Bronchial Closure Research Articles

EComment. Post-pneumonectomy bronchopleural fistula

We read with interest the article by Andreetti et al. regarding the treatment of post-pneumonectomy bronchopleural fistula (PPBPF) by self-expandable stent and we agree that this modality can be in the armamentarium of cardiothoracic surgeons [1]. PPBPF is one of the most serious and lethal complications in thoracic surgery. There are well-known predisposing factors related to this devastating postoperative complication such as extensive bronchial devascularization, right-sided pneumonectomy, long residual bronchial stump, neoadjuvant or adjuvant chemotherapy, regional radiotherapy, diabetes mellitus, steroid therapy, prolonged mechanical ventilation, history of smoking, pre-existing empyema, incomplete resection of cancer at the bronchial margins, decreased albumin levels (less than 3.5 mg/dL), male gender, and technique of bronchial stump closure [2, 3]. From the beginning of thoracic surgery, many different methods have been used to prevent the development of PPBPF [2, 3]. Pedicled pericardial flap or pericardial fat pad, pleura, intercostal muscle, diaphragm, and azygos vein (for right pneumonectomy) have been used as an additional coverage of bronchial stub wound with very good results [2, 3]. Brewer et al. in 1953 were the first ones who reported on their experimental and clinical work on the use of pedicled pericardial fat graft for reinforcement of bronchial closure in patients with pulmonary resection [4]. Taghavi et al. in 2005, in their retrospective study of 96 patients who underwent pneumonectomy (89.2% for primary lung cancer) and had covered bronchial stump with a pedicled pericardial flap, did not notice any evidence of PPBPF during the perioperative and postoperative period (mean follow up 15 ± 21.2 months) [2]. Sfyridis et al. in 2007, in their prospective randomised trial of 70 patients with diabetes mellitus who underwent pneumonectomy and were randomised to have their bronchial stump covered with an intercostal muscle flap or not; found that the group with the covered bronchial stump had a lower incidence of PPBPF (0% versus 8.8%; p = 0.02) and of empyema (0% versus 7.4%; p = 0.05) compared with the group not covered, at a mean follow-up of 18 ± 9.2 months [3]. Endobronchial valves have also been used to good effect in patients with persistent pulmonary air leaks (refractory to other therapy) secondary to alveolopleural fistula and to bronchopleural fistula as well [5]. In conclusion, in high risk patients the consideration of an effective method for covered bronchial stump for the prevention of the development of PPBLF is very important. Therefore, the multidisciplinary approach for the ideal treatment of patients with PBPF should be on an individual basis and is of paramount importance. Conflict of Interest: None declared

Detecting the efficacy of cyanoacrylate onto bronchial closure on an animal model

Bronchopleural fistula is a serius complication that may lead to mortality following pulmonary resection. In our study, it was aimed to investigate the efficacy of tissue adhesive cyanoacrylate onto bronchial closure methods. During this experimental study totally 40 sheep lung and trachea were removed together for either manuel closure, stapler or cyanoacrylate. After left pneumonectomy, four groups was formed; in group I, 4/0 Premilene® suture was used with continuous horizontal matrix + over and over sutures. Bronchial stapler was used in group II. In group III, same techniques were used with group I and cyanoacrylate was applied. In group IV, bronchial suturing was achieved using 4/0 Premilene® in a continuous horizontal suture and then cyanoacrylate was applied. Each specimen was intubated with an endotracheal tube which was connected to a sphgmomanometer. The pressure level causing air bubbles was recorded inside the water. The median leakage pressure (300 mmHg) was significantly higher in group III (p0.05). Tissue adhesive cyanoacrylate was successful in preventing the leakage of bronch. We suggest that more expanded studies will provide cyanoacrylate to be used in bronchial closure after the pneumonectomy.

Risk Factors for Bronchopleural Fistula After Right Pneumonectomy: Does Eliminating the Stump Diverticulum Provide Protection?

Bronchopleural fistula (BPF) remains an important source of morbidity and mortality after right pneumonectomy. We reviewed our 18-year institutional experience with right pneumonectomy to identify risks factors for BPF. From 1992 to 2010, a total of 145 patients who underwent right pneumonectomy were identified from an institutional database. Median age was 56 years. Most patients (66.2%) underwent surgery for non-small cell lung cancer. Sixty-seven patients (46.2%) received either chemotherapy or radiotherapy before surgery. Medical records were reviewed for 14 variables potentially predictive for BPF, including two airway closure techniques (standard bronchial closure and carinal closure). Variables predictive of BPF by univariate analysis were entered into a logistic regression model. The overall mortality rate was 13.1% (n=19), with 15.9 and 10.5% mortality in the bronchial closure and carinal closure groups, respectively (P=0.33). The overall BPF rate was 7.6% (n=11), with a 3.9% (3 of 76) rate in the carinal closure group compared to 11.6% (8 of 69) in the bronchial closure group (P=0.08). Seven of eight bronchial closure patients who developed BPF required operative repair. Only one of three patients who developed BPF after carinal closure did not spontaneously heal after open drainage. Multivariate analysis identified preoperative radiation dose (P=0.042) and bronchial closure (P=0.041) as independent risk factors for BPF, while the length of postoperative ventilation before development of BPF approached significance (P=0.057). In our experience, higher preoperative radiation doses are a risk factor for BPF after right pneumonectomy, while carinal closure exerts a protective effect.

Triple Reinforcement of Bronchial Stump

Various methods are used to prevent bronchopleural fistula following anatomical lung resection, as bronchopleural fistula constitutes a life-threatening complication. Pleural flaps are less vascularized, whereas an intercostal muscle flap, although well vascularized, does not offer enough strength for repair. We describe here the use of pleural flaps to strengthen a bronchial closure and cover the defect. Subsequently, an intercostal muscle flap is buttressed over the bronchial stump.

Bronchial Flap Closure of the Lower Membranous Trachea

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.

Bronchial closure methods and risks for bronchopleural fistula in pulmonary resections: how a surgeon may choose the optimum method?

There is debate about which bronchial closure technique is the best to prevent bronchopleural fistulas (BPFs). We aim to assess the effect of bronchial closure procedures and patients' characteristics on BPF occurrence in pulmonary resections. Bronchial closures in 625 consecutive patients were assessed. Stumps were closed by manual suturing in 204 and by mechanical stapling in 421 cases. In the mechanical stapling group, stapling supported by manual suture was performed in 170 cases. BPFs occurred in 3.8%. Of these, stapling was used in 5.0%, whereas manual suturing was used in 1.5% (P=0.04). BPFs were more prevalent among patients who had undergone pneumonectomy (P<0.01), right pneumonectomy (P<0.01), stapler closure (P<0.01), patients with co-factors (P<0.01), and patients who had undergone preoperative neo-adjuvant (P=0.01) or postoperative adjuvant therapy (P=0.03). There was no difference in the frequency of BPF between patients with and without adjuvant support in the stapling group. The optimum bronchial closure method has to be chosen by considering the patient and bronchus based characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in risky patients. An additive support suture on the bronchial stump does not decrease the risk of BPF.

Acellular Dermal Matrix Closure of Catastrophic Bronchopleural Fistula

Early, complete disruption of bronchial closure is a rare complication after pulmonary resection that will result in almost certain death if immediate intervention is not taken. We present a case of a catastrophic bronchopleural fistula that was successfully closed using an Alloderm patch (LifeCell Corp, Branchburg, NJ) in the acute setting.

Bronchopleural Fistula Treated With a Silicone-Covered Bronchial Occlusion Stent

Bronchopleural fistula (BPF), one of the potentially fatal complications after pulmonary resection, remains a therapeutic challenge. We present a case of postpneumonectomy BPF successfully managed with a silicone-covered bronchial occlusion stent. The BPF was successfully occluded without complications, and there was no stent migration or any other problem seen at the 1-year follow-up. This novel technique can be an effective option for the treatment of postoperative BPF.

Bronchial Flap Closure of the Right Lower Lobe Bronchus

We describe a novel method for closure of the bronchus intermedius, after right lower lobectomy, using a flap derived from the lower lobe apical segmental bronchus. We have successfully used this technique in an endobronchial carcinoid tumor occurring in a young man. It allowed middle lobe preservation despite a very proximal tumor position within the basal trunk bronchus. Adequate tumor margins were confirmed by on-table frozen section examination. This technique may have particular use in carcinoids or benign tumors.

Low incidence of bronchopleural fistula after pneumonectomy for lung cancer

Bronchopleural fistula (BPF) after pneumonectomy for NSCLC remains a highly morbid complication. We examined possible factors including the surgical techniques associated with BPF development. From 221 pneumonectomies for NSCLC, bronchial stump closure was mechanically performed in 192 patients and manually in the remaining 29. In all right-sided pneumonectomies mechanical closure was performed with associated stump coverage. In 114/130 left-sided procedures where mechanical closure was selected, bronchial stump remained uncovered. In the remaining 16 left-sided cases where manual stump closure was selectively performed, the stump was covered utilizing various tissues. Risk factors were classified into preoperative, intra-operative and postoperative. Five patients (2.3%) developed BPF. Univariate analysis revealed peri-operative transfusion, respiratory infection at the time of presentation, neoadjuvant therapy, right-sided pneumonectomy, manual type of bronchial closure, days of postoperative hospitalization and mechanical ventilation as significant risk factors for BPF development. Multivariate analysis followed revealing preoperative respiratory infection and right pneumonectomy as the only independent risk factors. In our series, a selected stump coverage policy showed a low incidence of BPF development. Mechanical stapling was superior to manual closure, although not as an independent factor. Early recognition of possible risk factors associated with fistula development is of paramount importance.

Morphological Assessment of Different Ways of Bronchial Stump Closure after Pneumonectomy

A method is developed to close the stump of the primary bronchus by outer compression with a shape-memory device. The process of bronchial stump healing under compression suture was morphologically examined. The novel method was compared with the routine Sweet-type hand-operated and the mechanical sutures. The compression suture heals the stump by primary intention with restoration of the typical airway epithelium on the stump bottom and prevention of the development of the bronchial fistulas.

Use of Amplatzer Device for Endobronchial Closure of Bronchopleural Fistulas

Bronchopulmonary fistula (BPF) is associated with high morbidity and mortality. It occurs as an uncommon but often severe complication of pneumonectomy. BPF may be treated by a range of surgical and medical techniques, including chest drain, Eloesser muscle flap, omental flap, transsternal bronchial closure, thoracoplasty, and prolonged therapy with antibiotic regimens. The use of bronchoscopy has been reported for the delivery of biological glue, coils, covered stents, and sealants. In this work, we describe a novel method of BPF closure using the Amplatzer device, which is commonly used for transcatheter closure of atrial septal defects.

The posterior membranous flap technique for bronchial closure after pneumonectomy

Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients - 89%), small cell lung cancer (one patient - 2.2%), mixed and other types of cancer (two patients - 4.4%), and non-neoplastic etiology (one patient - 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.

Carinaplasty Airway Closure: A Technique for Right Pneumonectomy

Bronchopleural fistula remains a significant source of morbidity and mortality after right pneumonectomy. We reviewed our initial experience with a novel "carinaplasty" airway closure technique aimed at reducing the risks of bronchopleural fistula. Since 2003, 51 consecutive patients who required right pneumonectomy at our institution underwent carinaplasty airway closure. Malignancy was the indication for pneumonectomy in all but 2 patients. Eighteen patients received preoperative radiation therapy, including 5 patients who received 6000 cGy or more. Postoperatively, 17 patients required mechanical ventilation for an average of 13 days (range, 3 to 42 days). Six operative deaths occurred, four (8.6%) of which were in the 46 patients who did not receive preoperative bleomycin. All deaths were secondary to respiratory failure. None of these patients demonstrated bronchopleural fistula despite mechanical ventilation for up to 30 days. In 2 patients, a small (< or = 2 mm) bronchopleural fistula developed at 3 and 4 months after operation, respectively. Both patients presented with minor symptoms and spontaneously healed within 1 month after open drainage. These data suggest that the carinaplasty airway closure may reduce the morbidity and mortality of bronchopleural fistula after right pneumonectomy. We speculate mechanisms include elimination of the bronchial stump diverticulum in combination with more submucosal blood supply at the suture line compared with the standard bronchial closures. We currently consider carinaplasty airway closure the technique of choice at our institution and plan continued evaluation.

Reinforcement Bronchial Stump Increases Early Mechanical Integrity: an ExVivo Experimental Study

Objective: The purpose of this study was to investigate the effects of different bronchial suture techniques, with and without tissue reinforcement, on the resistance to pressure of the bronchial stump.Materials and Methods: Fifty-four tracheo-bronchial trees obtained from the local slaughterhouse were prepared for manual closure. After right pneumonectomy, specimens were divided into three groups (n = 18). Interrupted suture pattern (group 1), continuous horizontal mattress+over-over continuous pattern (group 2) and continuous over-over + coverage with a diaphragmatic part with interrupted U sutures pattern (group 3) were used for bronchial closure. Multifilament absorbable 4–0 sutures were used in all specimens. Air leakage pressures were measured with a sphygmo-manometer.Results: Groups 1 and 2 had nearly equal mean air leakage pressures (98 ± 37 and 95 ± 51 mmHg, respectively, p = 0.985). Group 3 showed significantly higher mean leakage pressure (153 ± 66 mm-Hg, p = 0.002) compared to the other groups.Conclusion: Reinforcement of the bronchial stump with viable tissue contributes to the bronchial stump integrity by increasing the air leakage resistance.

Invited commentary

Invited commentary

CLC026 ORAL Bronchial closure after pneumonectomy for lung cancer

CLC026 ORAL Bronchial closure after pneumonectomy for lung cancer

Comparison of different bronchial closure techniques following pneumonectomy in dogs

The comparison of the histologic healing and bronchopleural fistula (BPF) complications encountered with three different BS closure techniques (manual suture, stapler and manual suture plus tissue flab) after pneumonectomy in dogs was investigated for a one-month period. The dogs were separated into two groups: group I (GI) (n = 9) and group II (GII) (n = 9). Right and left pneumonectomies were performed on the animals in GI and GII, respectively. Each group was further divided into three subgroups according to BS closure technique: subgroup I (SGI) (n = 3), manual suture; subgroup II (SGII) (n = 3), stapler; and subgroup III (SGIII) (n = 3), manual suture plus tissue flab. The dogs were sacrificed after one month of observation, and the bronchial stumps were removed for histological examination. The complications observed during a one-month period following pneumonectomy in nine dogs (n = 9) were: BPF (n = 5), peri-operative cardiac arrest (n = 1), post-operative respiratory arrest (n = 1), post-operative cardiac failure (n = 1) and cardio-pulmonary failure (n = 1). Histological healing was classified as complete or incomplete healing. Histological healing and BPF complications in the subgroups were analyzed statistically. There was no significant difference in histological healing between SGI and SGIII (p = 1.00; p > 0.05), nor between SGII and SGIII (p = 1.00; p > 0.05). Similarly, no significant difference was observed between the subgroups in terms of BPF (p = 0.945; p > 0.05). The results of the statistical analysis indicated that manual suture, stapler or manual suture plus tissue flab could be alternative methods for BS closure following pneumonectomy in dogs.

Postoperative ischemic change in bronchial stumps after primary lung cancer resection

The bronchopleural fistula (BPF) is a major complication after lung surgery. We have reviewed our experience with ischemic changes in bronchial stumps, some of which resulted in BPFs (we term this postoperative ischemic bronchitis (POIB)) and studied predisposing factors. A total of 1015 patients undergoing curative resection of lung cancers between 1991 and 2002 were reviewed. Details regarding bronchofiberscopic findings within the first 15 postoperative days were carefully reviewed with particular attention to factors possibly affecting the occurrence of POIB: the techniques for bronchial closure and mediastinal lymph node dissection (LND). Information about clinical profiles and histologic status was also analyzed. The incidence of POIB was 2.5% (29/1015), affecting 26 males and 3 females. The most common site was the right intermediate trunk stump (n=4; 7.1%), followed by the left upper (n=8; 3.4%), right lower (n=5; 3.4%), right middle (n=2; 3.3%), and left lower (n=4; 3.2%) lobar bronchial stumps. BPFs eventually resulted in 3 patients (10%) out of 29 with POIB and in 4 (0.4%) out of 986 without it (p<0.0001). Being male, a smoker, having diabetes mellitus, having postoperative respiratory complications and subcarinal LND proved to exert a significant impact with regard to POIB. Surgeons must bear in mind the possibility of POIB occurrence, especially in cases undergoing particular types of lobectomy (right middle and lower, left upper, right lower or right middle) accompanied by subcarinal LND and having postoperative respiratory complications. Moreover, in appropriate groups with tumors of the right upper lobe or left upper segment, limited mediastinal LND might allow avoidance of POIB.

Detecting the Limits of Bronchial Closure Methods in an Animal Model

Bronchopleural fistula is a serious complication of major lung resections that may lead to mortality. An experimental animal model was designed to find out the safest bronchial closure method by comparing leakage rates under pressure. The tracheobronchial trees of 50 freshly dead sheep were prepared for either manual closure or closure with a stapler. After left pneumonectomy, the specimens were divided into five groups (n = 10); 3/0 Premilene suture was used with two "u" sutures + interrupted sutures in Group I; in Group II, 3/0 Premilene sutures with continuous horizontal mattress + over-over continuous sutures were used. In Group III and IV the same techniques were used with 3/0 Vicryl. A stapler was used in Group V. Specimens were intubated with an endotracheal tube, connected to a sphygmomanometer, and subsequently positioned under water. The pressure level at which we detected air bubbles indicated the limits of the technique. The median leakage pressure resistance was significantly lower in Group III (135 mm Hg) ( P = 0.001). The best results were achieved by using the continuous horizontal mattress + over-over continuous suture technique. No statistical significance difference was found between the stapler group, Groups I, II, and IV in terms of median leakage pressures. This trial suggests that manual suture closure using an appropriate technique and monofilament materials is as safe as the stapler.