Bronchopleural Fistula Formation Research Articles

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.

The use of diaphragmatic flap for the main bronchus stump reinforcement in right-sided pneumonectomy performed for destructive pulmonary tuberculosis with drug resistance of <i>Mycobacterium tuberculosis</i>

INTRODUCTION. Drug-resistant tuberculosis with subtotal and total lesion of one of the lungs is the most common indication for pneumonectomy. This operation is accompanied by a high risk of postoperative complications, among which the most dangerous is pleural empyema with bronchopleural fistula. In this regard, the prevention of this complication is an extremely important task.TheOBJECTIVEwas to study the results of using a diaphragmatic flap to prevent the development of right main bronchus stump insufficiency with bronchopleural fistula in patients with destructive pulmonary tuberculosis. METHODS AND MATERIALS. A retrospective study was carried out for the period from 2015 to 2019. The study included 13 patients who underwent right-sided pneumonectomy with diaphragmoplasty of the right main bronchus stump. Indications for diaphragmoplasty were: persistent bacterial excretion at the time of surgery, pre-existing bronchopleural fistula, intraoperative pleural contamination, progressive course of a specific process.RESULTS. The postoperative period was smooth in 10 (77 %) patients. Postoperative complications developed in 3 (23 %) patients: in 1 (7.7 %) case, there was right main bronchus stump insufficiency with bronchopleural fistula and in 2 (15.3 %) cases, there were right main bronchus stump insufficiency without bronchopleural fistula. A satisfactory immediate result was achieved in 12 (92.3 %) patients.CONCLUSION. The diaphragmatic flap is a reliable material for plasty of the right main bronchus stump in order to prevent the formation of bronchopleural fistula in destructive pulmonary tuberculosis.

BRONCHOPLEURAL FISTULA POST LOBECTOMY: A RARE COMPLICATION WITH AN EVEN MORE UNUSUAL PRESENTATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The formation of a bronchopleural fistula (BPF) is a rare but known complication following major thoracic surgery. In a study by Nachira et al. looking at 835 patients in Italy who underwent major lung resection, 786 patients underwent lobectomy with 11 (1.3%) developing a BPF [1]. In other studies their incidence has been reported between 0.5-3% [2]. Here we present a case of an unusual presentation of this rare complication. CASE PRESENTATION: 73 y.o F former smoker was incidentally found to have right upper lobe (RUL) chondral myxoid tumor. She underwent bronchoscopy and video assisted thoracoscopy (VATS) with wedge resection of RUL and placement of chest tube without peri-operative complications. Later that day, rapid response was called as patient developed facial swelling, sensation of throat tightening and upper chest erythema with subcutaneous emphysema (SCE) (Figure 1). Initial thought was possible anaphylaxis from NSAIDs and treated as such. Patient later further deteriorated leading to intubation and transfer to the ICU. Second right-sided chest tube and skin holes placed on chest for relief of subcutaneous air. Patient was extubated next day. Due to persistent SCE (Figure 2) and need for respiratory support, patient received bilateral blow-holes and was downgraded to surgical floor after improvement. Symptoms again recurred requiring re-intubation. Blow-holes were extended and 3rd right-sided chest tube placed. She was taken for repeat VATS and found to have a BPF with adhesions. Lysis of adhesions was performed with RUL mediastinal drainage and mechanical pleural abrasion. The rest of patient's hospital course was uncomplicated with eventual removal of chest tubes and discharge. DISCUSSION: As discussed, our patient had a complicated post-operative course, complicated further by the unique presentation of her BPF. We found no previous literature or case reports illustrating similar presenting symptoms of BPFs. They typically present 1 - 12 weeks postoperatively [2]. Our patient did not fit this timeline and had a very atypical presentation which mimicked symptoms of an anaphylactoid reaction. Although diffuse subcutaneous emphysema has been a reported finding from BPFs [3], this was thought to be a normal result of recent surgical procedure. This uncommon presentation led to delay in appropriate management and extended hospital course for this patient. CONCLUSIONS: This case demonstrates a unique presentation of a potentially fatal complication of major thoracic surgeries. BPF formation may need to be considered in patients who present similarly in the future. REFERENCE #1: Nachira D, Chiappetta M, Fuso L, Varone F, Leli I, Congedo MT, Margaritora S, Granone P. Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre. ANZ J Surg.2018 Apr;88(4):322-326.doi: 10.1111/ans.13886. Epub 2017 Feb 1.PMID: 28147437. REFERENCE #2: Gaur P, Dunne R, Colson YL, Gill RR. Bronchopleural fistula and the role of contemporary imaging. J Thorac Cardiovasc Surg. 2014 Jul;148(1):341-7. doi: 10.1016/j.jtcvs.2013.11.009. Epub 2013 Dec 16. PMID: 24355543. REFERENCE #3: Anas Riehani, Olivia Wilcox, Wassim Mohammed Odeh, Michael Kehdi, and John Armstrong. Bronchopleural Fistula Presenting as diffuse Subcutaneous Emphysema. C46. PLEURAL DISEASE: CASE REPORTS II. May 1, 2017, A5647-A5647 DISCLOSURES: No relevant relationships by Inessa Bronshteyn, source=Web Response No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Ross Lavine, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response

Isсhemic change in bronchus stump after lung cancer resection

The OBJECTIVE of the study was to assess the changes in blood supply of the bronchus stump following lung resection with lymph node dissection.METHODS AND MATERIALS. Bronchial microcirculation was studied in 8 patients during pneumonectomy of the wall of the main bronchus using laser Doppler flowmetry method. In this paper, we present our observations of postoperative necrotic ischemic bronchitis after lobectomy with associated formation of bronchopleural fistula of the main bronchus and the failure of the stump of the lobular bronchus.RESULTS. Mobilization of the bronchus decreased microcirculation rate to (3.3±0.3) conventional units (c. u.), or to 74.5 %; lymphatic dissection further reduced microcirculation rate to (2.6±0.2) c. u., or to 60.2 %. An additional twisted suture was found to worsen ischemia. The normalized value of the amplitude decreased during the second minute of the dissection of the bronchus, indicating hypoxia. A 61-year-old patient with diabetes showed damage to the wall of the main bronchus 0.6 cm in size 7 days after undergoing the right lower lobectomy with lymphatic dissection. On the 19th day after the same procedure, the same patient developed an insolvency of the stump of the lower lobe bronchus, which was classified as a manifestation of ischemia. Postoperative ischemic bronchitis can occur in a true ischemic or an ulcerative necrotic form, and it can be diagnosed using a macroscopic picture in the context of fibrobronchoscopy. It occurs in (2.5–3.2) % of patients who underwent lung resections for cancer with lymphatic dissection.CONCLUSION. Ischemia of the bronchial wall during its mobilization plays a significant role in the etiology of bronchopleural fistula. Lymphatic dissection worsens microcirculation of the bronchial wall. Ischemic necrotic bronchitis can lead to formation of the bronchopleural fistula outside of the stump. High-risk patients require additional coverage of the bronchus stump with muscle or fat tissue.

Remote Right Main Pulmonary Bronchus Bronchopleural Fistula Formation after Microwave Ablation of Lung Tumor

Remote Right Main Pulmonary Bronchus Bronchopleural Fistula Formation after Microwave Ablation of Lung Tumor

Favorable clinical application for segmental bronchial closure based on experiment results.

We previously reported the clinical application of powered vascular staple (PVS) for closure of subsegmental or segmental bronchus (SSB). This study aimed to measure breakdown pressure in experiment and to investigate bronchopleural fistula (BPF) after thoracoscopic segmentectomy (TS). Part 1: a total of 30 cadaveric pigs were used, and bronchi were categorized into the following four groups: small [S, bronchial outer diameter (BOD) of 4-8 mm, n=8], medium (M, 9-10 mm, n=9), and large (L, >10 mm, n=13). We additionally added a single additional suture to compensate for weak sites with large BOD (group R, n=6). The pressure was slowly increased, and stump breakdown was observed. Part 2: we investigated the morbidity of BPF formation at follow-up of at least 6 months in a total of 217 patients. Part 1: the mean leak pressure was the highest in M, followed by groups S, R and L'. However, the significant difference was not found between S and R. Part 2: no BPF was observed, clinically. Based on experimental results and clinical experience, the proper selection of PVS should contribute to the safety, feasibility, and success as SSB closure.

BUBBLES IN THE BOX: RECURRENT PNEUMOTHORAX FROM BRONCHOPLEURAL FISTULA IN A PATIENT WITH RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: When considering Rheumatoid Arthritis (RA)-associated pulmonary diseases, formation of bronchopleural fistula (BPF) represents an extremely rare complication; and is often associated with peripheral pulmonary nodules that burst into the pleural cavity. We are presenting a case of BPF secondary to RA in the absence of underlying pulmonary nodules. CASE PRESENTATION: A 79-year-old Caucasian female with long-standing RA presented with progressive shortness of breath and chest tightness for 2 days. No reported cough, fever, or night sweats. No recent trauma; history of smoking, or drug abuse; and no past surgeries. Current RA medications are methotrexate, hydroxychloroquine, and prednisone. Chest exam revealed bilateral coarse crackles, decreased breath sounds and hyper-resonant percussion note over the right side. Labs showed neutrophilic leukocytosis (28,000, 95% Neutrophils) and normal chemistry panel. Chest X-ray revealed right-sided pneumothorax with right lung collapse and mediastinal shift to the left. Patient had acute hypoxic respiratory failure secondary to spontaneous right side tension pneumothorax and surgical chest tube was emergently placed. Computed Tomography of the chest (Figure 1) showed right pneumothorax, bilateral pulmonary fibrosis and no discrete pulmonary nodules were identified. After removing the surgical chest tube, air continued to build in the right pleural space and she became hypoxic. Pigtail drain was placed into the right pleural space; afterwards, O2 sats rose above 95%. Air leak and bubbling continued from the pigtail chest tube for 5 days and she did not tolerate chest tube clamping. BPF was considered and cardio-thoracic surgery team was consulted. An open thoracotomy (Figure 2) revealed BPF at the apical segment of the right lower lobe, which was sutured and reinforced by parietal pleura. Pathological exam of the lung biopsy revealed fibrosing pleuritis with acute and chronic histiocytic inflammation and sub-pleural septal fibrosis, which was correlated to her long-standing RA and methotrexate therapy. DISCUSSION: Interstitial lung disease and pleural disease are the most common RA-associated pulmonary manifestations while spontaneous pneumothorax and BPF are among the extremely rare ones. Up to the best of our knowledge, all the previously reported cases of RA-associated BPFs were attributed to peripherally-located pulmonary nodules that necrotize and open into the pleural cavity. However, our patient had spontaneous pneumothorax and BPF with no evidence of pulmonary nodules in chest imaging or in pathology. CONCLUSIONS: Formation of BPF is a rare RA-associated pulmonary disease and is often associated with peripheral pulmonary nodules, which open into the pleural cavity and lead to the fistula formation. However, as demonstrated in our case, BPF in RA patients can form even in the absence of underlying rheumatic pulmonary nodules. Reference #1: Rueth N, Andrade R, Groth S, et al. Pleuropulmonary complications of rheumatoid arthritis: a thoracic surgeon's challenge. Ann Thorac Surg 2009; 88:e20.Rueth N, Andrade R, Groth S, et al. Pleuropulmonary complications of rheumatoid arthritis: a thoracic surgeon's challenge. Ann Thorac Surg 2009; 88:e20. Reference #2: Nishida C, Yatera K, Kunimoto M, et al. [A case of rheumatoid arthritis with pneumothorax due to subpleural pulmonary rheumatoid nodules]. Nihon Kokyuki Gakkai Zasshi 2008; 46:934. DISCLOSURES: No relevant relationships by Masoud AlZeerah, source=Admin input No relevant relationships by ASM ISLAM, source=Web Response No relevant relationships by Lusine Nahapetyan, source=Web Response No relevant relationships by AHMED TAHA, source=Web Response

A CASE OF TUBERCULOUS BRONCHOPLEURAL FISTULA MANAGED WITH OPEN WINDOW THORACOSTOMY

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary complications of tuberculosis are rare occurance in the developed world due to the widespread screening, early detection and prompt diagnosis. Here we present a case of tuberculous hydropneumothorax secondary to bronchopleural fistula formation in a 19 year old male and how we successfully managed the case with an Eloesser flap. CASE PRESENTATION: 20 year old male immigrant from Philippines with no significant past medical history presented to our hospital with complaints of worsening cough for past three months. On further questioning, he admitted to fifty pound weight loss over the same period. Physical examination was pertinent for absent breath sounds on the right side and increased resonance to percussion on the same side. A chest X ray obtained (Figure 1) showed large hydropneumothorax on the right side with complete collapse of the right lung. A chest tube for drainage was inserted immediately followed by a CT chest which showed concurrent findings. There was additional findings of extensive necrotic appearing consolidation involving portions of the right upper, middle and some portions of the lower lobe with perihilar necrotic lymphadenopathy. All of these pointed towards an infectious etiology. In the following microbiological work up, there was growth of Mycobacterium Tuberculosis in patient's sputum, but not in the drained pleural fluid. He was started on Rifampicin, Pyrazinamide, Isoniazide and Ethambutol. Since patient had a trapped lung with no signs of re-expansion, a decortication procedure with Eloesser flap to prevent re accumulation of fluid and assist re-expansion of the lung, was done (Figure 3) prior to discharge home. In one month follow up chest X ray, there was significant re-expansion of lung. On four month follow up, patient had significant improvement of his symptoms. The CT scan at four months showed healed flap and adequately re-expanded lung parenchyma (Figure 5). DISCUSSION: The active or chronic form of Mycobacterium Tuberculosis (MTB) infection can present in several ways. Bronchopleural fistula, a connection between bronchi or bronchioles and the pleural cavity, can form in both active and passive forms of MTB infection. Allowing re-expansion of a chronically collapsed lung requires surgical intervention. Pleurodesis through a VATS procedure to remove the fibrothorax is the initial step. Subsequently, an open window thoracostomy, or an Eloesser flap allows for long term drainage of the pleural fluid and creation of negative pressure within the thoracic cavity which aids the re-expansion of the collapsed lung. CONCLUSIONS: Tuberculosis is a disease with widespread prevalence in the developing world and it is important for physicians to be cognizant of its varying presentations, and keep it in their list of differentials when approaching diagnostically challenging cases. Reference #1: Donath J, Khan FA. Tuberculous and posttuberculous bronchopleural fistula: ten year clinical experience. Chest. 1984 Nov 1;86(5):697-703 Reference #2: Hurvitz RJ, Tucker BL. The Eloesser flap: past and present. The Journal of thoracic and cardiovascular surgery. 1986 Nov;92(5):958-61 Reference #3: Treasure RL, Seaworth BJ. Current role of surgery in Mycobacterium tuberculosis. The Annals of thoracic surgery. 1995 Jun 1;59(6):1405-9 DISCLOSURES: no disclosure on file for Dileep C Unnikrishnan; No relevant relationships by MOHANKUMAR DORAISWAMY, source=Web Response no disclosure on file for Wael Ghali; No relevant relationships by Ajay Narayan Venkatanarayan, source=Web Response

Bilateral pneumothorax complicating cystic metastases of bronchial squamous cell carcinoma under erlotinib.

Cystic lung metastases are a rare presentation in non-small cell lung cancer and occurs mainly in squamous cell carcinoma. We present the case of a 57-year-old woman with a lung squamous cell carcinoma and cystic lung metastases, who developed bilateral metachronous pneumothorax while being administered erlotinib in third-line treatment. The apparition of a pneumothorax under chemotherapy is most often the result of tumor necrosis and formation of bronchopleural fistula. However, very few cases have been reported under targeted therapies, and to our knowledge this is the first case under erlotinib. This complication is potentially life-threatening, especially due to the possibility of pneumothorax bilateralization.

A systematic review and meta-analysis-does chronic obstructive pulmonary disease predispose to bronchopleural fistula formation in patients undergoing lung cancer surgery?

we conducted this systematic meta-analysis to determine the association between chronic obstructive pulmonary disease (COPD) and risk of bronchopleural fistula (BPF) in patients undergoing lung cancer surgery. Literature retrieval was performed in PubMed, Embase and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) served as the summarized statistics. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Sensitivity analysis was performed to further examine the stability of pooled OR. Publication bias was detected by both Begg's test and Egger's test. Eight retrospective observational studies were included into this meta-analysis. The overall summarized OR was 2.03 (95% CI: 1.44-2.86; P<0.001), revealing that COPD was significantly associated with the risk of BPF after lung cancer surgery. In subgroup analysis, the relationship between COPD and BPF occurrence remained statistically prominent in the subgroups stratified by statistical analysis (univariate analysis, OR: 1.91; 95% CI: 1.35-2.69; P<0.001; multivariate analysis, OR: 3.18; 95% CI: 1.95-5.19; P<0.001), operative modes (pneumonectomy, OR: 2.11; 95% CI: 1.15-3.87; P=0.016) and in non-Asian populations (OR: 2.36; 95% CI: 1.18-4.73; P=0.016). No significant impact of COPD on BPF risk was observed in Asian patients (OR: 1.48; 95% CI: 0.85-2.57; P=0.16). No significant heterogeneity or publication bias was discovered across the included studies. Our meta-analysis indicates that COPD can significantly predispose to BPF formation in patients undergoing lung cancer surgery. Because some limitations still exist in this meta-analysis, our findings should be further verified and modified in the future.

Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis.

Residual disease at the bronchial stump (RDBS) is regarded as an important factor possibly resulting in bronchopleural fistula (BPF) after lung cancer surgery, but this has not been confirmed. We conducted this meta-analysis to evaluate the effects of RDBS on BPF formation in patients undergoing lung cancer surgery. PubMed and EMBASE databases were searched for full-text articles that met our eligibility criteria. Odds ratios (ORs) with 95% confidence interval (95% CI) served as the summarized outcomes. Q-test and I(2) statistic were used to evaluate the level of heterogeneity, determining the fixed-effect model or random-effect model for quantitative synthesis. Sensitivity analysis was conducted to identify the possible origins of heterogeneity. The publication bias was assessed by Begg's test. A total of eight retrospective observational studies were included in our meta-analysis. In overall analysis, the pooled outcomes indicated that RDBS was significantly associated with BPF formation after lung cancer surgery (OR: 3.12; 95% CI: 1.72-5.64; P < 0.001). In subgroup analysis, the pooled outcomes revealed a significantly increased risk of post-pneumonectomy BPF in patients with RDBS (OR: 2.78; 95% CI: 1.06-7.28; P = 0.037). The subgroup analysis assessing the effects of RDBS on post-lobectomy BPF was given up due to the scarcity of available data. No heterogeneity was revealed within this meta-analysis. No evidence for publication bias was detected by Begg's test. Our meta-analysis indicates that RDBS is positively associated with the increased risk of BPF in patients undergoing lung cancer surgery. The further analysis also reveals an increased risk of post-pneumonectomy BPF in patients with RDBS. More accurate and comprehensive evidence should be collected and summarized in updated meta-analyses.

Туберкулезные эмпиемы плевры как предикТ ор леТ ального исхода у больных Туберкулезом легких

Aim. To study the effectiveness of standard complex of medical events at TB empyema of pleura (TEP) in surgical in-patients of TB hospital. Management of patients with TEP corresponded with the protocols and standards of medical care, and also with basic principles of surgical treatment of empyema. Material. The retrospective investigation of thoracic department patient's past medical history data in 2011—2012. Results and discussion. In 97% (31) of cases empyema was organized due to the lungs destruction with formation of bronchopleural fistula which changed qualitatively the progress of disease. A total of lethal ends counted up to 62,5%. The massiveness of TB process plays the significant role in thanatogenesis and its evolution caused by the variety of interconnected factors. The basic clinic forms of TB according to the autopsy were the fibro-cavernous TB and caseous pneumonia (90% of cases). The acute progress of TEP was due the interaction of drug resistant (DR/MDR) strains of TB mycobacteria (73% of cases) in combination with non-specific polymicrobial microflora (50%). For example, 50% of patients' death occurred in the first 15 days of staying in the thoracic department. Thus, the progress of TEP among patients with wide-spread destructive forms of lungs TB is the lethal predictor and low effectiveness of medical events translate them into the palliative category.

A Clinical Risk Model for the Evaluation of Bronchopleural Fistula in Non-Small Cell Lung Cancer After Pneumonectomy

There are no reliable risk factors to predict bronchopleural fistula (BPF) formation in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC). This study aims to create a validated clinical model based on the risk factors for BPF after pneumonectomy. The model to estimate the risk of BPF may help select patients for intervention therapy to reduce the rate of BPF after pneumonectomy. This retrospective analysis included 684 patients with NSCLC who underwent pneumonectomy at our institution from 1995 to 2012. The rates of BPF were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for the BPF and based on which a clinical model for the prediction of the incidence of BPF was formed. The incidence of BPF was 4.4% (30 of 684 patients). Three factors were independently associated with BPF after pneumonectomy for NSCLC: neoadjuvant therapy (hazard ratio, 2.479), diabetes mellitus (hazard ratio, 1.061), and age 70 years or older (hazard ratio, 1.175). A scoring system for BPF was developed by assigning 2 points for a major risk factor (neoadjuvant therapy) and 1 point for each minor risk factor (diabetes mellitus and age ≥ 70 years). The 684 patients were divided into a low-risk group (score, 0 to 1), moderate-risk group (score, 2), and high-risk group (score, ≥ 3), with respective incidences of early BPF after pneumonectomy of 2.4%, 18.2%, and 58.3% This model, based on readily available clinical characteristics, can estimate the risk of BPF after pneumonectomy in the NSCLC patients, independent of early BPF and late BPF classifications. This model could be used to select patients for intervention therapy (parenteral alimentation, control of blood glucose level, oxygen therapy, and strengthening the antibiotic treatment) if validated in independent data sets.

Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study†

The pedicled intercostal muscle flap (IMF) is a high quality vascularized tissue commonly used to buttress the bronchial stump after pneumonectomy or bronchial anastomosis after sleeve lobectomy in order to prevent bronchopleural fistula formation. The evaluation of the viability of the muscle flap is difficult. The aim of this study was the assessment of the application of indicyanine green fluorescence for the evaluation of IMF perfusion. The study included 27 patients (10 males and 17 females), mean age 62.6 years (47-77 years). Indocyanine green fluorescence (ICG) was used for objective assessment of the IMF quality by a near-infrared camera system (Photodynamic Eye(®), Hamamatsu Photonics, Japan). The following factors that may have an impact on the quality of the IMF were assessed: age, gender, body mass index, comorbidities, IMF length and thickness and timing of the harvesting during the procedure. The following surgical pulmonary resections with IMF harvesting were performed: 12 pneumonectomies, 2 sleeve lobectomies and 13 lobectomies. Intercostal muscle flap (IMF) was harvested before rib spreader insertion in 23 patients (85%) and at the end of the surgery in 4 patients (15%). The mean length and thickness of the harvested intercostal muscle were 19.9 ± 2.9 cm (range 13-24 cm) and 2.4 cm ± 0.7 cm (range 1.0-3.5 cm), respectively. Indocyanine green angiography showed ischaemia in the distal part of the muscle in all cases, despite the lack of obvious macroscopic signs. Median length of the ischaemic part was 4 cm (range 0.5-20 cm). The IMF length and thickness had a significant impact on the length of the ischaemic segment. In 24 patients, the ischaemic part of the muscle flap was severed. In 3 patients with the longest ischaemic segment (11, 13 and 20 cm), an alternative tissue was used to cover the bronchial stump. No major complications occurred. Our preliminary results confirmed the simplicity and high efficacy of ICG in the assessment of intercostal muscle blood perfusion. ICG was superior to macroscopic evaluation and influenced surgical proceeding.

Improving bronchial stump necrosis outcomes with the use of platelet-poor plasma?

DOI of original article: 10.1016/j.jss.2012.1 * Corresponding author. Indianapolis, IN 462 E-mail address: meddoc22@yahoo.com. 0022-4804/$ e see front matter a 2014 Elsev http://dx.doi.org/10.1016/j.jss.2013.02.046 Despite many advances and modifications in surgical technique, the development of postoperative bronchopleural fistula (BPF) following pulmonary resection remains a dreaded complication. Morbidity and mortality following BPF development can be exceptionally high [1,2]. Consequently, renewed efforts are being directed toward preemptive strategies to minimize the risk of BPF formation. Although several proposed risk factors have been identified, necrosis and/or the presence of vascular ischemia following surgery seems to play a prominent role in the development of BPFs [3,4]. Consequently, attention has focused on the intracellular milieu and role of cytokines, growth factors, and local hemostatic mechanisms in tissue necrosis and wound healing. The use of platelet-rich plasma (PRP) has been utilizedwith growing success in a number of clinical applications [5e7]. From these studies, PRP appears to play a crucial role in modulating local wound inflammation, hemostasis, and tissue remodeling. Paradoxically, in contrast to these studies, in a paper recently published in the Journal of Surgical Research, Santana-Rodriguez et al. reported a significant decrease in bronchial stump necrosis using local application of plateletpoor plasma (PPP) following pneumonectomy [8]. Whereas

Bilateral pneumothorax complicating cystic metastases of bronchial squamous cell carcinoma under erlotinib

Cystic lung metastases are a rare presentation in non-small cell lung cancer and occurs mainly in squamous cell carcinoma. We present the case of a 57-year-old woman with a lung squamous cell carcinoma and cystic lung metastases, who developed bilateral metachronous pneumothorax while being administered erlotinib in third-line treatment. The apparition of a pneumothorax under chemotherapy is most often the result of tumor necrosis and formation of bronchopleural fistula. However, very few cases have been reported under targeted therapies, and to our knowledge this is the first case under erlotinib. This complication is potentially life-threatening, especially due to the possibility of pneumothorax bilateralization.

Bronchoscopic Blood Patch Delivery for Treatment of Persistent Bronchopleural Fistula

INTRODUCTION: Bronchopleural Fistula (BPF) may result from a primary pathological process or iatrogenic causes such as accidental alveolar over-distention during mechanical ventilation. One study estimated BPF formation associated with mechanical ventilation at approximately 23%, 67% of which was associated with mortality.

Percutaneous transhepatic drainage of lung abscess through a diaphragmatic fistula caused by a penetrating liver abscess

Liver abscesses occurring just below the diaphragm can penetrate or perforate the thoracic cavity, resulting in lung abscess or pyothorax. Although surgical or percutaneous transpleural drainage is often required in such cases, the latter approach has some risks, including hemothorax and bronchopleural fistula formation when the cavity is surrounded by normal lung parenchyma. The present report describes a treatment technique of percutaneous transhepatic drainage through the diaphragmatic fistula to avoid the risks of a transpulmonary approach in a case of lung abscess caused by a penetrating liver abscess.

Spontaneous bilateral pneumothorax in metastatic renal cell carcinoma on sunitinib therapy

Bilateral spontaneous pneumothorax is a rare occurrence in patients with both primary and metastatic lung cancer. Pneumothorax occurring as a complication of vascular endothelial growth factor receptor (VEGFR) inhibitor therapy has not been previously described in the medical literature. Sunitinib malate is a VEGFR inhibitor approved for the treatment of advanced renal cell carcinoma. We present a patient with metastatic renal cell carcinoma manifested as bilateral pulmonary nodules who developed a bilateral spontaneous pneumothorax 3 weeks after initiation of sunitinib therapy. We believe that sunitinib therapy resulted in necrosis of multiple pleural-based pulmonary nodules with central cavernization and ultimately rupture with bronchopleural fistula formation. Based on this experience, we advise that practitioners exercise caution when prescribing anti-VEGFR therapy in patients with pleural-based pulmonary metastases and recognize that the efficacy and toxicity of these agents may be closely linked.

Pulmonary hydatid disease: Is capitonnage mandatory following cystotomy?

Pulmonary hydatid disease still remains an important healthcare problem. Conservative operative interventions including cystotomy or cystotomy with capitonnage are the two commonly used techniques. There is still significant controversy, however, over selection of these two procedures. In this retrospective analysis of 66 patients with hydatid disease, we employed three types of interventions, Group A, ( n = 5) cystotomy alone with closure of bronchial openings; Group B, ( n = 54) cystotomy with capitonnage and Group C, ( n = 7) lobectomy over a period of seven years in our patients and compared their postoperative outcome in terms of morbidity and mortality. Our data show that cystotomy with capitonnage is associated with low rates of postoperative prolonged air leak, bronchopleural fistula formation, empyema formation [mean complication rate 0.12% (Mean 0.08; 0.151–95% CI)] as compared to cystotomy alone with closure of bronchial openings [mean complication rate 44% (Mean 2.20; 3.18–95% CI)]. The lobectomy group was excluded from the comparison, as this approach is quite different from the cystostomy based enucleation techniques. We conclude that capitonnage with cystotomy may be a preferred procedure due to its lower rate of complications.