Surgical treatment of bronchial rupture in blunt chest trauma: a review of literature

Abstract

Bronchial rupture by blunt chest trauma is rare. We present a case of bronchial injury after blunt chest trauma that was repaired surgically by primary reconstruction. We performed a review of literature to verify if primary reconstruction is suitable for the treatment of adult patients with blunt bronchial injury. A systematic search was conducted to identify cohort studies of bronchial rupture after blunt chest trauma in adult patients between 1985 and 2016 (n=215 articles). Studies were included concerning four or more patients and in case patient data could be extracted. This resulted in 19 articles for final review, consisting of 155 patients. Mean age of 155 patients was 28 (range, 18-60) years. The main bronchus was mostly injured (81%), in 5% including an injury of the trachea and in 14% lobar bronchi injury. Surgical repair was performed in 95% of patients: primary anastomosis in 72%, pneumonectomy in 15%, lobectomy or sleeve resection in 12% and other in 1%. Perioperative mortality rate was 10%. Other complications occurred in 17% (empyema, rebleeding, stenosis and fistula, among others). Data concerning the occurrence of long-term complications or long-term follow-up was not found. Statistical evaluation could not be performed due to lack of consistent patient data. No strong recommendations regarding type and timing of surgery can be made based on the available literature. Based on our multidisciplinary opinion we would advocate primary anastomosis in case of stable vital signs with the goal to preserve healthy lung parenchyma. Moreover, it may be considered transferring these rare cases to an experienced thoracic and trauma surgery center.

Keywords: Bronchus; review; rupture; surgery; trauma.

Figure 1

Computed tomography scan during initial assessment of the patient at the emergency department, in this coronal plane revealing subcutaneous emphysema, left sided pneumothorax and pneumomediastinum. Furthermore, a suggestion of a rupture of the left main bronchus can be seen.

Figure 2

Bronchoscopy at diagnosis and during follow-up. (A) Bronchoscopy showing a complete rupture of the left main bronchus, 3 cm distal of the carina (arrow); (B) bronchoscopy 3 months after surgery. The left upper lobe and lower lobe were scaled as normal. The lumen of the distal left main bronchus was circular slightly narrowed (20% narrowing of lumen). Bronchial mucosa was still irritated and vulnerable; (C) bronchoscopy 9 months after surgery. A circular narrowing of 20% at the distal side of the left main bronchus was present. Bronchial mucosa was recovered with no mucosal defects or granulation tissue.

Figure 3

The completely transected left main bronchus is visualized after mediastinal dissection of pulmonary veins, aortic arch and main pulmonary artery (1). A primary end-to-end repair with interrupted 3-0 polydioxanone sutures (PDS) was performed and visualized in this video. Available online: http://www.asvide.com/article/view/27401

Figure 4

Flow-volume curve at 9 months of follow-up. Black line: normal curve; blue line: curve of patient’s flow volume; X-axis: volume (L), Y-axis: flow (L/s).

Figure 5

Flowchart of the selection of eligible articles.