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J Thorac Cardiovasc Surg 1996;112:328-334
© 1996 Mosby, Inc.
GENERAL THORACIC SURGERY |
From the Division of Thoracic Surgery, Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia.
Received for publication June 2, 1995 Accepted for publication Oct. 2, 1995. Address for reprints: M. Ashour, FRCS, Associate Professor of Thoracic Surgery, King Khalid University Hospital, P. O. Box 7805, Riyadh 11472, Saudi Arabia.
Abstract
On the basis of the morphologic and hemodynamic features in 17 patients with bilateral bronchiectasis, a new subclassification is proposed. Accordingly, two types of bronchiectasis were recognized: perfused and nonperfused. Whereas perfused bronchiectasis has intact pulmonary artery flow and cylindrical bronchiectatic changes, the nonperfused type involves an absent pulmonary artery flow, retrograde filling of the pulmonary artery through the systemic circulation, and cystic bronchiectatic changes. A policy of unilateral resection of nonperfused bronchiectasis and preservation of the perfused type was adopted in 17 patients with bilateral bronchiectasis during an 8-year period. There were 9 women and 8 men with an average age of 28.6 ± 7 years (range 18 to 48 years). Fifteen patients had mixed bronchiectasis (perfused type on one side and nonperfused on the other side) and two had localized bilateral nonperfused type. The average duration of follow-up was 38.3 ± 24.9 months (range 13 to 111 months). In the 15 patients with mixed bronchiectasis, excellent (N = 8) or good (N = 7) results were achieved in all cases. On the other hand, the two patients with bilateral nonperfused bronchiectasis did not benefit from unilateral resection. This outcome implies that with perfused bronchiectasis the deranged function is likely to resolve with time. In the face of the general criticism of the traditional morphologic classification system, the proposed functional classification not only reflects the degree of severity of the disease process, but also predicts whether the involved lung will have a measure of respiratory function with regard to gas exchange. Thus the question of which side to resect and which to preserve is defined more precisely. (J THORAC CARDIOVASCSURG1996;112:328-34)
Bronchiectasis or dilation of the bronchi was first described by Laenec in 1918.
1 Since then classifications of varying complexities have been proposed. On the basis of examination of morbid specimens, Roles and Tod 2 described five types of bronchiectasis: tubular, early fusiform, late fusiform, fusosaccular, and saccular. Later, Reid 3 described three types of bronchiectasis taking into consideration the findings on bronchography.
The word bronchiectasis as currently used is a descriptive term that fails to indicate which type of the disease may have a measure of respiratory function with regard to gas exchange. Moreover, hemodynamic alterations specific to each type of bronchiectasis, to my knowledge, have not been reported before. To investigate these aspects of the disease, a prospective study of 17 patients with bilateral bronchiectasis was undertaken. On the basis of these hemodynamic alterations, a new subclassification is proposed. Its impact on the surgical treatment of patients with bronchiectasis is also discussed.
Patients and methods
Seventeen patients with bilateral bronchiectasis were studied prospectively, before operation, during a period of 8 years (1987 to 1993). Computed tomography (CT) of the chest and complete bilateral bronchograms were done in all patients to identify the morphologic features of the disease. To determine the various hemodynamic alterations in these patients, ventilation/perfusion (V/Q) lung scan, pulmonary angiography, and thoracic aortography were done. Bronchoscopy was done routinely to rule out endobronchial lesions as a cause for the disease. Cardiorespiratory assessment included blood gas analysis, full pulmonary function tests, and electrocardiograms. Sputum was cultured routinely for pyogenic organisms and tubercular bacilli.
Indications for operation included production of large amounts of sputum and recurrent hemoptysis. After operation, all patients received intensive chest physiotherapy and the appropriate antibiotics. The operative procedures involved unilateral lung resection of the more severely affected side only. This was identified as the side having cystic bronchiectatic changes and being nonperfused according to V/Q lung scan and pulmonary angiography. The various operations done on the basis of this selection criterion are shown in Table I. Resected specimens were sent for histologic examinations.
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Results
There were eight men and nine women with an average age of 28.6 ± 7 years (range, 18 to 48 years) (Table II). All patients had chronic productive cough for an average period of 12.6 ± 6.1 years (range, 2 to 23 years). Ten (58.8%) of 17 had hemoptysis as well. Severity of hemoptysis ranged from frequent blood-tinged sputum to massive hemoptysis up to 300 ml of fluid. Average duration of hemoptysis was 1.9 ± 4.5 years (range, 6 months to 19 years). Sputum culture results were available for 16 patients. The culture grew normal flora in 10 (58.8%), Haemophilus influenzae in 4 (23.5%), and Pseudomonas aeruginosa in 2 (11.8%). Sputum was negative for acid fast bacilli in all patients.
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Discussion
Dilation and hypertrophy of bronchial circulation and extensive bronchopulmonary anastomotic channels in bronchiectasis were described by Leibow, Hales, and Lindskog 4 in 1949 and Pump 5 in 1972. Darke and Lewtas 6 recognized two patterns of bronchopulmonary shunts, those with forward and those with reverse flow. These hemodynamic alterations were generalized descriptive findings and were not linked to a particular type of bronchiectasis.
To my knowledge, hemodynamic alterations specific to each type of bronchiectasis have not been reported before. This study showed that the pattern of pulmonary perfusion in patients with bronchiectasis was not uniform, and hemodynamic alterations specific to each type of bronchiectasis were demonstrated. Thus when the morphologic features of bronchiectasis were correlated with angiographic findings two types of bronchiectasis were recognized, nonperfused and perfused. All lungs with cylindrical bronchiectatic changes were found to be perfused (Fig. 1), whereas those with cystic changes were nonperfused (Fig. 2). This discrepancy in the pattern of pulmonary perfusion reflected the difference in the severity of the disease process. An absent pulmonary artery flow indicated an end-stage disease. This observation was supported by histologic examination of the resected segments. On the other hand, intact pulmonary artery flow indicated a lesser inflammatory process.
In nonperfused bronchiectasis (N = 19 lungs), the involved lungs showed absent pulmonary artery flow, retrograde filling of the pulmonary artery through systemic circulation, and cystic bronchiectatic changes. As a result of the pulmonary capillary bed destruction in these lungs, pulmonary capillary resistance increased and thus the shunted blood was forced to travel through the pulmonary artery toward the hilum (Fig. 4, B). This phenomenon was described previously as reversal of pulmonary artery flow. 6 Consequently, the contrast injected during pulmonary angiography cannot sufficiently penetrate into the pulmonary artery because of the hemodynamic block created by the opposing stream of the systemic inflow. Thus a false impression of an empty artery is born (Fig. 6, A and B). With this understanding in mind, lungs with nonperfused bronchiectasis are unlikely to have a respiratory function with regard to gas exchange. Moreover, this shunt in hemodynamic terms corresponds to a patent ductus arteriosus, an event that might cause left ventricular strain and dyspnea. 7 Furthermore, the thin-walled dilated bronchial vessels may rupture, thus causing hemoptysis during the course of the disease. 8 In this series, 9 of the 10 patients who had hemoptysis were known to have nonperfused bronchiectasis, unilaterally in 7 patients and bilaterally in 2.
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In view of all these observations, a policy of resecting nonperfused bronchiectasis and preserving the perfused type was adopted. This resection not only served to remove the major source of sepsis with its possible role in spill-over infection to other lung tissues, but also corrected the state of massive bronchopulmonary shunt. As a result, the perfused bronchiectatic parts would be in a better position for the deranged functions to return to normal in time. Seventeen patients were operated on. In the 15 patients with mixed disease, all patients had either excellent (N = 8) or good (N = 7) results. All seven patients with good results felt much better and the question of further operation to the other side was not raised. Seven of eight patients with hemoptysis became free of symptoms. On the other hand, two patients with localized bilateral nonperfused disease did not benefit from unilateral resection alone and continued to have hemoptysis. This result suggests that unilateral resection in patients with localized bilateral nonperfused bronchiectasis is inadequate. Instead, staged bilateral resections are likely to offer more favorable outcome.
When dealing with bilateral bronchiectasis, most surgeons operate on the more severely affected side first. 9-11 Opposite from this approach, Kergin 12 elected to operate on the less severely affected side first. This sharp swing in the philosophy of surgical management had two pitfalls. First, the term more severely affected side did not involve descriptive criteria to be recognized. Second, operating on the less severely affected side first may result in resection of lung tissues that have a measure of respiratory function.
In the face of the general criticism of the traditional morphologic classification system for bronchiectasis as being inadequate, 1,13 the proposed functional classification not only reflects the degree of severity of the disease process, but also predicts which type may have a measure of respiratory function. Thus the question of which side to resect and which to preserve is defined more precisely.
References
This article has been cited by other articles:
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  A. H. Alzeer, A. F. Al-Mobeirek, H. A. K. Al-Otair, U. A. F. Elzamzamy, I. A. Joherjy, and A. S. Shaffi Right and Left Ventricular Function and Pulmonary Artery Pressure in Patients With Bronchiectasis* Chest, February 1, 2008; 133(2): 468 - 473. [Abstract] [Full Text] [PDF]
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 K. M. Al-Kattan, M. A. Essa, W. M. Hajjar, M. H. Ashour, W. N. Saleh, and M. A. Rafay Surgical results for bronchiectasis based on hemodynamic (functional and morphologic) classification J. Thorac. Cardiovasc. Surg., November 1, 2005; 130(5): 1385 - 1390. [Abstract] [Full Text] [PDF]
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 M. Ashour, W. Hajjar, K. Al-Kattan, M. Essa, A. Al-Rhaman Al-Motrafi, A. Al-Saddique, and A. El-Bakry Intra-operative heparin release during lung surgery Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 839 - 843. [Abstract] [Full Text] [PDF]
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G. Haciibrahimoglu, M. Fazlioglu, A. Olcmen, A. Gurses, and M. A. Bedirhan Surgical management of childhood bronchiectasis due to infectious disease J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1361 - 1365. [Abstract] [Full Text] [PDF]
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 J. Mazieres, M. Murris, A. Didier, J. Giron, M. Dahan, J. Berjaud, and P. Leophonte Limited operation for severe multisegmental bilateral bronchiectasis Ann. Thorac. Surg., February 1, 2003; 75(2): 382 - 387. [Abstract] [Full Text] [PDF]
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T. Fujimoto, L. Hillejan, and G. Stamatis Current strategy for surgical management of bronchiectasis Ann. Thorac. Surg., November 1, 2001; 72(5): 1711 - 1715. [Abstract] [Full Text] [PDF]
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D. Prieto, J. Bernardo, M. J. Matos, L. Eugenio, and M. Antunes Surgery for bronchiectasis Eur. J. Cardiothorac. Surg., July 1, 2001; 20(1): 19 - 24. [Abstract] [Full Text] [PDF]
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