Bronchial Stump Research Articles

Thoracoscopic Lobectomy for Congenital Lung Malformation in Children: Evolving Management Strategies and Their Impact in Outcomes

BackgroundThe aim of this study was to determine the incidence of complications after thoracoscopic lobectomy in children according to a verified classification. Secondary aim was to evaluate the modifications made in our management protocol in order to decrease the rate of complications. MethodsRetrospective study of pediatric patients in whom a lobectomy was performed for congenital lung malformation (CLM) in our institution between 2003 and 2021. The following data were collected: demographics, preoperative clinical symptoms, surgical technical details, and postoperative complications following the Clavien-Dindo (CD) classification. Main outcome measure was the presence of complications in the first month after lung lobectomy. Results90 lobectomies were performed in 89 patients. There were 46 girls (51.6%) and 43 boys with a median age of 12.4 months. Most patients (86.6%) remained asymptomatic until the surgical procedure. Postsurgical complications were detected in 26 cases (28.8%) and distributed into their respective category according to CD classification. In our experience, closure of the bronchial stump with interrupted suture or placement of an endoloop showed a statistically significant association with complications (p = 0.022 and p = 0.006 respectively). Moreover, patients in which a device combining sealing and section was used showed significantly fewer complications (p = 0.006). ConclusionsThoracoscopic lobectomy continues to be a challenging procedure. The CD grading system for postoperative complications has proved to be useful in this setting. Evolving surgical strategies and new miniaturized endosurgical devices have enabled a safer and quicker procedure with a positive impact in the development of complications. Level of EvidenceIII.

The Effect of Main Bronchus Stump Closure Method on the Incidence of Stump Failure during Pneumonectomy for Tuberculosis

The objective: to evaluate the effectiveness of various methods for the main bronchus stump closure when performing pneumonectomy for destructive pulmonary tuberculosis.Subjects and Methods. Treatment results of 1211 tuberculosis patients from 1958 to 2022 were studied. The patients were treated in three clinical phthisiopulmonary centers. All of them underwent pneumonectomy with closure of the main bronchus stump by different methods.Results. We studied results of using different methods for suturing the main bronchus during pneumonectomy. For this purpose, the incidence of early fistulae of the bronchial stump and mortality from bronchopleural complications were assessed. The worst result was observed when using a mechanical suture (21.7% and 8.3%, respectively), the combination of polyspast-circular ligature with mechanical suture improved the effectiveness (2.3% and 4.6%, respectively), and the best result was demonstrated by the stump-free method of bronchus closure offered by D.B. Giller et al. (0.3% and 0.1%, respectively).

Complex surgical management of main bronchus stump failure: a case report highlighting treatment challenges and successful outcome

Complex surgical management of main bronchus stump failure: a case report highlighting treatment challenges and successful outcome

The methods of bronchial stump buttressing in post-pneumonectomy bronchopleural fistula prevention: a systematic review

Introduction The bronchopleural fistula remains one of the most severe complications after pneumonectomy. Several surgical methods may enhance bronchial stump healing and reduce the occurrence of BFP. Usually, surgeons use tissue buttressing, such as intercostal muscle flap, parietal pleura, pericardium fat pad, or mediastinal fat, to reinforce the bronchial stump. This paper reviews the literature describing the impact of different buttressing tissues on the occurrence of early post-pneumonectomy bronchopleural fistula.Material and methods We included all studies that described the use of bronchial stump buttressing in patients after pneumonectomy. Studies written in languages other than English were excluded. The search was performed using PubMed, Google Scholar, Embase, COCHRANE databases, and the clinical trial registry (www.clinicaltrials.gov) on December 1, 2023. We used the following search input: "lung cancer" AND "pneumonectomy" AND ("bronchopleural fistula" OR "BPF") AND ("tissue buttressing" OR "intercostal muscle flap" OR "mediastinal fat pad"). We analyzed the types of studies, the numbers of patients, and the most important conclusions. We performed descriptive statistics.Results Twenty-seven articles on the use of bronchial tissue buttressing were identified. Nine papers were rejected due to small sample size (<20 patients), surgical operation other than pneumonectomy or lobectomy, or papers older than 30 years. Ultimately, sixteen articles were included in the analysis. Among them, three papers highlighted the statistically significant influence of bronchial stump buttressing in reducing the risk of bronchopleural fistula (BPF) formation. Descriptive statistics were reported in nine studies, and two papers included the assessment of the blood perfusion in the buttressing tissue. Only one study was a randomized trial featuring a control group for comparison.Discussion Buttressing the bronchial stump remains a controversial issue in thoracic surgery. It could be beneficial for high-risk patients. Among different tissues, the ideal one has still not been identified. Future research should incorporate control groups and intraoperative assessments of the blood supply to the tissue employed for bronchial buttressing.

Retention Rate of Free Pericardial Fat Grafts after Bronchial Stump Coverage.

The postoperative course of the graft tissue after bronchial stump coverage remains unclear. We retrospectively analyzed 44 patients who underwent anatomical lung resection followed by bronchial stump coverage using free pericardial fat grafts. All patients underwent minimally invasive video-assisted thoracoscopic surgery. Computed tomography scans showed a graft retention rate of 100% on 60 days after surgery, 61% on 180 days, and plateauing at around 20% after 1 year. Free pericardial fat grafts, harvested minimally invasively, demonstrated a promising retention rate after surgery, making them a suitable option for patients with a high risk of bronchopleural fistula.

I will grasp what needs to be grasped. Grasping right upper bronchial stump to reveal A1+3. Grasping left bronchial stump to reveal left pulmonary vein. Careful, non-grasping, retraction of left lung during lymphadenectomy.

I will grasp what needs to be grasped. Grasping right upper bronchial stump to reveal A1+3. Grasping left bronchial stump to reveal left pulmonary vein. Careful, non-grasping, retraction of left lung during lymphadenectomy.

Treatment of late left bronchopleural fistula after left pneumonectomy through right thoracic approach assisted by extracorporeal membrane oxygenation

BackgroundBronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO).Case presentationWe report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO).ConclusionsAdvanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients.

Diaphragmoplasty and myoplasty of the main bronchus stump in right-sided pneumonectomy performed for destructive pulmonary tuberculosis

Diaphragmoplasty and myoplasty of the main bronchus stump in right-sided pneumonectomy performed for destructive pulmonary tuberculosis

Hyalinizing clear cell carcinoma of the left main bronchus diagnosed with Ewing sarcoma breakpoint region 1::activating transcription factor 1 fusion: A case report

Rationale: Hyalinizing clear cell carcinoma (HCCC) of the bronchus is extremely rare. In addition, its rarity makes an accurate histological diagnosis difficult. Herein, we report a case of HCCC in the left main bronchus diagnosed by the detection of Ewing sarcoma breakpoint region 1::activating transcription factor 1 (EWSR1::ATF1) fusion transcript using reverse transcription-polymerase chain reaction (RT-PCR). Patient concerns: A 56-year-old woman presented with a tumor obstructing the left main bronchus on physical examination computed tomography. A bronchoscopic biopsy confirmed a malignant tumor but did not provide a definitive diagnosis. Interventions: Sleeve resection of the left main bronchus was performed. The intraoperative frozen section was negative for cancer in both the proximal and distal bronchial stumps. Diagnosis: General immunohistochemical staining was performed, and mucoepidermoid carcinoma and HCCC were suspected. RT-PCR revealed positive results for EWSR1::ATF1 fusion transcript, and the tumor was finally diagnosed as HCCC. Outcomes: The patient was discharged without any postoperative complications. Sixty-five months have passed since surgery, and no cancer recurrence has been observed. Lessons: Although hematoxylin and eosin staining and immunostaining alone were not sufficient to distinguish HCCC from mucoepidermoid carcinoma and other malignant tumors, adding genetic testing for EWSR1 rearrangement led to a definitive pathological diagnosis.

Are precautions actually a risk factor in the development of bronchopleural fistula after pneumonectomy? A retrospective analysis of 299 cases.

Bronchopleural fistula most commonly occurs after pneumonectomies, with high morbidity and mortality. A preventive approach is essential. Risk factors can be classified depending on the patient, anatomy, surgical technique, and other causes. Patients (n = 370) who underwent pneumonectomy between 2010 and 2020 were evaluated. The digital media and archive files of the patients (n = 299) were reviewed retrospectively. While 271 patients (90.6%) were male, 28 (9.4%) were female. The mean age was 56.63years. The bronchopleural fistula rate was 14.7% (44/299). Serum protein deficiency, right pneumonectomy, completion pneumonectomy, bronchial manual suturing, advanced stage, prolongation of time after neoadjuvant therapy, length of drain and hospital stay, tissue support for the stump, and short bronchial stump were significant for bronchopleural fistula. Smoking in patients operated on for malignancy and low serum albumin value in benign and chronic infectious diseases were significant in terms of fistula. In patients who developed bronchopleural fistula, the 5-year survival rate was 18.4%. The most important risk factors in bronchopleural fistula depend on the surgical technique and so are completely preventable. Contrary to the literature, short stump and tissue support to the stump were found to be risk factors for fistula. In addition, the effect of the time between neoadjuvant therapy and operation should be examined in further studies.

Bronchopleural Fistula after Lobectomy for Lung Cancer: How to Manage This Life-Threatening Complication Using Both Old and Innovative Solutions.

Our goal is to evaluate the correct management of broncho-pleural fistula (BPF) after lobectomy for lung cancer. We retrospectively reviewed our 25-years' experience and reported our strategies and our diagnostic algorithm for the management of post-lobectomy broncho-pleural fistula. Five thousand one hundred and fifty (5150) patients underwent lobectomy for lung cancer in the period between 1998 and 2023. A total of 44 (0.85%) out of 5150 developed post-operative BPF. In 11 cases, BPF was solved by non-invasive treatment. In nine cases, direct surgical repair of the bronchial stump allowed BPF resolution. In 14 cases, a completion intervention was performed. In six cases, we performed open window thoracostomy (OWT) after lobectomy; in two cases, the BPF was closed by percutaneous injection of an n-butyl cyanoacrylate glue mixture. In two cases, no surgical procedure was performed because of the clinical status of the patient at the time of fistula developing. Thirty-day and ninety-day mortality from fistula onset was, respectively, 18.2% (eight patients) and 22.7% (ten patients). Thirty-day and ninety-day mortality after completion pneumonectomy (12 patients) was, respectively, 8.3% (one patient) and 16.6% (two patients). The correct management of BPF depends on various factors: timing of onset, size of the fistula, anatomic localization, and the general condition of the patient. In the case of failure of various initial therapeutic approaches, completion intervention or OWT could be considered.

Costal cartilage as a promising technique for large bronchial fistula closure in fistulous empyema: a case report

BackgroundThere is no high level of evidence for the treatment of fistulous empyema. We report here a promising technique for closure of a bronchopleural fistula using costal cartilage as a bronchial embolus.Case presentationThe patient is a 79-year-old man. A computed tomography scan diagnosed a fistulous empyema associated with perforation of lung abscess of right middle lobe. After thoracoscopic curettage of the right empyema cavity, right middle lung resection and intercostal muscle flap coverage over the bronchial stump were performed. Seven months after the surgery, a bronchopleural fistula developed. Bronchoscopy revealed fistulas in the middle lobe bronchus and B3b. After the open window thoracostomy, the empyema cavity was cleaned up. The empyema cavity remained from the anterior to the lateral thoracic region of the second to fourth ribs. A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for skin and thickened parietal pleura to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage was sutured and fixed with five stitches with 3-0 PDS. The visceral pleura was covered with the thickened parietal pleura and skin and fixed airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure. The drain was removed on the 21st day. As of 21 months postoperatively, the skin and thickened parietal pleura flap has maintained its integrity, and there has been no evidence of pus or recurrence of air leaks.ConclusionIn the case of a fistulous empyema extending anteriorly, costal cartilage can be easily harvested, making it a promising option as a lid for fistula closure.

Preventive Esophagomyobronchoplasty as a Reliable Prophylaxis of Bronchial Stump Failure and Bronchopleural Fistula after Pneumonectomy in Lung Cancer

Introduction. At present, bronchial stump failure after pneumonectomy ranges from 1% to 20%, and mortality — from 20 to 75%. In past decades, various methods of preventive bronchoplasty have been introduced and improved in order to reduce the incidence of the bronchial stump failure and bronchopleural fistula. However, the existing methods fail to prove their predominant effectiveness to be suggested as a “gold standard” for prevention of the bronchial stump failure during pneumonectomy. A method introduced by the authors enables an additional tissue mobilization with uncontrolled circulatory disturbance of the “biological flap” to be avoided. Aim. To evaluate the results and effectiveness of preventive esophagomyobronchoplasty in clinical practice. Materials and methods. The suture of “preventive esophagomyobronchoplasty” of the bronchial stump after pneumonectomy in lung cancer was developed and introduced into the clinical practice of the Thoracic Surgery Unit. The study involves a statistical analysis of bronchial stump failures as well as bronchopleural fistulas before and after the introduction of preventive esophagomyobronchoplasty. Results and discussion. A retrospective analysis of 224 clinical observations proves a zero probability of such complications after pneumonectomy as bronchial stump failure and bronchial fistula in case of preventive esophagomyobronchoplasty. The incidence of pleural empyema does not exceed 1.3%. Notably, pleural empyema implies longer duration of stay, additional examination, expensive drugs, as well as direct threatening life of a patient. Conclusion. Since 2015, when the new method of bronchial stump formation has been introduced into clinical practice, the rate of complications in the form of bronchial stump failure was reduced from 10.5% to 0%.

Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer.

Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications. All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively. Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes. Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

Nil Intervention is at Times the Best Intervention

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions. Keywords: Pneumonectomy; Pleura; Hydropneumothorax; Case Report; India.

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema.

The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF). We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect. In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased. Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

Risk factors for bronchopleural fistula based on surgical procedure and sex in 4794 consecutive patients undergoing anatomical pulmonary resection.

Bronchopleural fistula (BPF) is a lethal complication, even in the modern era. Therefore, we investigated the details of patients with BPF to select an appropriate surgical strategy. This retrospective study included 4794 consecutive patients who underwent anatomical pulmonary resection between 2008 and 2022. We evaluated the predictors of BPF using a multivariable analysis and investigated the mortality and clinical course after BPF in detail. BPF was observed in 32 patients (0.67%). In the multivariable analysis, the predictors for BPF were male sex (odds ratio [OR], 6.91), the body mass index (OR, 2.40), the vital capacity (%VC) (OR, 2.93), surgery performed (right lower lobectomy [OR, 10.92], right middle and lower lobectomy [OR, 6.97], and right pneumonectomy [OR, 16.68]), and additional resection of surrounding organs (OR, 3.47). Among the risk factors, surgery performed and male sex were very strong risk factors, with the frequency itself very low in females (0.1%). The 90-day mortality was 15.6%, and the 5-year overall survival in patients with BPF was 28.1%. Our study revealed that independent risk factors and consideration of the surgical methods and sex might help determine whether or not special attention should be given to the bronchial stump, which will be of great help in surgical strategies.

Pneumonectomy for Primary Lung Tumors and Pulmonary Metastases: A Comprehensive Study of Postoperative Morbidity, Early Mortality, and Preoperative Clinical Prognostic Factors.

Pneumonectomy is a major surgical resection that still remains a high-risk operation. The current study aims to investigate perioperative risk factors for postoperative morbidity and early mortality after pneumonectomy for thoracic malignancies. We retrospectively analyzed all patients who underwent pneumonectomy for thoracic malignancies at our institution between 2014 and 2022. Complications were assessed up to 30 days after the operation. Mortality for any reason was recorded after 30 days and 90 days. A total of 145 out of 169 patients undergoing pneumonectomy were included in this study. The postoperative 30-day complication rate was 41.4%. The 30-day-mortality was 8.3%, and 90-day-mortality 17.2%. The presence of cardiovascular comorbidities was a risk factor for major cardiopulmonary complications (54.2% vs. 13.2%, p < 0.01). Postoperative bronchus stump insufficiency (OR: 11.883, 95% CI: 1.288-109.591, p = 0.029) and American Society of Anesthesiologists (ASA) score 4 (OR: 3.023, 95% CI: 1.028-8.892, p = 0.044) were independent factors for early mortality. Pneumonectomy for thoracic malignancies remains a high-risk major lung resection with significant postoperative morbidity and mortality. Attention should be paid to the preoperative selection of patients.

БРОНХИАЛЬНЫЙ СВИЩ – ГРОЗНОЕ И КОВАРНОЕ ОСЛОЖНЕНИЕ В ОНКОЛОГИЧЕСКОЙ ПРАКТИКЕ

Bronchopleural fistula is one of the most dangerous complications in thoracic surgery and can occur both in the early postoperative period (especially in the first 7-10 days after surgical treatment) and many years after surgery. In most cases, the appearance of a bronchial fistula is associated with the progression of the oncological process, post-radiation changes in the bronchus stump, and also with a persistent pulmonary infection. The incidence of bronchus suture failure after pneumonectomy for non-small cell lung cancer is 1.5-12.5%, after lobectomy – 1-4%. Among the predictors of the development of this complication, there are: male sex, age over 65 years, patients with severe (ASA 3 or higher) and numerous concomitant diseases, right-sided and extended operations, combined antitumor treatment. A special role in the prevention of the development of bronchopleural fistula is given to surgical techniques for covering the bronchus stump with various tissues, mainly the pleura or muscles. The treatment of bronchial fistula involves the relief of the general inflammatory reaction, the sanitation of the residual pleural cavity and the direct closure of the defect, using various options for broncho- and thoracoplasty.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

ObjectiveTo evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. MethodsPatients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. ResultsDuring the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. ConclusionsEmpiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.