Development Of Bronchopleural Fistula Research Articles

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.

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.

Prevalence and treatment outcome of bronchopleural fistula: a multi-center study in Ethiopia

PurposeThe study aimed to assess the magnitude, risk factors, and management outcome of patients with a bronchopleural fistula at multiple centres in Ethiopia.Method and materialsA ten years (September 2012 - August 2021) institution-based multicenter retrospective cohort study was conducted from September 13 to September 30, 2021. we surveyed the cards of all patients having a diagnosis of bronchopleural fistula for the last 10 years. The document was reviewed using an extraction checklist. Descriptive statistics (mean, standard deviation, frequency, percentages) and crosstabulation were used to describe the outcome variable.ResultA total of 52(2%) patients were diagnosed to have bronchopleural fistula out of 2546 patients admitted to the cardiothoracic unit in three hospitals from September 2012 - August 2021 and 69% of study participants were male. The mean age of study participants was 33.42 years with SD = 12.5. Thirty-one (60%) of the cases spontaneously developed a bronchopleural fistula and 20 (38%) were post-surgical and 1(2%) was a post-traumatic fistula. Of the total of post-surgical bronchopleural fistula, 14 (26.9%) of them were lung resection, 4 (7.7%) were hydatid cystectomy and 1(1.9%) are decortications, and bullectomy respectively. of the total post-lung resection, 8 (57%) were pneumonectomies followed by 3 (21.5%) Lobectomy, 2 (14.5%) wedge resection and 1(7%) bilobectomy respectively. Fifty patients were managed surgically and two patients were managed conservatively. Bronchopleural fistula (BPF) was closed in 40 (85.4%) and there were two (3.9%) deaths, and the cause of death was sepsis secondary to pneumonia of the contralateral lung in one case.ConclusionHaving thoracic surgery is a risk factor for the development of bronchopleural fistula. Management of bronchopleural fistula needs to be individualized.

Risk factors for bronchopleural fistula after lobectomy for lung cancer.

Bronchopleural fistula (BPF) after lobectomy for lung cancer is a rare but serious complication. This study aimed to stratify the risk factors of BPF. Patients who underwent lobectomy without bronchoplasty and preoperative treatment for lung cancer between 2005 and 2020 were retrospectively reviewed. We examined the association between the incidence of BPF and background factors, including comorbidities, preoperative blood test results, respiratory function, surgical procedure, and extent of lymphadenectomy. Among the 3,180 patients who underwent lobectomy, 14 (0.44%) developed BPF. The median interval from surgery to BPF onset was 21 days (range, 10-287). Two of the 14 patients died of BPF (mortality rate, 14%). All 14 patients who developed BPF were men and had undergone right lower lobectomy. Other factors significantly associated with the development of BPF were older age, heavy smoking, obstructive ventilatory failure, interstitial pneumonia, history of malignancy, history of gastric cancer surgery, low serum albumin levels, and histology. Multivariable analysis in the subgroup of men who underwent right lower lobectomy revealed that high level of serum C-reactive protein and a history of gastric cancer surgery were significantly associated with BPF, whereas bronchial stump coverage was inversely associated with BPF. Men who underwent right lower lobectomy were at increased risk of BPF. The risk was higher when the patient had high serum C-reactive protein or a history of gastric cancer surgery. Bronchial stump coverage might be effective in patients at high risk of BPF.

Surgical Treatment of Bronchopleural Fistulas on the Background of Pleural Empyema

Pleural empyema (EP) is one of the most complex nosologies of thoracic surgery. Mortality in this disease reaches 28% according to the literature. The causes of the development of nonspecific empyema of the pleura are various purulent-destructive lung diseases, as well as inflammatory diseases, surgical interventions and injuries. The presence or absence of bronchopleural fistula (BPS) is crucial in determining the prognosis of treatment of pleural empyema. This article is devoted to the study of the issues of surgical treatment of BPS against the background of various EP variants. Objective. To evaluate the effectiveness of using fibrin glue as a regeneration stimulator in the treatment of patients with bronchopleural fistulas on the background of pleural empyema. Materials and methods. In the I. V. Davydovsky State Clinical Hospital No. 23, for the treatment of patients with EP complicated by the development of bronchopleural fistula, an integrated approach is used using the concept of biological stimulation of tissue repair through the use of fibrin glue obtained by cryoprecipitation. Results. Our experience based on the study of 136 patients with pleural empyema of various etiologies (post-pneumonic (n=76), post-resection (n=11), covid-associated (n=49)) shows encouraging results. The clinical efficacy of using fibrin glue as a stimulator of tissue repair was 91,89% in the group of post-pneumonic EP, 66,66% in the group of post-resection EP and 90,9% in the group of covid-associated EP. However, the results obtained require further analysis and study.Conclusion. Despite the achievements of recent decades in antibiotic therapy, the improvement of surgical techniques and new minimally invasive methods of treatment, the problem of the development of bronchopleural fistulas remains relevant to this day. Knowledge of the issues of pathogenesis, risk factors, as well as the improvement of therapeutic tactics in the development of this formidable complication will increase the effectiveness of treatment and improve the prognosis of this category of patients. The use of biological stimulators of tissue repair based on own blood plasma may be a promising direction of treatment of this complex pathology.

XENOPERICARD COMBINED WITH NPWT (NEGATIVE PRESSURE WOUND THERAPY) IN THE TREATMENT OF ADVANCED PLEURAL EMPYEMA WITH BRONCHOPLEURAL FISTULA (CLINICAL FOLLOW-UP)

The development of bronchopleural fistula (BPS) against the background of advanced pleural empyema, as a result of severe pneumonia, is a formidable complication. The most significant obstacle in the surgical treatment of this group of patients is: a pronounced comorbid background, low functional indicators of patients, high requirements for surgical technique when performing reconstructive plastic interventions in BPS. Multiple surgical methods for treating bronchopleural fistulas are suggested. The first of these were to suture the defect. However, access through the infected pleural cavity leads to suture eruption and recurrence of the fistula, despite the fact that some authors have proposed combining these operations with various variants of myoplasty, thoracoplasty, removal of the fibrous capsule of empyema. Unsatisfactory functional and cosmetic outcomes during these surgical interventions led to the development of endoscopic, minimally invasive surgical interventions. Modern technologies allow temporary endoscopic bronchiococclusion, which stops the release of air from the defect. However, at the same time, she "turns off " part of the lung tissue from the gas exchange. Prolonged bronchial occlusion leads to the development of pneumonia with an outcome in the destruction of lung tissue. Our team of authors treatment of bronchopleural fistula with xenopericardium in combination with negative pressure therapy. This area seems to us very promising, and in this work we would like to share our first experience.

Risk factors and outcomes of bronchopleural fistula after bronchoplasty in patients with non-small cell lung cancer: a retrospective multivariate analysis.

BackgroundBronchopleural fistula (BPF) is a rare but severe complication following bronchoplasty. Identification of the risk factors for the development of BPF after bronchoplasty may contribute to better perioperative management, thereby further improving the prognosis of these patients. However, few studies have focused on the risk factors for BPF after bronchoplasty. This study aimed to explore the risk factors and outcomes for BPF after bronchoplasty in patients with non-small cell lung cancer (NSCLC).MethodsThe data of NSCLC patients who underwent bronchoplasty between September 2005 and August 2020 in our institution were retrospectively reviewed. Detailed information on demographic characteristics, preoperative assessment, perioperative outcomes were collected from Western China Lung Cancer Database. The diagnosis of BPF was confirmed by bronchoscopy. Risk factors for BPF were assessed by univariate and multivariate logistic regression analysis.ResultsA total of 503 patients were included in this study, including 132 (26.2%) cases of broncho-vascular plasty, 340 (67.6%) cases of bronchial sleeve lobectomy, and 31 (6.2%) cases of bronchial wedge plasty. Among these patients, 16 (3.2%) developed postoperative BPF. Six patients with BPF died during hospital-stay, including two cases of severe hemoptysis, and four cases of pyothorax and respiratory failure caused by BPF. One of the other ten patients underwent reoperation. After univariate and multivariate logistic regression analysis, preoperative Charlson Comorbidity Index (CCI) ≥2 [odds ratio (OR) =5.120, 95% confidence interval (CI): 1.193–21.985, P=0.028], right middle and/or lower lobectomy (OR =4.840, 95% CI: 1.133–20.686, P=0.033), and residual tumor in the bronchial margin (OR =4.160, 95% CI: 1.106–15.644, P=0.035) were identified as independent risk factors for postoperative BPF.ConclusionsAlthough complication rate of BPF after bronchoplasty is low, the mortality of BPF is high. Patients with higher CCI, those who undergo right middle and/or lower lobectomy, and those with residual tumor in the bronchial margin are at increased risk of BPF. This study highlights the importance of preoperative evaluation and good intraoperative management to prevent this catastrophic complication.

Akciğer rezeksiyonları sonrası gelişen bronkoplevral fistül tedavisinde omentoplasti

Purpose: Bronchopleural fistula (BPF) is a complication that can occur after pulmonary resections onset may be early or late. This study aims to present our results using omentoplasty in the treatment of BPF.&#x0D; Materials and Methods: We retrospectively evaluated the data of patients who developed BPF after pulmonary resection between 2010 and 2020. The results of the patients who underwent omentoplasty during surgical revision for BPF were analyzed in terms of surgical methods used, timing of the procedure, and surgical success.&#x0D; Results: BPF formed in 52 (2.1%) of 2486 patients who underwent anatomical lung resection. Fourteen (26.9%) of the patients with BPF were treated with omentoplasty. All of the patients were men and the median age was 58 years (range, 27-75 years). Among the patients who underwent omentoplasty, the median time from pulmonary resection to BPF development was 22 days (range, 4-221 days). The median time from BPF development to omentoplasty was 9.5 days (range, 4-485 days). Seven (50%) of the patients developed BPF after pneumonectomy and the other 7 (50%) after lobectomy. Most post-pneumonectomy BPFs occurred after right pneumonectomy (n=6, 85.7%). BPF developing after right pneumonectomy constituted 43% of all BPFs (n=6). Surgical success was achieved in 13 (92.9%) of the 14 patients who underwent BPF closure with omentoplasty.&#x0D; Conclusion: Omentoplasty has low complication and high success rates and can be used safely for the treatment of BPF.

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

Is the flap reinforcement of the bronchial stump really necessary to prevent bronchial fistula?

Background/aimThe development of bronchopleural fistula (BPF) remains the most severe complication of lung resection, especially after pneumonectomy. Studies provide controversial reports regarding the benefits of flap reinforcement of the bronchial stump (FRBS) in preventing BPF’s occurrence.MethodsThis is a retrospective cohort study of 558 patients that underwent lung resection in a 12-year period (from 2007 to 2018). Ninety patients (16.1%) underwent pneumonectomy. Patient follow-up period varied from 1 to 12 years.ResultsOut of 558 patients in this study, 468 (83.9%) underwent lobectomy, and the remnant underwent pneumonectomy. In 114 cases with lobectomy, only 24.4% had FRBS, meanwhile in 56 cases with pneumonectomy only 62.2% had FRBS. BPF occurred in 8 patients with lobectomy (1.7%) and in 10 patients with pneumonectomy (11.1%). Among cases with post-pneumonectomy BPF, 6 (10.7%) had FRBS performed, while no FRBS was performed among patients with post-lobectomy BPF, although these data weren’t statistically (p > 0.05). In 24 patients (20 lobectomies and 4 pneumonectomies) with lung cancer (10.4%) neoadjuvant treatment was performed, in which 20 patients underwent chemotherapy and 4 underwent radiotherapy. FRBS was applied in each of the above 24 operative cases, but only in 4 of them the BPF was verified.ConclusionThe idea of enhancing the blood supply through the FRBS for BPF prevention has gain traction. Although FRBS has been identified as valuable and effective method in BPF prevention following lung resection, our study results did not support this evidence.

Problem Terapeutik pada Empiema Terlokulasi karena Tuberkulosis

Background: Pleural effusion is the most common complication of pulmonary tuberculosis (TB). Some coexist with secondary infection could worsen clinical presentation as empyema. The incidence of pleural effusion in the early stage of empyema due to TB infection is about 31%. Somehow, untreated empyema increased in-hospital mortality. Case: A woman with unregulated diabetes mellitus was referred with organized empyema. The etiology of empyema is based on a specific process of TB infection with the ADA value of empyema fluid was 128 mg/dl. We decided to perform decortication with the result loculated empyema and bronchopleural fistula 2 cm in the inferior lobe of the right lung. The patient did not recover well. Unfortunately, fluidopneumothorax was found on a chest CT scan with contrast. Thoracotomy was performed and another bronchopleural fistula was found which length was about 1 cm in superior lobe of the right lung. Discussion: The worsening condition of the patient was caused by the occurrence of postoperative bronchopleural fistula. It was visualized as pulmonary TB with perforation of cavity nessessity. On the other hand, the condition could be worsened by the hyperglycemic state in an immunocompromised individual. Summary: Loculated empyema is a condition caused by bronchopleural fistula, the presence of a connecting cavity between pleural and bronchus which occurred less than 48 hours. Local and systemic factors might explain the development of bronchopleural fistula. Well management of the loculated empyema by knowing the etiology could improve the life survival of the patient.

Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization.

BackgroundDuring anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula.MethodsBefore reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared.ResultsICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula.ConclusionsICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.

Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre

The bronchopleural fistula (BPF) is a rare but potentially fatal complication of major thoracic surgery. The purpose of this work is to investigate the risk factors associated with the development of fistulas after lobectomy and pneumonectomy. We retrospectively reviewed the records of 835 patients who underwent major anatomic lung resection at our centre from January 2003 to December 2013. Of these, 49 underwent pneumonectomy (P group) and 786 lobectomy (L group). A total of 18 patients (2.6%) developed a BPF in the postoperative period, of which there were 11 in the L group (1.3%) and seven in the P group (14.28%). The 30-day mortality was 0.05% (one patient after right pneumonectomy). In the L group, three patients developed a fistula after a left lobectomy and eight after a right one, of which four developed after bilobectomy. Univariate analysis showed that induction therapy, lower lobectomy, manual suture of the bronchus, 'not covered' bronchial stump, empyema, postoperative anaemia and pulmonary infections and mechanical ventilation >24 h are associated with the development of fistulas after lobectomy. Multivariate analysis confirmed that induction therapy, manual closure of the bronchus, postoperative pulmonary infections and anaemia are the main risk factors involved in our series. In the P group, four patients developed a fistula after a right pneumonectomy and three after a left one. Postoperative empyema and pulmonary infections, mechanical ventilation >24 h and female gender emerged as the main risk factors on univariate analysis, while on multivariate analysis, only the female gender presented a trend towards significance. Postoperative pulmonary infections, empyema and mechanical ventilation >24 h are strongly associated with the development of BPFs after both pneumonectomy and lobectomy in our series.

72-Year-Old Female With a Bronchopleural Fistula Status Post Completion Right Pneumonectomy

SESSION TITLE: Cardiovascular Disease Case Report PostersSESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PMINTRODUCTION: Incidence of bronchopleural fistula (BPF) after pneumonectomy is reported to be 1-5% for cancer resections, with a reported mortality of 30-50%. It is more common after right-sided pneumonectomy secondary to various considerations including lack of local tissue coverage. Other risk factors include completion pneumonectomy, previous mediastinal/hilar radiation, prolonged mechanical ventilation, post-pneumonectomy empyema, residual tumor at the bronchial stump, and technical factors including devascularization, incomplete bronchial stump closure, or failure to provide supplemental tissue coverage of the bronchial stump. When the bronchial stump remains elongated, this leads to pooling of airway secretions and resultant BPF development.CASE PRESENTATION: 72 year old female who presented with low grade fevers and shortness of breath one and a half weeks after undergoing an open right lobectomy converted to completion pneumonectomy for bronchogenic adenocarcinoma. Intraoperatively it was noted that the bronchial stump was difficult to manage, requiring oversewing and application of tissue adhesive. One month later, the patient was transferred for definitive treatment which included debridement of the right pleural space, resection of the elongated bronchial stump, and intrathoracic transposition of a pedicled right serratus anterior muscle flap. Following serial operative packing exchanges, the modified Clagett procedure was completed with chest closure 8 days after re-exploration.DISCUSSION: Treatment of BPF is divided into acute and chronic phases. If BPF develops early after surgery (within 2 weeks) it is likely related to technical failure of the bronchial stump closure. Clinically it may present as a persistent or continuous air leak, progressive subcutaneous emphysema, and/or respiratory insufficiency/failure. If the BPF develops later in the postoperative course, it is likely due to inadequate healing or rupture of the bronchial stump. These patients usually present with fevers and/or productive coughs and are in danger of aspiration though the bronchial stump into the contralateral lung.CONCLUSIONS: At the time of reoperation, the bronchial stump should be covered with a vascularized pedicle of tissue including either muscle, pericardial fat pad, or omentum. If the pleural space appears clean, it may be closed using the Clagett procedure.Reference #1: Liberman M. and Cassivi SD. Bronchial Stump Dehiscence: Update on Prevention and Management. Seminar of Thoracic and Cardiovascular Surgery. 2007: 19:366-373.DISCLOSURE: The following authors have nothing to disclose: Lawrence Greiten, Stephen CassiviNo Product/Research Disclosure Information SESSION TITLE: Cardiovascular Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Incidence of bronchopleural fistula (BPF) after pneumonectomy is reported to be 1-5% for cancer resections, with a reported mortality of 30-50%. It is more common after right-sided pneumonectomy secondary to various considerations including lack of local tissue coverage. Other risk factors include completion pneumonectomy, previous mediastinal/hilar radiation, prolonged mechanical ventilation, post-pneumonectomy empyema, residual tumor at the bronchial stump, and technical factors including devascularization, incomplete bronchial stump closure, or failure to provide supplemental tissue coverage of the bronchial stump. When the bronchial stump remains elongated, this leads to pooling of airway secretions and resultant BPF development. CASE PRESENTATION: 72 year old female who presented with low grade fevers and shortness of breath one and a half weeks after undergoing an open right lobectomy converted to completion pneumonectomy for bronchogenic adenocarcinoma. Intraoperatively it was noted that the bronchial stump was difficult to manage, requiring oversewing and application of tissue adhesive. One month later, the patient was transferred for definitive treatment which included debridement of the right pleural space, resection of the elongated bronchial stump, and intrathoracic transposition of a pedicled right serratus anterior muscle flap. Following serial operative packing exchanges, the modified Clagett procedure was completed with chest closure 8 days after re-exploration. DISCUSSION: Treatment of BPF is divided into acute and chronic phases. If BPF develops early after surgery (within 2 weeks) it is likely related to technical failure of the bronchial stump closure. Clinically it may present as a persistent or continuous air leak, progressive subcutaneous emphysema, and/or respiratory insufficiency/failure. If the BPF develops later in the postoperative course, it is likely due to inadequate healing or rupture of the bronchial stump. These patients usually present with fevers and/or productive coughs and are in danger of aspiration though the bronchial stump into the contralateral lung. CONCLUSIONS: At the time of reoperation, the bronchial stump should be covered with a vascularized pedicle of tissue including either muscle, pericardial fat pad, or omentum. If the pleural space appears clean, it may be closed using the Clagett procedure. Reference #1: Liberman M. and Cassivi SD. Bronchial Stump Dehiscence: Update on Prevention and Management. Seminar of Thoracic and Cardiovascular Surgery. 2007: 19:366-373. DISCLOSURE: The following authors have nothing to disclose: Lawrence Greiten, Stephen Cassivi No Product/Research Disclosure Information

No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether manual closure of the bronchial stump is safer with lower failure rates than mechanical closure using a stapling device following anatomical lung resection. One hundred and twenty-nine papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question as they included sufficient number of patients to reach conclusions regarding the issues of interest for this review. Complications, complication rates and operation time were included in the assessment. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. When looking at manual vs mechanical staples, it was noted that stapler failure can occur in around 4% of cases. The rate of bronchopleural fistula (BPF) development varied more in patients who underwent manual closure (1.5-12.5%) than in patients who underwent mechanical closure (1-5.7%). Although most of the studies reviewed showed no statistical differences between manual and mechanical closure in terms of BPF development, one study, however, showed that manual closure was significantly associated with lower numbers of postoperative BPF, while another study showed that mechanical closure is significantly associated with lower incidence of BPF. When looking at the role of the learning curve and training opportunities, it seems that the surgeon's inexperience when using mechanical staples can contribute to BPF development. A surgeon's experience can play a major role in the prevention of BPF development in patients having manual closure. Manual closure can provide a cheap and reliable technique when compared with costs incurred from using staplers, it is applicable in all situations and can be taught to surgeons in training with an acceptable risk. However, there is a lack of evidence to suggest that manual closure is better than mechanical stapler closure following anatomical lung resection.

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

THORACIC SURGERY Which technique is the best for the surgical management of empyema thoracis in children?

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Tander B, Bicakci U, Gunaydin M, et al. THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):130-132. doi:10.5114/kitp.2013.36132. APA Tander, B., Bicakci, U., Gunaydin, M., Demirel, D., Rizalar, R., & Ariturk, E. et al. (2013). THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), 130-132. https://doi.org/10.5114/kitp.2013.36132 Chicago Tander, Burak, Unal Bicakci, Mithat Gunaydin, Dilek Demirel, Riza Rizalar, Ender Ariturk, and Ferit Bernay. 2013. "THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 10 (2): 130-132. doi:10.5114/kitp.2013.36132. Harvard Tander, B., Bicakci, U., Gunaydin, M., Demirel, D., Rizalar, R., Ariturk, E., and Bernay, F. (2013). THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), pp.130-132. https://doi.org/10.5114/kitp.2013.36132 MLA Tander, Burak et al. "THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 10, no. 2, 2013, pp. 130-132. doi:10.5114/kitp.2013.36132. Vancouver Tander B, Bicakci U, Gunaydin M, Demirel D, Rizalar R, Ariturk E et al. THORACIC SURGERYWhich technique is the best for the surgical management of empyema thoracis in children?. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):130-132. doi:10.5114/kitp.2013.36132.

Postpneumonectomy bronchial stump recurrence and bronchopleural fistula

To reduce the incidence of postpneumonectomy local recurrence, and to prevent the onset of bronchopleural fistula. A long bronchial stump with a short tumor-free bronchial margin has been found to be associated with a higher incidence of local recurrence, and with the development of bronchopleural fistula in some cases. 134 patients underwent pneumonectomy for non-small-cell lung cancer in 2 institutions. Bronchial stump length was measured intra-and postoperatively. 30-day postoperative mortality was 2.9%. There were 3 postoperative bronchopleural fistulas after right pneumonectomy (3/61) and one after left pneumonectomy (1/73; p=0.2; fistula was more frequent in the long-stump group), which were successfully treated with carina sutures in 75% of cases. The overall incidence of local recurrence was strongly related to the presence of tumoral microinvasion in the resection margin (100%). To prevent postpneumonectomy bronchial stump complications, it might be useful to use carina closure instead of bronchial closure. Carina closure can reduce local recurrence, significantly reduce the fistulization rate, and eliminate the stump diverticulum. Reduction of the length of the bronchial stump can be achieved using a TA Roticulator linear stapler.