics, nonpharmacologic measures such as chest physiotherapy, and surgical procedures involving removal of the affected portion or portions of the lung. In general, treatment goals are to control infections and improve bronchial hygiene. General measures include avoidance of smoking and second-hand smoke, proper nutrition, and ensuring proper immunizations, including yearly influenza vaccinations. Depending on the specific cause of bronchiectasis, additional medical therapies may be warranted. This is especially true in patients with immunoglobulin deficiency, who could benefit from administration of intravenous or subcutaneous immunoglobulin for passive protection (Boren et al., 2008).

The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients in which medical treatment has failed and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess (Agasthian et al., 1996; Annest et al., 1982). There is a broad consensus concerning the indications for surgical removal. The surgical treatment is based on two physiopathologic hypotheses. First, the resection involves removal of lung tissue with destroyed bronchi that are no longer functional. Second, it permits the removal of a localized area of bronchiectasis, which could otherwise be involved in the infectious contamination of adjacent territories (Mazieres et al., 2003).

Mazierez and colleagues bring some arguments to help in the selection of patients who should be considered for operation (Mazieres et al., 2003). First, respiratory function and performance status must be compatible with the anesthetic risk. Second, the resection should be done quite early in the evolution of the disease because of the risk of contamination of healthy bronchi by an "active" territory and because of the low morbidity when the pulmonary function is good (Etienne et al., 1996). Third, operation is recommended for patients exhibiting disabling bronchiectasis with hemoptysis or a recurring infection that becomes resistant to medical treatment. Fourth, the etiology of bronchiectasis should not be considered in the decision for operation. Some studies showed the benefit of operation in primary ciliary dyskinesia (Simit et al., 1996), Kartagener's syndrome (Figure 4) (Mazieres et al., 2003), and in hypogammaglobulinemia (Cohen et al., 1994). Lastly, the ideal candidate has a nonhomogenous disease. Some territories are more severely involved and constitute real targets. The removal of an active infectious territory may protect the healthy bronchi from infectious contamination. Removal of diseased segments can break the vicious circle as described by Cole and colleagues, and stop the progression of the disease (Cole et al., 1985). In children growth retardation due to bronchiectasis and drop in school attendance secondary to the illness should be included in the indications for surgery as well (Sirmali et al., 2006).

Perfusion isotopic lung scans using 99m Tc albumin particles in microspheres 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. Bronchial arteriography may be done 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

Treatment options for the management of bronchiectasis include pharmacologic agents such as antibiotics, nonpharmacologic measures such as chest physiotherapy, and surgical procedures involving removal of the affected portion or portions of the lung. In general, treatment goals are to control infections and improve bronchial hygiene. General measures include avoidance of smoking and second-hand smoke, proper nutrition, and ensuring proper immunizations, including yearly influenza vaccinations. Depending on the specific cause of bronchiectasis, additional medical therapies may be warranted. This is especially true in patients with immunoglobulin deficiency, who could benefit from administration of intravenous or subcutaneous immunoglobulin for passive protection (Boren et al., 2008). The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients in which medical treatment has failed and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess (Agasthian et al., 1996; Annest et al., 1982). There is a broad consensus concerning the indications for surgical removal. The surgical treatment is based on two physiopathologic hypotheses. First, the resection involves removal of lung tissue with destroyed bronchi that are no longer functional. Second, it permits the removal of a localized area of bronchiectasis, which could otherwise be involved

in the infectious contamination of adjacent territories (Mazieres et al., 2003).

the indications for surgery as well (Sirmali et al., 2006).

Mazierez and colleagues bring some arguments to help in the selection of patients who should be considered for operation (Mazieres et al., 2003). First, respiratory function and performance status must be compatible with the anesthetic risk. Second, the resection should be done quite early in the evolution of the disease because of the risk of contamination of healthy bronchi by an "active" territory and because of the low morbidity when the pulmonary function is good (Etienne et al., 1996). Third, operation is recommended for patients exhibiting disabling bronchiectasis with hemoptysis or a recurring infection that becomes resistant to medical treatment. Fourth, the etiology of bronchiectasis should not be considered in the decision for operation. Some studies showed the benefit of operation in primary ciliary dyskinesia (Simit et al., 1996), Kartagener's syndrome (Figure 4) (Mazieres et al., 2003), and in hypogammaglobulinemia (Cohen et al., 1994). Lastly, the ideal candidate has a nonhomogenous disease. Some territories are more severely involved and constitute real targets. The removal of an active infectious territory may protect the healthy bronchi from infectious contamination. Removal of diseased segments can break the vicious circle as described by Cole and colleagues, and stop the progression of the disease (Cole et al., 1985). In children growth retardation due to bronchiectasis and drop in school attendance secondary to the illness should be included in

dyskinesia is suspected may be done (Deslauriers et al., 1998).

**6. Therapy for bronchiectasis**

Fig. 4. Computed tomography scan showing the classic image of Kartagener's syndrome caharacterized by dextrocardia and cylindrical bronchiectasis in the right upper lobe (patient's left side).

## **7. Preoperative preparation**

Careful preoperative preparations are of the utmost importance to reduce operation-related morbidity and mortality. The preoperative treatment should include reducing airway obstruction and elimination of microorganisms from the lower respiratory tract, which consists of antimicrobial therapy, postural physiotherapy, bronchodilators, and corticosteroids (Agasthian et al., 1996). Patients should be well prepared during the preoperative period with regard to infection to minimize postoperative complications. Bacterial infections, particularly those involving potentially necrotizing agents such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumonia, and various anaerobes, remain important causes of bronchiectasis, particularly when there is a delay in treatment or other factors that prevent eradication of the infection (Deslauriers et al., 1998). Antimicrobial therapy is particularly true in the setting of mycobacterial disease, such as M. tuberculosis and various environmental mycobacterial species. Patients with focal bronchiectasis and M. avium complex infection typically are started on a three-or four-drug regimen for 2-3 months before surgery based on in vitro susceptibility testing of the isolated organism.

Preoperative bronchoscopy should be routinely done to rule out benign or malignant cause of obstruction. Preoperative bronchoscopic examinations were performed in 117 (81.8%) of our patients as an adjuvant diagnostic method, to rule out benign or malignant bronchial obstruction, and for localization, collection of samples for microbiology, and bronchial toilet. We consider it essential in the preoperative evaluation and tracheobronchial cleaning of all

Surgical Treatment of Bronchiectasis 301

drains are placed into the thoracic cavity before the thorax is closed. All resected specimens are examined histopathologically in order to confirm the diagnosis. At the end of the procedure, the bronchial suture is bronchoscopically checked, and secretions are removed from the airways. Patients are extubated in the operating room. When postoperative mechanical ventilation was necessary, a standard endotracheal tube is substituted for the

Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation (Laros et al., 1988). It was reported that the symptoms persisted when incomplete resection was carried out (Campbell & Lilly, 1982). We performed complete resection in 82.5% of our patients and preoperative symptoms resolved completely in 75.9% and improved in 15.7%, i.e. 92.8% benefited from the surgery. In the light of these findings, we suggest that complete resection should be performed for the surgical treatment of bronchiectasis and that incomplete resection should only be used for the palliative treatment of certain life-threatening symptoms. In our study, postoperative complications were observed in 11% of patients that underwent complete resection and in 80% of those that underwent incomplete resection (Eren et al., 2007). When suspicious lung regions are not excised with the aim of sparing as much lung tissue as possible, a second operation that carries a higher morbidity and mortality might be required to remove the residual diseased tissues (Sirmali et al., 2007). Therefore, we suggest that, during intraoperative examinations, if suspected areas that could not be determined by radiological examination are present, these parenchymal areas should be resected to perform complete resection and to decrease relapse rates. Bronchopulmonary development continues during childhood and the space occupied by the resected segments would be filled by the healthy lung segments. Therefore, surgeons should not refrain from wide resection of the lung to achieve complete resection of the diseased area (Sirmali et al., 2007). Incomplete resection should not be preferred in children except for palliative treatment of

The goal of surgery is to excise all diseased lung areas whenever possible and to preserve as much healthy lung parenchyma as possible. It is known that even 2 or 3 preserved segments can fill the hemithorax (Campbell & Lilly, 1982). As recommended, we suggested to protect the anatomic structure of the superior segment in cases of bronchiectasis of the lower lobe when the superior segment of this lobe was normal (Fujimoto et al., 2001). In such patients, the superior segment had undergone a compensatory increase in volume and the affected basal segments had become small. Thus, the functional value of the superior segment was similar to that of the lower lobe (Yuncu et al., 2006). Patients with an uninvolved apical segment were found to have better spirometric values than those with more extensive

Surgical treatment is usually offered only when the diseased area is well localized and restricted to one or several segments within the same lobe. Multiple or bilateral bronchiectasis is generally regarded as a contraindication to operation. From the end of the 1970s onward, some thoracic surgeons have suggested that bilateral bronchiectasis is not a contraindication to

**10. Resection for multisegmental bilateral bronchiectasis**

double-lumen tube (Zhang et al., 20101).

life threatening complications.

disease (Ashour et al., 1996).

**9. Complete resection and preserved segments**

patients. In our study, patients in whom bronchoscopy was not performed had a significantly higher rate of postoperative complications (Eren et al., 2007). Patients should be preoperatively monitored until they produced less than 20 mL/day of sputum with little purulence. Operation should be not conducted until bronchofibroscopy showed no engorgement or edema in the tunica mucosa bronchiorum (Zhang et al., 2010).

Most patients with chronic suppurative disease of the lungs are malnourished, often to a considerable degree, as a result of the long-standing catabolic state these patients experience. If malnutrition is present, an aggressive preoperative regimen of nutritional supplementation is advised (Sherwood et al., 2005). Pulmonary function studies should be preoperatively performed in all patients. The patients with bronchiectasis are showed a mixed or obstructive ventilatory pattern. In patients with low FEV1 (<60% of the predicted value) the postoperative complication rate was significantly high. This indicated that surgery should be delayed in cases of severe inflammation until adequate control has been achieved (Eren et al., 2007).

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.

Balloon tamponade of the bleeding bronchus, which can be performed under emergency conditions is an effective method to manage massive hemoptysis in bronchiectasis patients. Embolization of the bronchial artery is a good alternative, capable of stopping the hemorrhage in 75—90% of the cases ( Freitag et al., 1994). On the other hand, once the first episode of hemorrhage is stopped, preoperative assessment should be promptly undertaken because recurrence in the first month after the embolization is frequent and fatal (Fujimoto et al., 2001; Mal et al., 1999). Planning surgical operation in patients with hemoptysis should involve bronchoscopic as well as radiological assessments. Yielding 2% false negative and 1% false positive results, HRCT is a fairly reliable method for the diagnosis of bronchiectasis (Young et al., 1991). In such cases the most appropriate approach is to excise the pathological regions both depicted by HRCT and identified by bronchoscopy.

## **8. Surgical technique**

A left-sided double-lumen endotracheal tube is used to avoid contralateral contamination of secretions. In children under 13 years old, in whom the double-lumen endotracheal tube is not used, bronchoscopy should be performed, and the bronchus of the side ready for resection should be cleaned by aspiration before the introduction of an endotracheal tube. A Fogarty embolectomy catheter may be used as a bronchus blocker in children (Eren et al., 2007). A thoracic epidural catheter is employed when an open approach is planned based on the extent of resection. In patients in whom a thoracoscopic lobectomy or segmentectomy is performed, the epidural is omitted. An arterial line and urinary catheter are placed.

Posterolateral thoracotomy or video-assisted thoracoscopic surgery (VATS) were performed for lung resection. Thoracotomy is performed so as to conserve as much muscle as possible. The resection type is selected according to the affected sides and cardiopulmonary reserve (Balkanli et al., 2003). Excessive bronchial dissection is avoided, and peribronchial tissues are preserved. The bronchial stump may manually be sutured with nonabsorbable materials or closed with a mechanical stapler. The bronchial stump is kept short. Stump covering with mediastinal pleura or tissue is performed. Complete resection is defined as an anatomic resection of all affected segments assessed preoperatively by either HRCT. Two silicon

patients. In our study, patients in whom bronchoscopy was not performed had a significantly higher rate of postoperative complications (Eren et al., 2007). Patients should be preoperatively monitored until they produced less than 20 mL/day of sputum with little purulence. Operation should be not conducted until bronchofibroscopy showed no

Most patients with chronic suppurative disease of the lungs are malnourished, often to a considerable degree, as a result of the long-standing catabolic state these patients experience. If malnutrition is present, an aggressive preoperative regimen of nutritional supplementation is advised (Sherwood et al., 2005). Pulmonary function studies should be preoperatively performed in all patients. The patients with bronchiectasis are showed a mixed or obstructive ventilatory pattern. In patients with low FEV1 (<60% of the predicted value) the postoperative complication rate was significantly high. This indicated that surgery should be delayed in cases of severe inflammation until adequate control has been

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

Balloon tamponade of the bleeding bronchus, which can be performed under emergency conditions is an effective method to manage massive hemoptysis in bronchiectasis patients. Embolization of the bronchial artery is a good alternative, capable of stopping the hemorrhage in 75—90% of the cases ( Freitag et al., 1994). On the other hand, once the first episode of hemorrhage is stopped, preoperative assessment should be promptly undertaken because recurrence in the first month after the embolization is frequent and fatal (Fujimoto et al., 2001; Mal et al., 1999). Planning surgical operation in patients with hemoptysis should involve bronchoscopic as well as radiological assessments. Yielding 2% false negative and 1% false positive results, HRCT is a fairly reliable method for the diagnosis of bronchiectasis (Young et al., 1991). In such cases the most appropriate approach is to excise the

A left-sided double-lumen endotracheal tube is used to avoid contralateral contamination of secretions. In children under 13 years old, in whom the double-lumen endotracheal tube is not used, bronchoscopy should be performed, and the bronchus of the side ready for resection should be cleaned by aspiration before the introduction of an endotracheal tube. A Fogarty embolectomy catheter may be used as a bronchus blocker in children (Eren et al., 2007). A thoracic epidural catheter is employed when an open approach is planned based on the extent of resection. In patients in whom a thoracoscopic lobectomy or segmentectomy is

Posterolateral thoracotomy or video-assisted thoracoscopic surgery (VATS) were performed for lung resection. Thoracotomy is performed so as to conserve as much muscle as possible. The resection type is selected according to the affected sides and cardiopulmonary reserve (Balkanli et al., 2003). Excessive bronchial dissection is avoided, and peribronchial tissues are preserved. The bronchial stump may manually be sutured with nonabsorbable materials or closed with a mechanical stapler. The bronchial stump is kept short. Stump covering with mediastinal pleura or tissue is performed. Complete resection is defined as an anatomic resection of all affected segments assessed preoperatively by either HRCT. Two silicon

performed, the epidural is omitted. An arterial line and urinary catheter are placed.

pathological regions both depicted by HRCT and identified by bronchoscopy.

engorgement or edema in the tunica mucosa bronchiorum (Zhang et al., 2010).

achieved (Eren et al., 2007).

**8. Surgical technique**

judge with great accuracy the segments that are involved.

drains are placed into the thoracic cavity before the thorax is closed. All resected specimens are examined histopathologically in order to confirm the diagnosis. At the end of the procedure, the bronchial suture is bronchoscopically checked, and secretions are removed from the airways. Patients are extubated in the operating room. When postoperative mechanical ventilation was necessary, a standard endotracheal tube is substituted for the double-lumen tube (Zhang et al., 20101).

## **9. Complete resection and preserved segments**

Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation (Laros et al., 1988). It was reported that the symptoms persisted when incomplete resection was carried out (Campbell & Lilly, 1982). We performed complete resection in 82.5% of our patients and preoperative symptoms resolved completely in 75.9% and improved in 15.7%, i.e. 92.8% benefited from the surgery. In the light of these findings, we suggest that complete resection should be performed for the surgical treatment of bronchiectasis and that incomplete resection should only be used for the palliative treatment of certain life-threatening symptoms. In our study, postoperative complications were observed in 11% of patients that underwent complete resection and in 80% of those that underwent incomplete resection (Eren et al., 2007). When suspicious lung regions are not excised with the aim of sparing as much lung tissue as possible, a second operation that carries a higher morbidity and mortality might be required to remove the residual diseased tissues (Sirmali et al., 2007). Therefore, we suggest that, during intraoperative examinations, if suspected areas that could not be determined by radiological examination are present, these parenchymal areas should be resected to perform complete resection and to decrease relapse rates. Bronchopulmonary development continues during childhood and the space occupied by the resected segments would be filled by the healthy lung segments. Therefore, surgeons should not refrain from wide resection of the lung to achieve complete resection of the diseased area (Sirmali et al., 2007). Incomplete resection should not be preferred in children except for palliative treatment of life threatening complications.

The goal of surgery is to excise all diseased lung areas whenever possible and to preserve as much healthy lung parenchyma as possible. It is known that even 2 or 3 preserved segments can fill the hemithorax (Campbell & Lilly, 1982). As recommended, we suggested to protect the anatomic structure of the superior segment in cases of bronchiectasis of the lower lobe when the superior segment of this lobe was normal (Fujimoto et al., 2001). In such patients, the superior segment had undergone a compensatory increase in volume and the affected basal segments had become small. Thus, the functional value of the superior segment was similar to that of the lower lobe (Yuncu et al., 2006). Patients with an uninvolved apical segment were found to have better spirometric values than those with more extensive disease (Ashour et al., 1996).

## **10. Resection for multisegmental bilateral bronchiectasis**

Surgical treatment is usually offered only when the diseased area is well localized and restricted to one or several segments within the same lobe. Multiple or bilateral bronchiectasis is generally regarded as a contraindication to operation. From the end of the 1970s onward, some thoracic surgeons have suggested that bilateral bronchiectasis is not a contraindication to

Surgical Treatment of Bronchiectasis 303

resection remain the same as for conventional resection. But not all the patients with bronchiectasis who needed operations were suitable for VATS lobectomy; severe scarring and adhesions on computed tomographic scan should be considered . The severity of adhesions to the chest wall, the hilum, and especially in the fissure, typically seen in inflammatory disease, was the key limiting factor for a safe VATS lobectomy (Weber et al., 2001). Adhesions need to be dissected to explore the relevant anatomy. If there were dense adhesions (such as destroyed lobes mainly after tuberculosis with or without aspergillosis) or enlarged lymph nodes, especially calcified, open operations were required (Zhang et al.,

Bronchiectasis was considered the best lung benign disease suitable for VATS lobectomy (Yim, 2002). The VATS major resection has demonstrated to be a safe procedure when performed by experienced physicians. Postoperative pain after VATS is uncommon as compared with open surgery. Other documented advantages include better preservation of pulmonary function in the early postoperative period, earlier return to full activities, and better quality of life after recovery. One major advantage of VATS resection is that it allows recruitment of older and sicker patients with multiple comorbidities who would otherwise not be candidates for resection through a conventional thoracotomy approach (Farjah et al., 2009; Gonzales-Aragoneses et al., 2009). In study of Zhang and collegeus, the patients with VATS had a shorter length of stay in the hospital, fewer complications, and less pain in the

Bronchiectasis is an inflammatory disease of the lungs and the risk of developing postoperative empyema is higher than in other cases. Empyema, on the other hand, is a risk factor for bronchopleural fistula (Sirmali et al., 2006). Therefore, we suggest reinforcement of the bronchial stump in all patients. Bronchopleural fistula can be observed in as many as 9.1% of the cases (Fujimoto et al., 2001). Fujimoto and colleagues argued that the bronchial stump should be reinforced when the inflammation in the lung of bronchiectasis patients could not be effectively controlled (Fujimoto et al., 2001). We, however, suggest reinforcement the bronchial stump in all cases. Additionally, to avoid empyema, we recommend postoperative bacterial culture of thoracic effusion if the remaining lung shows signs of persisting inflammation. Sputum retention is common because patients with this disease might have problems with ciliary motion and postoperative expectoration, which would be easily disrupted (Fujimoto et al., 2001). In our series, respiratory physiotherapy was re-initiated on the first post-operative day, and continued for 2 weeks after discharge. We used bronchoscopy for sputum aspiration during the early postoperative period if physiotherapy was not effective. Virtually all patients had specific or large-spectrum

In bronchopleural fistula, drainage of the infected space is a key initial step to limit damage to the remaining lung. Bronchopleural fistula noted very early after the initial resection may be treated with primary reclosure and rebuttressing of the stump; later bronchopleural fistula usually require rib resection and creation of an Eloesser flap, followed by bronchopleural fistula closure and subsequent Clagett procedure, for successful treatment (Sugarbaker et al., 2009). The presence of a significant intrathoracic "space" appears to be more common after major lung resection for infectious lung disease such as bronchiectasis compared with other indications for surgery. The use of transposed muscle such as

postoperative period than those with thoracotomies (Zhang et al., 2011).

intravenous antibiotic therapy for 1 week (Eren et al., 2007).

**12. Postoperative complication**

2011).

resection (George et al., 1979; Fujimoto et al., 2001). Nevertheless, the patients reported in the literature remained quite rare. The therapeutic options in nonfocal bronchiectasis are limited. Most of the time patients are treated with antibiotics and physiotherapy. Recently, progress has been made with the use of new antibiotics and inhalation of tobramycin solution in cases of Pseudomonas aeruginosa colonization (Barker et al., 2000). These therapies allow a good quality of life and symptomatic improvement for several years, but the usual evolution is a progression toward chronic respiratory failure with a poor prognosis and selection of resistant strains (Annest et al., 1982; Keistinen et al., 1997). Transplantation remains indicated for homogenous disease and for patients with advanced disease with seriously compromised pulmonary function and chronic respiratory failure (Hasan et al., 1995). The 3-year survival rate is 75% for patients undergoing double-lung transplantation (Barlow et al., 2000). Some investigators have proposed a radical operation for bilateral bronchiectasis (Kittle et al., 1985; Laros et al., 1988) but others report a higher mortality with pneumonectomy (McGovern et al., 1988). Considering the limited and palliative effect of medical treatment and the risk of transplantation or radical operation, it seems that a limited operation should be offered to some patients with diffuse bronchiectasis.

Mazierez and collegues suggested that surgical indications were offered to patients with multisegmental and severe bronchiectasis if (1) optimal medical treatment and physiotherapy were no longer efficient, (2) bleeding and sputum production were recurrent and abundant, (3) severely damaged territories could be identified, and (4) performance status and pulmonary function were compatible with the anesthetic risk (Mazierez et al., 2003).

Surgery in multiple segments on different lobes is technically more difficult, resulting in higher morbidity and mortality.21 However, pulmonary resection is indicated early in patients with multisegmentar bronchiectasis, before other portions of the lung become grossly diseased. Our purpose in these patients was to protect as much pulmonary function as possible, with the aim of removing only the affected areas of different lobes. The types of procedures in different studies were presented in Table 3.

Table 3. Type of operation

#### **11. Video-assisted thoracoscopic surgery**

VATS for major lung resection has become a more frequent procedure in recent years with promising outcome. VATS represents a new approach; the indications for VATS major

resection (George et al., 1979; Fujimoto et al., 2001). Nevertheless, the patients reported in the literature remained quite rare. The therapeutic options in nonfocal bronchiectasis are limited. Most of the time patients are treated with antibiotics and physiotherapy. Recently, progress has been made with the use of new antibiotics and inhalation of tobramycin solution in cases of Pseudomonas aeruginosa colonization (Barker et al., 2000). These therapies allow a good quality of life and symptomatic improvement for several years, but the usual evolution is a progression toward chronic respiratory failure with a poor prognosis and selection of resistant strains (Annest et al., 1982; Keistinen et al., 1997). Transplantation remains indicated for homogenous disease and for patients with advanced disease with seriously compromised pulmonary function and chronic respiratory failure (Hasan et al., 1995). The 3-year survival rate is 75% for patients undergoing double-lung transplantation (Barlow et al., 2000). Some investigators have proposed a radical operation for bilateral bronchiectasis (Kittle et al., 1985; Laros et al., 1988) but others report a higher mortality with pneumonectomy (McGovern et al., 1988). Considering the limited and palliative effect of medical treatment and the risk of transplantation or radical operation, it seems that a limited operation should be offered to

Mazierez and collegues suggested that surgical indications were offered to patients with multisegmental and severe bronchiectasis if (1) optimal medical treatment and physiotherapy were no longer efficient, (2) bleeding and sputum production were recurrent and abundant, (3) severely damaged territories could be identified, and (4) performance status and pulmonary

Surgery in multiple segments on different lobes is technically more difficult, resulting in higher morbidity and mortality.21 However, pulmonary resection is indicated early in patients with multisegmentar bronchiectasis, before other portions of the lung become grossly diseased. Our purpose in these patients was to protect as much pulmonary function as possible, with the aim of removing only the affected areas of different lobes. The types of

> Zhang n, %

Pneumonectomy 13 (5.4) 12 (8.3) 90 (11.3) 40 (19.9) 7 (20) 1 (1.7) Lobectomy 189 (79.4) 82 (55.4) 497 (62.9) 90 (44.7) 17 (48.5) 33 (56.8) Bilobectomy 7 (4.7) 56 (7.1) 21 (10.4) 2 (5.7) 2 (3.4)

segmentectomy 31 (13.0) - 110 (14) - 5 (14.2) 11 (18.9)

Segmentectomy 10 (4.2) 17 (11.4) 37 (4.7) 16 (7.9) 4 (11.4) 11 (18.9) Basal segmentectomy - 16 (10.8) - - - -

lingulectomy - 5 (3.3) - - - -

middle lobectomy - 4 (2.7) - - - -

VATS for major lung resection has become a more frequent procedure in recent years with promising outcome. VATS represents a new approach; the indications for VATS major

Sırmali n, %

Haciibrahimoglu n, %

Giovannetti n, %

function were compatible with the anesthetic risk (Mazierez et al., 2003).

Eren n; %

lingulectomy - 34 (16.9) -

procedures in different studies were presented in Table 3.

n, %

**11. Video-assisted thoracoscopic surgery**

some patients with diffuse bronchiectasis.

Operation type Balkanli

Lobectomy &

Lobectomy &

Basal segmentectomy &

Basal segmentectomy &

Table 3. Type of operation

resection remain the same as for conventional resection. But not all the patients with bronchiectasis who needed operations were suitable for VATS lobectomy; severe scarring and adhesions on computed tomographic scan should be considered . The severity of adhesions to the chest wall, the hilum, and especially in the fissure, typically seen in inflammatory disease, was the key limiting factor for a safe VATS lobectomy (Weber et al., 2001). Adhesions need to be dissected to explore the relevant anatomy. If there were dense adhesions (such as destroyed lobes mainly after tuberculosis with or without aspergillosis) or enlarged lymph nodes, especially calcified, open operations were required (Zhang et al., 2011).

Bronchiectasis was considered the best lung benign disease suitable for VATS lobectomy (Yim, 2002). The VATS major resection has demonstrated to be a safe procedure when performed by experienced physicians. Postoperative pain after VATS is uncommon as compared with open surgery. Other documented advantages include better preservation of pulmonary function in the early postoperative period, earlier return to full activities, and better quality of life after recovery. One major advantage of VATS resection is that it allows recruitment of older and sicker patients with multiple comorbidities who would otherwise not be candidates for resection through a conventional thoracotomy approach (Farjah et al., 2009; Gonzales-Aragoneses et al., 2009). In study of Zhang and collegeus, the patients with VATS had a shorter length of stay in the hospital, fewer complications, and less pain in the postoperative period than those with thoracotomies (Zhang et al., 2011).

## **12. Postoperative complication**

Bronchiectasis is an inflammatory disease of the lungs and the risk of developing postoperative empyema is higher than in other cases. Empyema, on the other hand, is a risk factor for bronchopleural fistula (Sirmali et al., 2006). Therefore, we suggest reinforcement of the bronchial stump in all patients. Bronchopleural fistula can be observed in as many as 9.1% of the cases (Fujimoto et al., 2001). Fujimoto and colleagues argued that the bronchial stump should be reinforced when the inflammation in the lung of bronchiectasis patients could not be effectively controlled (Fujimoto et al., 2001). We, however, suggest reinforcement the bronchial stump in all cases. Additionally, to avoid empyema, we recommend postoperative bacterial culture of thoracic effusion if the remaining lung shows signs of persisting inflammation. Sputum retention is common because patients with this disease might have problems with ciliary motion and postoperative expectoration, which would be easily disrupted (Fujimoto et al., 2001). In our series, respiratory physiotherapy was re-initiated on the first post-operative day, and continued for 2 weeks after discharge. We used bronchoscopy for sputum aspiration during the early postoperative period if physiotherapy was not effective. Virtually all patients had specific or large-spectrum intravenous antibiotic therapy for 1 week (Eren et al., 2007).

In bronchopleural fistula, drainage of the infected space is a key initial step to limit damage to the remaining lung. Bronchopleural fistula noted very early after the initial resection may be treated with primary reclosure and rebuttressing of the stump; later bronchopleural fistula usually require rib resection and creation of an Eloesser flap, followed by bronchopleural fistula closure and subsequent Clagett procedure, for successful treatment (Sugarbaker et al., 2009). The presence of a significant intrathoracic "space" appears to be more common after major lung resection for infectious lung disease such as bronchiectasis compared with other indications for surgery. The use of transposed muscle such as

Surgical Treatment of Bronchiectasis 305

Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation. It was reported that the symptoms persisted when incomplete resection was carried out. When suspicious lung regions are not excised with the aim of sparing as much lung tissue as possible, a second operation that carries a higher morbidity and mortality might be required to remove the residual diseased tissues. Therefore, we suggest that, during intraoperative examinations, if suspected areas that could not be determined by radiological examination are present, these parenchymal

areas should be resected to perform complete resection and to decrease relapse rates.

bronchiectasis can be performed with acceptable morbidity and low mortality.

bronchiectasis. *J Thorac Cardiovasc Surg*, Vol.83, No.4, pp. 546-550

prognostic factors. *Tuber Lung Dis,* Vol.77, No.2, pp. 168-72

patients. *Eur J Cardiothorac Surg*, Vol.24, No.5, pp. 699-702

*Thorac Cardiovas Surg,*Vol.119, No.3, pp. 466–476

syndrome. *Thorax*, Vol.35, No.6, pp. 449–452

**14. References**

pp. 481–485

Surgery in multiple segments on different lobes is technically more difficult, resulting in higher morbidity and mortality. However, pulmonary resection is indicated early in patients with multisegmentar bronchiectasis, before other portions of the lung become grossly diseased. Our purpose in these patients was to protect as much pulmonary function as possible, with the aim of removing only the affected areas of different lobes. VATS represents a new approach; the indications for VATS major resection remain the same as for conventional resection. But not all the patients with bronchiectasis who needed operations were suitable for VATS lobectomy; severe scarring and adhesions on computed tomographic scan should be considered. When necessary, surgical treatment of

Agasthian, T.; Deschamps, C., Trastek, VF., Allen, MS. & Pairolero, PC. (1996). Surgical management of bronchiectasis. *Ann Thorac Surg*, Vol.62, No.4 , pp. 976-978 Al-Kattan, KM.; Essa, MA., Hajjar, WM., Ashour, MH., Saleh, WN. & Rafay, MA. (2005).

Ashour, M.; Al-Kattan, KM., Jain, SK., Al-Majed, S., Al-Kassimi, F., Mobaireek, A., Al-Hajjaj,

Balkanli, K.; Genc, O., Dakak, M., Gurkok, S., Gozubuyuk, A., Caylak, H. & Yucel, O. (2003).

Barker, AF.; Couch, L., Fiel, SB., Gotfried, MH., Ilowite, J., Meyer, KC., O'Donnell, A., Sahn,

Barlow, CW.; Robbins, RC., Moon, MR., Akindipe, O., Theodore, J. & Reitz, BA. (2000).

Bertelsen, S.; Struve-Christensen, E., Aasted, A. & Sparup, J. (1980). Isolated middle lobe

Campbell, DN. & Lilly, JR. (1982). The changing spectrum of pulmonary operations in infants and children. *J Thorac Cardiovasc Surg*, Vol.83, No5. , pp. 680-685.

Surgical results for bronchiectasis based on hemodynamic (functional and morphologic) classification *J Thorac Cardiovasc Surg* , Vol.130, No.5, pp. 1385-1390 Annest, LS.; Kratz, JM. & Crawford, FA Jr. (1982). Current results of treatment of

M. & Al-Zear, A. (1996). Surgery for unilateral bronchiectasis: results and

Surgical management of bronchiectasis: analysis and short-term results in 238

SA., Smith, LJ., Stewart, JO., Abuan, T., Tully, H., Van, Dalfsen J., Wells, CD. & Quan, J. (2000). Tobramycin solution for inhalation reduces sputum Pseudomonas aeruginoa density in bronchiectasis. *Am J Respir Crit Care Med* , Vol.162, No.2 Pt 1,

Heart-lung versus double-lung transplantation for suppurative lung disease. *J*

atelectasis: aetiology, pathogenesis, and treatment of the so-called middle lobe

latissimus dorsi minimizes the potential complications in this setting, including postresection empyema or prolonged air leak (Sugarbaker et al., 2009). The rate of complications in the current literature varies between 9.4% and 24.6%. Mortality ranges from 0% to 8.3% in the literature (Fujimoto et al., 2001). Postoperative complications in different studies were presented in Table 4.

Table 4. Postoperative complications

## **13. Conclusion**

Bronchiectasis is pathologically defined as a condition in which there are abnormal and permanent dilatations of proximal bronchi. Bronchiectasis can occur as focal or localized disease, or in a diffuse manner. Overall, one-third of cases of bronchiectasis are unilateral and affect a single lobe, one-third are unilateral but affect more than one lobe, and one-third are bilateral. Recurrent pulmonary infection during childhood is an important factor in the etiology. In developing countries, tuberculosis is still one of the most important causes of bronchiectasis. Bronchial obstruction from either endobronchial pathology or external compression can also be an acquired factor predisposing to the development of bronchiectasis.

Treatment options for the management of bronchiectasis include pharmacologic agents such as antibiotics, nonpharmacologic measures such as chest physiotherapy, and surgical procedures involving removal of the affected portion or portions of the lung. The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients in which medical treatment has failed and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess. The preoperative treatment should include reducing airway obstruction and elimination of microorganisms from the lower respiratory tract, which consists of antimicrobial therapy, postural physiotherapy, bronchodilators, and corticosteroids. Preoperative bronchoscopy should be routinely done to rule out benign or malignant cause of obstruction.

latissimus dorsi minimizes the potential complications in this setting, including postresection empyema or prolonged air leak (Sugarbaker et al., 2009). The rate of complications in the current literature varies between 9.4% and 24.6%. Mortality ranges from 0% to 8.3% in the literature (Fujimoto et al., 2001).  Bronchiectasis can occur as focal or localized disease, or in a diffuse manner. Overall, one-third of cases of bronchiectasis are unilateral and affect a single lobe, one-third are unilateral but affect more than one lobe, and one-third are bilateral. Recurrent pulmonary infection during childhood is an important factor in the etiology. In developing countries, tuberculosis is still one of the most important causes of bronchiectasis. Bronchial obstruction from either endobronchial pathology or external compression can also be an acquired factor predisposing to the development of

Treatment options for the management of bronchiectasis include pharmacologic agents such as antibiotics, nonpharmacologic measures such as chest physiotherapy, and surgical procedures involving removal of the affected portion or portions of the lung. The goals of surgical therapy for bronchiectasis are to improve the quality of life for those patients in which medical treatment has failed and to resolve complications such as empyema, severe or recurrent hemoptysis, and lung abscess. The preoperative treatment should include reducing airway obstruction and elimination of microorganisms from the lower respiratory tract, which consists of antimicrobial therapy, postural physiotherapy, bronchodilators, and corticosteroids. Preoperative bronchoscopy should be routinely done to rule out benign or

Prolonged air-leak 6 (2.5) 7 (4.8) 21 (2.7) 3 (1.7) 2 (3.2) 1 (2.9) 1 (2.2)

Cobanoglu n, %

Haciibrahimoglu n, %

Giovannetti n, %

different studies were presented in Table 4.

n, %

Eren n, %

Zhang n, %

Atelectasis 7 (2.9) 11 (7.6) 16 (2) 8 (4.5) 4 (6.4) -

Complication Balkanli

Postoperative

Residual

Bronchial

Bronchopleural

Postoperative

Severe supraventricular arrhythmias

Respiratory

**13. Conclusion**

bronchiectasis.

malignant cause of obstruction.

Table 4. Postoperative complications

Complete and anatomic resection should be done with preservation of as much lung function as possible to avoid cardiorespiratory limitation. It was reported that the symptoms persisted when incomplete resection was carried out. When suspicious lung regions are not excised with the aim of sparing as much lung tissue as possible, a second operation that carries a higher morbidity and mortality might be required to remove the residual diseased tissues. Therefore, we suggest that, during intraoperative examinations, if suspected areas that could not be determined by radiological examination are present, these parenchymal areas should be resected to perform complete resection and to decrease relapse rates.

Surgery in multiple segments on different lobes is technically more difficult, resulting in higher morbidity and mortality. However, pulmonary resection is indicated early in patients with multisegmentar bronchiectasis, before other portions of the lung become grossly diseased. Our purpose in these patients was to protect as much pulmonary function as possible, with the aim of removing only the affected areas of different lobes. VATS represents a new approach; the indications for VATS major resection remain the same as for conventional resection. But not all the patients with bronchiectasis who needed operations were suitable for VATS lobectomy; severe scarring and adhesions on computed tomographic scan should be considered. When necessary, surgical treatment of bronchiectasis can be performed with acceptable morbidity and low mortality.

#### **14. References**

Surgical Treatment of Bronchiectasis 307

Karadag, B.; Karakoc, F., Ersu, R., Kut, A., Bakac, S. & Dagli, E. (2005). Non-cystic fibrosis

Karakoc, GB.; Yilmaz, M., Altintas, DU. & Kendirli, SG. (2001). Bronchiectasis: still a

Keistinen, T.; Saynajakangas, O., Tuuponen, T. & Kivela, SL. (1997). Bronchiectasis: an

Khair, OA.; Davies, RJ. & Devalia, JL. (1996). Bacterial-induced release of inflammatory mediators by bronchial epithelial cells. *Eur Respir J*, Vol.9, pp. 1913–1922 Kim, JS.; Tanaka, N., Newell, JD., Degroote, MA., Fulton, K., Huitt, G. & Lynch, DA. (2005).

King, PT. (2009). The pathophysiology of bronchiectasis. *International Journal of COPD*, Vol.4,

Kittle, CF.; Faber, LP., Jensik, RJ. & Warren, WH. (1985). Pulmonary resection in patients

Lapa e Silva, JR.; Guerreiro, D., Noble, B., Poulter, LW. & Cole, PJ. (1989). Immunopathology of experimental bronchiectasis. *Am J Respir Cell Mol Biol*, Vol.1, pp. 297–304 Laros, CD.; Van den Bosch, JM., Westermann, CJ., Bergstein, PG., Vanderschueren, RG. &

Loukides, S.; Bouros, D., Papatheodorou, G., Lachanis, S., Panagou, P. & Siafakas, NM.

Mal, H.; Rulon, I., Mellot, F., Brugiere, O., Sleiman, C., Menu, Y. & Fournier, M. (1999).

Mazie`res, J.; Murris, M., Didier, A., Giron, J., Dahan, M., Berjaud, J. & Le´ophonte, P. (2003).

McGovern, EM.; Trastek, VF., Pairolero, PC. & Payne, WS. (1988). Completion

Miller, JI. (2000). Bacterial infections of the lungs and bronchial compressive disorders. In:

Nicotra, MB.; Rivera, M., Dale, AM., Shepherd, R. & Carter, R. (1995). Clinical,

Prieto, D.; Bernardo, J., Matos, MJ., Eugenio, L. & Antunes, M. (2001). Surgery for

30 bronchiectatic patients. *J Thorac Cardiovasc Surg*, Vol.95, pp. 119-123 Levin, DL. (2002). Radiology of pulmonary Mycobacterium avium-intracellulare complex.

treatment responsiveness. *Chest* Vol.128, No.6, pp. 3863–3869

after pneumonectomy. *Ann Thorac Surg*, Vol.40, pp 294–299

threatening hemoptysis. *Chest*, Vol.115, pp. 996—1001

bronchiectasis. *Eur J Cardiothorac Surg*, Vol.20, pp. 19-23

*Respiration*, Vol.72, No.3, pp. 233–238

*Clin Chest Med*, Vol.23, pp. 603–612

*Chest,* Vol.121, pp. 81–87

*Surg*, Vol.75, pp.382–387

Williams & Wilkins, Philadelphia

cohort. *Chest*, Vol.108, pp. 955– 961

pp. 141–146

2784–2787

pp. 411–419

problem. *Pediatr Pulmonol,* Vol.32, pp. 175–178

bronchiectasis in children: a persisting problem in developing countries.

orphan disease with a poorly understood prognosis. *Eur Respir J,* Vol.10, No.12, pp.

Nontuberculous mycobacterial infection: CT scan findings, genotype, and

Knaepen, PJ. (1988). Resection of more than 10 lung segments. A 30-year survey of

(2002). Exhaled H2O2 in steady-state bronchiectasis: relationship with cellular composition in induced sputum, spirometry, and extent and severity of disease.

Immediate and long-term results of bronchial artery embolization for life-

Limited Operation for Severe Multisegmental Bilateral Bronchiectasis *Ann Thorac*

pneumonectomy: indications, complications and results. *Ann Thorac Surg*, Vol.46,

Shields TW, editor. *General thoracic surgery*. 5th ed. Pp. 1048-1051, Lippincott

pathophysiologic, and microbiologic characterization of bronchiectasis in an aging

Cobanoglu, U.; Yalcinkaya, İ., Er, M., Isik, AF., Sayir, F. & Mergan, D. (2011). Surgery for

Cohen, AJ.; Roifman, C., Brendan, J., Mullen, M., Reid, B., Weisbrod, G. & Downey, GP.

Deslauries, J.; Goulet, S. & Francois, B. (1998). Surgical treatment of bronchiectasis and

Dogru, D.; Nik-Ain, A., Kiper, N., Gocmen, A., Ozcelik, U., Yalcin, E. & Aslan, AT. (2005).

Eller, J.; Lapa, e Silva JR., Poulter, LW., Lode H. & Cole, PJ. (1994). Cells and cytokines in

Eren, S.; Esme, H. & Avci, A. (2007). Risk factors affecting outcome and morbidity in the

Boren, EJ.; Teuber, SS. & Gershwin, ME. (2008). A Review of Non-Cystic Fibrosis Pediatric

Etienne, T.; Spiliopoulos, A. & Megevand, R. (1993). Bronchiectasis: indication and timing

Farjah, F.; Wood, DE., Mulligan, MS., Krishnadasan, B., Heagerty, PJ., Symons, RG. & Flum,

Fujimoto, T.; Hillejan, L. & Stamatis, G. (2001). Current strategy for surgical management of

George, SA.; Leonardi, HK. & Overholt, RH. (1979). Bilateral pulmonary resection for bronchiectasis: a 40-year experience. *Ann Thorac Surg*, Vol.28, No.1, pp. 48–53 Giovannetti, R.; Alifano, M., Stefani, A., Legras, A., Grigoroiu, M., Collet, JY., Magdelenat, P.

Haciibrahimoglu, G.; Fazlioglu, M., Olcmen, A., Gurses, A. & Bedirhan, MA. (2004). Surgical

Hasan, A.; Corris, PA., Healy, M., Wrightson, N., Gascoigne, AD., Waller, DA., Wilson, I.,

for end-stage septic lung disease. *Thorax*, Vol.50, No.5, pp. 565–566

for lung cancer. *J Thorac Cardiovasc Surg,* Vol.137, No.6, pp. 1415–1421 Freitag, L.; Tekolf, E., Stamatis, G., Montag, M. & Greschuchna, D. (1994). Three years

chronic bronchial infection. *Ann N Y Acad Sci*, Vol.725, pp. 331–345

Bronchiectasis. *Clinic Rev Allerg Immunol*, Vol.34, pp. 260–273

bronchiectasis. *Ann Thorac Surg,* Vol.72, No.5, pp. 1711-1715

*Crit Rev Oncol Hematol*, Vol.71, No.3, pp. 266 –271

*Cardiovasc Surg*, Vol.127, No.5, pp. 1361-1365

for surgery. *Ann Chir*, Vol.47, No.8, pp. 729–735

*Respir J*, Vol.7, No.11, pp. 2033—2037

hypogammaglobulinaemic patients. *Thorax,* Vol.49, No.5, pp. 509–510 Cole, PJ.; Roberts, DE., Higgs, E. & Prior, C. (1985). Colonising microbial load a cardinal

"vicious circle" host mediated damage. *Thorax*, Vol.40, pp. 227

(ed.), pp. 300–309, ON: Decker, Hamilton

*J Trop Pediatr,* Vol.51, No.6; pp. 362–365

*Vol.*6, No.1, pp. 25–32

392-398

bronchiectasis: The effect of morphological types to prognosis. *Ann Thorac Med,*

(1994). Localised pulmonary resection for bronchiectasis in

concept in the pathogenesis and treatment of progressive bronchiectasis due to

broncholithiasis. In: *Advanced therapy in thoracic surgery,* Franco, LF., Putnam, JB,

Bronchiectasis: the consequence of late diagnosis in chronic respiratory symptoms.

surgical management of bronchiectasis. *J Thorac Cardiovasc Surg*, Vol.134, No.2, pp.

DR. (2009). Safety and efficacy of video-assisted versus conventional lung resection

experience with a new balloon catheter for the management of haemoptysis. *Eur*

& Regnard, JF. (2008). Surgical treatment of bronchiectasis: early and long-term results Interactive. *CardioVascular and Thoracic Surgery*, Vol.7,No.4 ,pp. 609–612 Gonzalez-Aragoneses, F,; Moreno-Mata, N., Simon-Adiego, C., Peñalver-Pascual, R.,

Gonzalez-Casaurran, G. & Perea, LA. (2009). Lung cancer surgery in the elderly.

management of childhood bronchiectasis due to infectious disease*. J Thorac*

Hilton, CJ., Gould, FK. & Forty, J. (1995). Bilateral sequential lung transplantation

**18**

*Romania*

**Role of Thoracomyoplasty Procedures in**

*Surgical Clinic 4, University of Medicine and Pharmacy from Targu-Mures,*

Petre Vlah-Horea Botianu and Alexandru Mihail Botianu

**Modern Surgery for Intrathoracic Suppurations**

Both thoracoplasty and muscle transposition are rarely performed procedures in modern thoracic surgery (Deslauriers et al., 2002). Their importance comes from the fact that these procedures are usually indicated in desperate cases, with failed medical treatments and who cannot be cured through standard procedures such as resection or decortication. For these patients, thoracomyoplasty operations are often the last chance for cure and sometimes even

In our days, most of the intrathoracic suppurations can be managed without surgery, through antibiotics and minor procedures such as thoracocenthesis or tube-thoracostomy (Davies et al., 2011). Overall, about 10-15% of patients with intrathoracic suppurations still require some form of major surgical treatment. Out of them, most can be managed through less invasive and mutilating procedures (Pardos-Gea et al., 2011, Zahid et al., 2011), which

Tuberculosis (TB) requires a special attention. Although TB infection by itself is not an indication for such procedures, many cases with chronic disease present with features making them candidates for thoracomyoplasty procedures. In our experience, almost half of the patients requiring thoracomyoplasty operations had different forms of TB lesions

Bronchial fistula is frequently solved with the use of muscle flaps, alone or in combination with thoracoplasty. Simple closure by suturing through an inflamed tissue has very few chances of success, making reinforcement with a viable flap almost mandatory in most cases. In many cases, the muscle flaps are used as a plug to close the bronchial defect, without direct suture of the edges of the fistula (Hollaus et al., 1999, Zaheer et al., 2009).

**1. Introduction**

life-saving procedures (Botianu et al., 2010a).

expansion of the lung;

(Botianu P. et al., 2010a).

**2. Modern indications of thoracomyoplasty procedures**

make thoracomyoplasty a quite rarely indicated procedure:

lesions with major technical difficulties.

## **Role of Thoracomyoplasty Procedures in Modern Surgery for Intrathoracic Suppurations**

Petre Vlah-Horea Botianu and Alexandru Mihail Botianu *Surgical Clinic 4, University of Medicine and Pharmacy from Targu-Mures, Romania*

## **1. Introduction**

308 Topics in Thoracic Surgery

Reid, L. (1950). Reduction in bronchial subdivisions in bronchiectasis. *Thorax*, Vol.5, pp. 223–

Sherwood, JT.; Mitchell, JD. & Pomerantz, M. (2005). Completion pneumonectomy for chronic mycobacterial disease. *J Thorac Cardiovasc Surg,* Vol.129, pp. 1258–1265 Sirmali, M.; Karasu, S., Turut, H., Gezer, S., Kaya, S., Tastepe, I. & Karaoğlanoğlu, N. (2006).

Smit, HJ.; Schreurs, AJ., Van den Bosch, JM. & Westermann, CJ. (1996). Is resection of

Sugarbaker DJ.; Bueno R, Krasna MJ, Mentzer ZJ & Zellos L. (2009). *Adult Chest Surgery*, The

Weber, A.; Stammberger, U., Inci, I., Schmid, RA., Dutly, A. & Weder, W. (2001).

Whitwell, F. (1952). A study of the pathology and pathogenesis of bronchiectasis. *Thorax*,

Yim, AP. (2002). VATS major pulmonary resection revisited– controversies, techniques, and

Young, K.; Aspestrand, F. & Kolbenstvedt, A. (1991). High resolution CT and

Yuncu, G.; Ceylan, KC., Sevinc, S., Ucvet, A., Kaya, SO., Kiter, G., Unsal, S. & Ozsinan, F.

Zhang, P.; Zhang, P., Jiang, S., Jiang, G., Zhou, X., Ding, J. & Gao, W. (2011). Video-Assisted Thoracic Surgery for Bronchiectasis. *Ann Thorac Surg,* Vol.91, pp. 239–243 Zheng, L.; Tipoe, G., Lam, WK., Leung, RY., Ho, JC., Shum, IH., Ooi, GC., Ip, MS. & Tsang,

bronchography in the assessment of bronchiectasis. *Acta Radiol*, Vol.32, pp. 439-441

(2006). Functional results of surgical treatment of bronchiectasis in a developing

KW. (2000). Up-regulation of circulating adhesion molecules in bronchiectasis. *Eur*

McGraw-Hill Companies, ISBN 978-0-07-145912-9, China

Surgical management of bronchiectasis in childhood. *Eur J Cardiothorac Surg,*

bronchiectasis beneficial in patients with primary ciliary dyskinesia? *Chest*, Vol.109,

Thoracoscopic lobectomy for benign disease–a single centre study on 64 cases. *Eur J*

247

Vol.31, No.1, pp. 120-123

*Cardiothorac Surg*, Vol.20, pp. 443– 844

*Respir J*, Vol.16, No.4, pp. 691–696

results. *Ann Thorac Surg*, Vol.74, pp. 615–623

country. *Arch Bronconeumol*, Vol.42, No.4, pp. 183-188

pp. 1541–1544

Vol.7, pp. 213–219

Both thoracoplasty and muscle transposition are rarely performed procedures in modern thoracic surgery (Deslauriers et al., 2002). Their importance comes from the fact that these procedures are usually indicated in desperate cases, with failed medical treatments and who cannot be cured through standard procedures such as resection or decortication. For these patients, thoracomyoplasty operations are often the last chance for cure and sometimes even life-saving procedures (Botianu et al., 2010a).

## **2. Modern indications of thoracomyoplasty procedures**

In our days, most of the intrathoracic suppurations can be managed without surgery, through antibiotics and minor procedures such as thoracocenthesis or tube-thoracostomy (Davies et al., 2011). Overall, about 10-15% of patients with intrathoracic suppurations still require some form of major surgical treatment. Out of them, most can be managed through less invasive and mutilating procedures (Pardos-Gea et al., 2011, Zahid et al., 2011), which make thoracomyoplasty a quite rarely indicated procedure:

Tuberculosis (TB) requires a special attention. Although TB infection by itself is not an indication for such procedures, many cases with chronic disease present with features making them candidates for thoracomyoplasty procedures. In our experience, almost half of the patients requiring thoracomyoplasty operations had different forms of TB lesions (Botianu P. et al., 2010a).

Bronchial fistula is frequently solved with the use of muscle flaps, alone or in combination with thoracoplasty. Simple closure by suturing through an inflamed tissue has very few chances of success, making reinforcement with a viable flap almost mandatory in most cases. In many cases, the muscle flaps are used as a plug to close the bronchial defect, without direct suture of the edges of the fistula (Hollaus et al., 1999, Zaheer et al., 2009).

Role of Thoracomyoplasty Procedures in Modern Surgery for Intrathoracic Suppurations 311

plombage with different materials became popular, being then almost abandoned.

very popular at a certain moment of the development of thoracic surgery.

a subperiosteal plane for rib resection (Hopkins et al., 1985).

**3.3 Main types of thoracoplasty**

1997, Botianu 2005, 2008).

scoliosis.

(Alexander 1936).

In our days, most thoracoplasties are done in a single operative step, intrapleural and using

Over the time, more than 100 thoracoplasty procedures were described, many of them being in fact minor modifications or combinations of previously described techniques; such a big number of techniques is by itself an indication for the dificulties encountered in this kind of surgery. We present a brief description of the most important techniques, all of them being

**The Schede thoracoplasty** is a very "radical" procedure developed for empyema and involving the resection of ribs, intercostal spaces and parietal pleura overlying the empyema cavity. The wound was left opened and the visceral pleura from the empyema cavity was placed in direct contact with healthy tissues represented by extracostal chest wall muscles and subcutaneous tissue (Schede 1890). For small empyema cavities it may be a reasonable procedure but for big cavities the procedure is a very mutilant one. With different modifications, it is still used today for highly selected cases of empyema (Stobernack et al.,

**The Sauerbruch thoracoplasty (paravertebral)** was indicated for empyema cavities that extended more in the vertical axis than in the horizontal one and involved a 4-6 cm length resection of the posterior part of the ribs. The main disadvantages were the risk of respiratory failure due to the paradoxical movements of the chest wall and the secondary

**The Andre Maurer thoracoplasty** (**descendant)** involves complete excision of the first 2 ribs and partial removal of the ribs 3-5, leaving intact only the anterior part of them; it was performed extrapleurally, in one or more steps according to the patient's biological status. **The Alexander thoracoplasty** was designed for treatment of lung TB and involved a subperiosteal and extrapleural removal of the first 8-9 ribs; for a better collapse the removal of the first rib and the transverse vertebral apophyses was considered to be mandatory. For a better tolerance of the procedure, it was performed in 3 steps at 3 weeks intervals. With this strategy and a good selection of the patients, Alexander achieved an important improvement of the results, with a 10% mortality and 90% rate of healing in survivors

**The Archibald thoracoplasty** involved resection of the first 3 ribs and introduction of the pectoral muscles in the extrapleural space to maintain the collapse of the lung; a particular

Postoperative empyema is also an indication for thoracomyoplasty procedures in selected cases (Garcia-Yuste et al., 1998, Regnard et al., 2000). A particular technical aspect is that the previous thoracotomy reduces the availability of the neighbourhood flaps. The need to have some flaps available in case of postoperative complications is the main argument for the use of muscle-sparing thoracotomies (Nosotti et al., 2010).

Intrathoracic muscle transposition (without thoracoplasty) has also some other indications such as reinforcement of high-risk sutures (Abolhoda et al., 2009, Thingnam et al., 2011), repair of esophageal and tracheal defects (Kotzampassakis et al., 2009, Meyer et al., 2004), pericardial and diaphragmatic reconstruction (Kobayashi et al., 2009), dynamic cardiomyoplasty for end-stage heart failure (Chachques et al., 2008), salvage of infected vascular prosthesis (Mitra et al., 2005) etc.

## **3. Thoracoplasty**

### **3.1 Historical background**

The term "thoracoplasty" was introduced by Estlander (1879) who performed resection of multiple fragments of ribs ("resectio costorum multiplex") to achieve obliteration of an underlying empyema (Estlander, 1879). The operation became popular mainly as a method of lung collapse to achieve healing of tuberculosis before the introduction of modern TB chemotherapy. In fact, thoracoplasty procedures dominated chest surgery before the 1950's and played an essential role in the development of thoracic surgery as a distinct specialty. After 1950-60's, the interest for this procedure decreased due to the introduction of medical treatment (antibiotics and specific TB drugs) and development of other less mutilating and more effective surgical procedures (Deslauriers et al., 2002, Horrigan & Snow, 1990).

#### **3.2 Terminology**

Thoracoplasty is a procedure that targets the resolution of a cavity (pleural or pulmonary) by collapsing the chest wall through rib resection and/or plombage; according to the way this collapse is achieved, there are different terms which are used to describe the procedure:

Many authors use the term "classic" thoracoplasty, with different meanings depending on time and geographical location. For example, in Europe, in the 1910-20's, "classic" thoracoplasty referred to the procedures described by Estlander and Schede, which were then replaced by the procedures described by Andre Maurer and Sauerbruch; the later became also "classic" for the American surgeons who trained in Europe. In the USA, after 1930, the technique described by Alexander became the standard thoracoplasty performed for lung collapse in order to heal lung TB. In the 1950's, the osteoplastic techniques and plombage with different materials became popular, being then almost abandoned.

In our days, most thoracoplasties are done in a single operative step, intrapleural and using a subperiosteal plane for rib resection (Hopkins et al., 1985).

#### **3.3 Main types of thoracoplasty**

310 Topics in Thoracic Surgery

Postoperative empyema is also an indication for thoracomyoplasty procedures in selected cases (Garcia-Yuste et al., 1998, Regnard et al., 2000). A particular technical aspect is that the previous thoracotomy reduces the availability of the neighbourhood flaps. The need to have some flaps available in case of postoperative complications is the main argument for the use

Intrathoracic muscle transposition (without thoracoplasty) has also some other indications such as reinforcement of high-risk sutures (Abolhoda et al., 2009, Thingnam et al., 2011), repair of esophageal and tracheal defects (Kotzampassakis et al., 2009, Meyer et al., 2004), pericardial and diaphragmatic reconstruction (Kobayashi et al., 2009), dynamic cardiomyoplasty for end-stage heart failure (Chachques et al., 2008), salvage of infected

The term "thoracoplasty" was introduced by Estlander (1879) who performed resection of multiple fragments of ribs ("resectio costorum multiplex") to achieve obliteration of an underlying empyema (Estlander, 1879). The operation became popular mainly as a method of lung collapse to achieve healing of tuberculosis before the introduction of modern TB chemotherapy. In fact, thoracoplasty procedures dominated chest surgery before the 1950's and played an essential role in the development of thoracic surgery as a distinct specialty. After 1950-60's, the interest for this procedure decreased due to the introduction of medical treatment (antibiotics and specific TB drugs) and development of other less mutilating and more effective surgical procedures (Deslauriers et al., 2002,

Thoracoplasty is a procedure that targets the resolution of a cavity (pleural or pulmonary) by collapsing the chest wall through rib resection and/or plombage; according to the way this collapse is achieved, there are different terms which are used to describe the procedure: - **in one or more stages** – according to the number of operative steps used. In the past many authors preferred to perform the thoracoplasty in more steps, with resection of 2- 3 ribs in each step, in order to lower the magnitude of the operative aggression and to reduce mortality (Alexander 1936). This was a reasonable attitude in the early years of thoracic surgery, when a lot of things that are today standard were not available (general anesthesia, oro-tracheal intubation, blood transfusion, antibiotics, electrocautery etc). Besides the need for more procedures, a specific disadvantage is the cavity movement phenomenon, in which the cavity just moves in one direction without any resolution; at the end, the patient will have some ribs resected and the same cavity in another position (Archibald 1926). In our days, most of these procedures are done in

a direct access to the pleural and/or pulmonary lesion.

of muscle-sparing thoracotomies (Nosotti et al., 2010).

vascular prosthesis (Mitra et al., 2005) etc.

**3. Thoracoplasty**

**3.1 Historical background**

Horrigan & Snow, 1990).

**3.2 Terminology**

a single step.

Over the time, more than 100 thoracoplasty procedures were described, many of them being in fact minor modifications or combinations of previously described techniques; such a big number of techniques is by itself an indication for the dificulties encountered in this kind of surgery. We present a brief description of the most important techniques, all of them being very popular at a certain moment of the development of thoracic surgery.

**The Schede thoracoplasty** is a very "radical" procedure developed for empyema and involving the resection of ribs, intercostal spaces and parietal pleura overlying the empyema cavity. The wound was left opened and the visceral pleura from the empyema cavity was placed in direct contact with healthy tissues represented by extracostal chest wall muscles and subcutaneous tissue (Schede 1890). For small empyema cavities it may be a reasonable procedure but for big cavities the procedure is a very mutilant one. With different modifications, it is still used today for highly selected cases of empyema (Stobernack et al., 1997, Botianu 2005, 2008).

**The Sauerbruch thoracoplasty (paravertebral)** was indicated for empyema cavities that extended more in the vertical axis than in the horizontal one and involved a 4-6 cm length resection of the posterior part of the ribs. The main disadvantages were the risk of respiratory failure due to the paradoxical movements of the chest wall and the secondary scoliosis.

**The Andre Maurer thoracoplasty** (**descendant)** involves complete excision of the first 2 ribs and partial removal of the ribs 3-5, leaving intact only the anterior part of them; it was performed extrapleurally, in one or more steps according to the patient's biological status.

**The Alexander thoracoplasty** was designed for treatment of lung TB and involved a subperiosteal and extrapleural removal of the first 8-9 ribs; for a better collapse the removal of the first rib and the transverse vertebral apophyses was considered to be mandatory. For a better tolerance of the procedure, it was performed in 3 steps at 3 weeks intervals. With this strategy and a good selection of the patients, Alexander achieved an important improvement of the results, with a 10% mortality and 90% rate of healing in survivors (Alexander 1936).

**The Archibald thoracoplasty** involved resection of the first 3 ribs and introduction of the pectoral muscles in the extrapleural space to maintain the collapse of the lung; a particular

Role of Thoracomyoplasty Procedures in Modern Surgery for Intrathoracic Suppurations 313