Search

Background: Complications cannot always be avoided and their treatment is an integral component of a high quality medical treatment. Complications of the central airways are rare but necessitate supportive treatment by an experienced thoracic surgeon., Objective: The reader should become acquainted with measures to prevent complications, to recognize and treat complications early and should understand the necessity for an interdisciplinary approach., Material and Methods: A selective literature research was supplemented by personal experiences and complemented with prospectively collected photographs., Results: There are risk constellations for the appearance of all the mentioned complications which the surgeon needs to know in order to be able to take measures for early detection of complications. Iatrogenic tracheal injuries and bronchial stump fistulae are rare (< 5 %) whereas recurrent laryngeal nerve palsy after left-sided pneumonectomy occurs in up to 30 % of cases., Discussion: After the occurrence of complications at the latest, it is very important to include experienced thoracic surgeons and other specialists when necessary to protect the patient from further damage.

In order to achieve respectable postoperative outcomes after lung resection it is essential to understand the mechanism of bronchus healing. The bronchus seal should be air-tight and consist of monofilament suture or staples. The bronchus suture should be covered with vital tissue (lung, mediastinum, muscle flap). A complication in the process of bronchus healing should be diagnosed as early as possible in order to stop the destructive effect of the infection as rapidly as possible., (© Georg Thieme Verlag KG Stuttgart · New York.)

The additional sealing of bronchial and gastrointestinal sutures and anastomoses, respectively, by means of fibrin sealant helped to significantly reduce the postoperative dehiscence rate; this rate amounted to 3.6% for additionally sealed bronchus stump occlusions and to 4.2% in gastrointestinal operations, whereby naturally in emergency abdominal operations the rate was higher (7.7%) than in elective surgery (3.8%). Eight postoperative bronchus stump fistulae and eleven out of the twenty-five gastrointestinal anastomotic dehiscences could be closed using a fibrin clot. Furthermore, fibrin occlusion of the pancreatic duct following Whipple's operation for the protection of the pancreatic-digestive anastomosis (n = 67) has turned out to be a success, since no postoperative pancreatic fistulae occurred, which resulted in the very low mortality rate of 1.5%. One more indication for fibrin sealing was the prevention of postoperative lymph fistulae by additional wound sealing (n = 123) and the fibrin occlusion of these fistulae (n = 18); the postoperative lymph fistulae rate amounted to only 3.3%. All 4 cases, as well as 14 other cases of existing lymph fistulae were healed quickly by instillation of fibrin. These relatively new, partly endoscopic, procedures using fibrin sealing proved to be very successful, because on the one hand postoperative fistulae could be largely avoided and on the other hand they could be treated without further operation.

In 1016 pulmonary resections we had 2,6% bronchial fistulae. 447 times we used interrupted suture (2,9% of bronchial stump insufficiency) and 542 times we used the Soviet bronchus stapling machine UKB 25 or 16 with 2,2% of fistulae.

Automatic stapling devices can be used for suturing the bronchus, pulmonary parenchyma and pulmonary vessels in lung resections. In particular, TA staplers have proved of great value in suturing the bronchial stump, helping to prevent the feared complication of stump insufficiency. No bronchopleural fistulae were recorded in a series of 220 lung resections.

A fistula of the bronchus developed in 48 (3.3%) of 1466 patients with lung resection for non-tuberculous disease operated between 1948 and 1974. Only 1 (0.55%) of the 181 patients operated between 1972 and 1974 developed a fistula. In this last series we used atraumatic needles only and handled the bronchial stump with utmost care. The stumps were always covered with good vascularized tissue. Antibiotics were instilled in the pleural cavity.