A 74-year-old man was admitted for right lower lobectomy with lower mediastinal and hilar lymph node dissection for squamous cell carcinoma. He had pulmonary emphysema secondary to smoking more than 50 pack-years. He had no diabetes mellitus, no history of steroid intake, and had not received chemotherapy or radiotherapy.
On postoperative day (POD) 10, the patient had pyrexia (38.4 °C), and C-reactive protein (CRP) was increased to 16.22 mg/dL. On POD 12, he developed subcutaneous emphysema. A BPF was suspected because of increasing air leakage through the chest tube and the broken appearance of the bronchial stump on chest computed tomography (Fig. 1).
Operation
On POD 13, reoperation was performed under general anesthesia. First, thoracoscopy in the lateral decubitus position confirmed the presence of the BPF, which was about 6–7 mm in diameter; the adhesions could be removed easily. Next, with the patient in the supine position, laparotomy was performed through a 7-cm skin incision; the right side of the omentum with a preserved right gastroepiploic artery was detached from the stomach for the omental flap. Lastly, with the patient back in the lateral position, the omental flap was led through the anterior mediastinum below the sternum and sutured above and below the bronchial fistula using two nonabsorbable mattress sutures. It was then fixed using three sutures to the parietal pleura without using fibrin sealant. A water test was not done, because the middle lobe held to the omental flap naturally and was expected to adhere soon. The fistula was covered with omentum and was not sutured directly for closure. Because the thoracic cavity had been narrowed due to inflammatory adhesions, and the working space was limited, the suturing technique was not straightforward. Finally, the BPF was covered with an omental flap. All procedures were done by VATS (Fig. 2). The thoracic space was washed using 2 L of saline, and the wound was closed with placement of an indwelling chest tube. The total surgical time was 4 h and 41 min, and blood loss was 100 mL.
After the reoperation, no air leakage was observed, and the chest drainage tube was removed on POD 4. The clinical decision was made based on the small quantity of drainage and the patient’s afebrile status, while still considering re-drainage if needed. Ceftazidime was administered intravenously for 2 weeks to treat the P. aeruginosa infection that was detected by cultures of the pleural effusion. The increased CRP level of 16.22 mg/dL before reoperation decreased to 7.19 mg/dL on POD 7 and to 1.64 mg/dL on POD 14. Although the patient complained of anorexia and pain for several days after the reoperation, his general condition was relatively better, and he was discharged 19 days after the reoperation (Fig. 3). At 2 years, he remained free from recurrence of cancer and infection.