Reply to Terzi et al.

Abstract

I thank Terzi et al. [1] for their comments on our article [2] and also thank EJCTS for giving me this opportunity to answer this question. Bronchopleural fistula (BPF) is a most serious complication in patients with tuberculosis-destroyed lungs who have undergone pneumonectomy. Halezeroglu et al. [3] consider that tuberculosis and preoperative empyema lead to BPF. We believe that the risk factors for BPF are the surgical suture technique, endobronchial tuberculosis, multidrug-resistant tuberculosis and pleural space infection, although postoperative BPF after pneumonectomy for tuberculosis-destroyed lungs has been decreasing steadily. The prevention of postoperative BPF in patients with tuberculosisdestroyed lungs is very important in chest surgery. The surgical process for a bronchial stump includes suturing and protection. The suturing includes full-thickness suture, stapler suture and so on. Pleural tissue, pericardial tissue and muscle flaps are used to protect the bronchial stump. But when a tuberculosis-destroyed lung is combined with endobronchial lesions, the suture line of the full-thickness suture and the stapler of the stapler suture for endobronchial tuberculosis may cause a ‘drainage effect’, which could lead to an infection in the chest. So, we think that the ‘drainage effect’ may lead to a BPF. Endobronchial tuberculosis has been demonstrated in up to 18% of tuberculosis patients. Vester et al. [4] think that the stapler is contraindicated when the bronchus is thickened, inflamed or of insufficient length. Thus, we think that the way in which we suture is more important than how the bronchial stump is protected. We suggest that the muscle flap that Terzi et al. [5] use to protect a bronchial stump could be used in the repair surgery after BPF. The extramucous suture technique for bronchia is a method that does not cross the bronchia mucous. In 1963, Xin et al. [6] reported 509 cases (including 487 of pulmonary tuberculosis and 22 of pulmonary suppuration) who underwent pulmonary resection. For the extramucous suture in a bronchia group of 200 patients, the incidence of BPF was 0%. For the full-thickness suture in a bronchia group of 200 patients, the incidence of BPF was 3.0% (six cases). For the stapler suture in a bronchia group of 109 patients, the incidence of BPF was 4.5% (five cases). The way we choose to suture is according to the situation of the mucous membrane. In our hospital, the extramucous suture technique has been routine for patients with endobronchial tuberculosis for half a century, and the incidence of BPF is very low. But reinforcing the bronchial stump with the surrounding tissues can decrease the incidence of postoperative BPF in tuberculosis-destroyed lungs. In addition, standard preand postoperative antituberculosis treatments and a careful operation often lead to satisfactory surgical effects. When patients suffer from multidrug-resistant pulmonary tuberculosis and endobronchial tuberculosis, selective operation indication, adequate preoperative antituberculosis treatment and endobronchial ultrasonic atomization are needed.