Bronchial Repair with Pulmonary Preservation for Severe Thoracic Trauma

With very great interest we read the article published by Rocco and Allen in the August 2001 issue of The Thoracic and Cardiovascular Surgeon on complex bronchial repair of the left bronchial and pulmonary arterial rupture after severe blunt trauma [1].

Complex repair of the airway, lung parenchyma and, in addition, pulmonary artery reconstruction is always challenging, even for an experienced surgeon. Therefore, the authors should be congratulated on their good result. Previously, we reported in the September 1995 issue of this journal on the successful surgical treatment of a young patient with a complex disruption of the right bronchial system [2]. Bronchial anastomoses have been performed in the past using non-absorbable sutures. However, many anastomotic complications have been noted [3]. Today, we use monofilar, slowly absorbing 4/0 PDS polydioxanone for bronchial sutures. No major long-term anastomotic complications have been observed with these sutures. In our case, follow-up bronchoscopy performed 12 months later showed an almost normal bronchial lumen with no anastomotic stenosis [2].

A high degree of suspicion for major bronchial rupture is needed in cases of persistent pneumothorax in spite of correct chest drainage. In this situation, emergency bronchoscopy is a very useful tool. It helps to establish the site, extent, and sometimes the nature of the bronchial rupture. It should be performed wherever possible for critical intrathoracic injuries after blunt chest trauma [2] [3]. Intubation is often a most challenging procedure in patients with thoracic trauma. Bronchoscopy is always useful for finding the correct position for the bronchial blocker and/or double-lumen tube, one-lung ventilation being mandatory for complex bronchial repairs. However, in our view, one should not spend too much time with it or other invasive endoscopic procedures. Emergency thoracotomy is necessary in order to evaluate the degree of bronchial rupture, the possibility of reconstruction, the presence of lung lacerations and/or associated vital organ contusions, and sometimes as a resuscitative measure.

Mayor pulmonary resection in those patients who are in a critical clinical situation is associated with a high mortality [4] [5]. Pneumonectomy is in itself a disease-like condition, so in our opinion, initial bronchial reconstruction should always be attempted in order to preserve uninjured lung areas for adequate gas exchange and to avoid early and late bronchial complications.

References

• 1 Rocco G, Allen M. Bronchial repair with pulmonary preservation for severe blunt trauma.  Thorac Cardiovasc Surg. 2001;  49 231-233
• 2 Sirbu H, Herse B, Schorn B, Huttemann U, Dalichau H. Successful surgery after complete disruption of the right bronchial system.  Thorac Cardiovasc Surg. 1995;  43 239- 241
• 3 Taskinen S O, Salo J A, Halttunen P EA. Tracheobronchial rupture due to blunt chest trauma: a follow-up study.  Ann Thorac Surg. 1989;  48 846-849
• 4 Thompson D A, Rowlands B J, Walker W E, Kuykendall R C, Miller P W, Fischer R. Urgent thoracotomy for pulmonary or trachoebronchial injury.  J Trauma. 1988;  28 276-279
• 5 Bowling R, Mavroudis C, Richardson J D, Flint L M, Howe W R, Gray L A. Jr . Emergency pneumonectomy for penetrating and blunt trauma.  Am Surg. 1985;  51 137-143