Incidence Of Bronchopleural Fistula Research Articles

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 Outcomes of Video-Assisted versus Open Pneumonectomy for Lung Cancer: A Real-World Study.

The safety, feasibility and potential benefits of Video-assisted thoracoscopic surgery (VATS) pneumonectomy remain to be investigated. Patients receiving VATS or Open pneumonectomy during the study period were included to compare surgical outcomes. Propensity-score matched (PSM) analysis was performed to eliminate potential biases. From 2013 to 2020, 583 consecutive patients receiving either VATS (105, 18%) or Open (478, 82%) pneumonectomy were included. Conversion from VATS to open was found in 20 patients (19.0%). The conversion patients had similar rates of major complications and perioperative mortality compared with the Open group. After PSM, 203 patients were included. No significant differences were observed in major complications and perioperative mortality between the two groups. For patients with stage pT2 tumors, the major complication rate in the VATS group was significantly lower than in the Open group (7.6% vs. 20.6%, p = 0.042). Compared with left pneumonectomy, the incidence of bronchopleural fistula (BPF) was significantly higher in right pneumonectomy for both VATS (0 vs. 16.7%, p = 0.005) and Open (0.7% vs. 6.5%, p = 0.002) approaches. Perioperative results of VATS pneumonectomy are non-inferior to those of the Open approach. Conversion to open surgery does not compromise perioperative outcomes. Patients with lower pT stage tumors who need pneumonectomy may benefit from VATS.

Therapeutic closure of bronchopleural fistulas using ethanol.

Bronchopleural fistula (BPF) leading to persistent air leak (PAL), be it a complication of pulmonary resection, radiation, or direct tumor mass effect, is associated with high morbidity, impaired quality of life, and an increased risk of death. Incidence of BPF following pneumonectomy ranges between 4.4% and 20% with mortality ranging from 27.2% to 71%. Following lobectomy, incidence ranges from 0.5% to 1.5% in reported series. BPFs are more likely to occur following right-sided pneumonectomy, while patients undergoing bi-lobectomy were more likely to suffer BPF than those undergoing single lobectomy. In addition to supportive care, including appropriate antibiotics and nutrition, management of BPF includes pleural decontamination, BPF closure, and ultimately obliteration of the pleural space. There are surgical and bronchoscopic approaches for the management of BPF. Surgical interventions are best suited for large BPFs, and those occurring in the early postoperative period. Bronchoscopic techniques may be used for smaller BPFs, or when an individual patient is no longer a surgical candidate. Published reports have described the use of polyethylene glycol, fibrin glues, autologous blood products, gel foam, silver nitrate, and stenting among other techniques. The Amplatzer device, used to close atrial septal defects has shown promise as a bronchoscopic therapy. Following their approval under the humanitarian device exemption program for treatment of prolonged air leaks, endobronchial valves have been used for BPF. No bronchoscopic technique is universally applicable, and treatment should be individualized. In this report, we describe two separate cases where we use an Olympus© 21-gauge EBUS-TBNA (endobronchial ultrasound–transbronchial needle aspiration) needle for directed submucosal injection of ethanol leading to closure of the BPF and subsequent successful resolution of PAL.

Morbidity and mortality of lobectomy or pneumonectomy after neoadjuvant treatment: an analysis from the ESTS database.

To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database. Retrospective analysis on 52982 anatomic lung resections registered in the ESTS database (July 2007-31 December 2017) (6587 pneumonectomies and 46395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared. 8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P = 0.87; 9.2% vs 9.9%, P = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P = 0.44). Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer.

Is low serum albumin associated with postoperative bronchopleural fistula in patients undergoing pulmonary resections?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether low serum albumin (sAlb) was associated with postoperative bronchopleural fistula (BPF) in patients undergoing pulmonary resections. Altogether 660 papers were found using the reported search, of which 5 retrospective cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four of the 5 cohort studies showed that the preoperative sAlb level in patients who experience a BPF was significantly lower than that in patients who did not experience a BPF. One of the 5 studies also reported that the incidence of BPF in patients with a lower sAlb (13.6%) was found to be significantly higher than that in patients with a higher sAlb (7.0%). The level of hypoalbuminaemia is not defined, but it may be <3.5 g/dl. This cut-off value of sAlb is assumed from the currently available retrospective data. No prospective study has been reported to address this issue. In summary, low preoperative sAlb can serve as a significant risk factor for postoperative BPF in patients undergoing pulmonary resections.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis.

Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings. A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis. The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47). The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

P3.04-012 Bronchial Sutures in Anatomic Pulmonary Resections: The Clinical Experience of 865 Cases: Topic: Miscellaneous I

Although the incidence of bronchopleural fistula (BPF) has decreased in past time, it remains a serious complication following pulmonary resection. Between 1999 and 2011, 865 patients with lung cancer underwent radical surgery. 732 (84,6%) males and 133 (15,4%) females were ranging between 22 and 79 years (average 55,2±8,1). We retrospectively reviewed the data for morbidity, mortality and complications, especially with regard to the type of bronchial suture. Tabled 1Rate BPF from the dependence of the type of bronchial sutureType of bronchial suturecasesBPF%Stapled closure210146,7%Stapled closure with additinal hand suture514244.7%Hand closure14110,7%Total865394,5% Open table in a new tab All patients underwent radical operations: 286 (33,1%) pneumonectomies, 501 (57,9%) lobectomies and 78 (9,0%) bilobectomies. In postoperative period 39 patients (4,5%) had complication – bronchopleural fistula. After pneumonectomy BPF took place in 33 (11,5%) cases, not differing significantly from the volume of lymph node dissection. After lobectomy BPF occurred statistically significant rare – in 6 (1,0%) cases. It should be noted, that the volume of lymph node dissection not significantly affect the frequency BPF. The most frequently BPF occured after pneumonectomies – 33 (26 on the right, 7 left). After lobectomies BPF occurred in less cases – 6 (2 on the right, 4 left). By using hand closure BPF occurred in 1 out of 141 (0,7%) cases. By using stapled closure – in 14 of 210 (6,7%). By using stapled closure with additional hand suture – 24 of 514 (4,7%). Thus the safest method of bronchus closure is hand suture. The stapled closure statistically significant increase the amount of BPF (p<0,05).

Neoadjuvant therapy and risk of bronchopleural fistula after lung cancer surgery: a systematic meta-analysis of 14 912 patients.

Neoadjuvant therapy has been extensively analyzed in studies addressing the risk factors of bronchopleural fistula, but their results vary hugely. Therefore, we conducted this meta-analysis to determine the association between neoadjuvant therapy and risk of bronchopleural fistula in patients undergoing lung cancer surgery. We searched PubMed and EMBASE to identify the full-text literatures that met our eligibility criteria. Odds ratio with 95% confidence interval served as the summarized statistics. Heterogeneity within this meta-analysis was evaluated by Q-test and I (2) statistic. Sensitivity analysis was performed for further assessments of robustness. Publication bias was detected by Begg's test and Egger's test. Thirty studies enrolling 14 912 lung cancer cases were included into this meta-analysis. The incidence of bronchopleural fistula was 2.4% (354/14 912) in the large scale. Overall, neoadjuvant therapy significantly increased the risk of bronchopleural fistula after pulmonary resections (odds ratio: 2.166; 95% confidence interval: 1.398-3.357; P = 0.001). In subgroup analysis, neoadjuvant radiotherapy (odds ratio: 3.914; 95% confidence interval: 1.401-10.935; P = 0.009) and chemo-radiation (odds ratio: 2.533; 95% confidence interval: 1.353-4.741; P = 0.004) were significantly associated with the bronchopleural fistula risk but neoadjuvant chemotherapy was not (odds ratio: 1.857; 95% confidence interval: 0.881-3.911; P = 0.104). The impact of neoadjuvant therapy on bronchopleural fistula occurrence remains statistically prominent in the other subgroups. Neoadjuvant therapy is significantly associated with the occurrence of bronchopleural fistula after lung cancer surgery. Both neoadjuvant radiotherapy and chemo-radiation significantly increase the bronchopleural fistula risk but neoadjuvant chemotherapy does not. Some limitations still exist in this meta-analysis. The updated high-quality studies can help to further confirm and enrich our discoveries in the future.

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

The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients

Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment. From January 2001 to December 2013, the records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed. The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively. The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment.

A meta-analysis of the impact of bronchial stump coverage on the risk of bronchopleural fistula after pneumonectomy.

The occurrence of bronchopleural fistula (BPF) after pneumonectomy is associated with high morbidity and mortality. The incidence of BPF in historical patients not subjected to bronchial stump coverage (BSC) was between 6 and 12% after pneumonectomy for lung cancer surgery or benign disease. BSC is considered an important prophylactic measure against BPF and is widely used, but its efficacy remains unknown. Our aim was to systematically review the literature, in order to quantify BPF risk in patients receiving or not receiving BSC with any tissue after pneumonectomy. We performed a systematic review in PubMed, for papers published between 1999 and 2012, analysing series of patients treated with pneumonectomy and including both patients receiving coverage and patients not receiving coverage. Both randomized and non-randomized series were eligible. Proportion of failures (i.e. BPF) was analyzed separately in the two groups (patients receiving BSC and patients not receiving BSC). For each study and for the overall series, 95% confidence interval (CI) (without continuity correction) of the observed proportion was calculated. Overall, 21 series were eligible, with 3879 patients (1774 receiving BSC and 2105 not receiving coverage). The decision to perform or not the BSC was randomized only in one small trial, limited to diabetic patients, showing a significant reduction of BPF in favour of coverage. In the 20 remaining studies, baseline risk of BPF in the group of patients receiving BSC and in the group of patients who did not receive coverage was different. In patients receiving coverage, the proportion of BPF was 6.3% (95% CI: 5.3-7.5%). In patients not receiving coverage, the proportion of BPF was 4.0% (95% CI: 3.2-4.9%). In recently published series, the vast majority of patients considered at high risk for BPF received BSC. This common practice hinders an unbiased estimate of the efficacy of BSC in reducing BPF risk. Results of this meta-analysis show that, despite a clear negative selection, the incidence of BPF in patients considered at high risk and receiving coverage was only slightly higher compared with patients considered at low risk and not covered. A randomized trial would help answer the question.

Methods of main bronchus stump closure and incidence of bronchopleural fistula after pneumonectomies for lung cancer (a retrospective single center review)

Background. Bronchopleural fistulas (BPFs) development after pneumo­nectomy remains a serious complication and is associated with high mortality rate. We evaluated incidence and risk factors, that influenced BPF rate after pneumonectomies for lung cancer patients treated at the Department of Thoracic Surgery and Oncology of the Institute of Oncology, Vilnius University, and compared different bronchial stump suturing techniques. Methods. It is a retrospective study. We reviewed 580 lung cancer patients who underwent pneumonectomies from January 1990 to January 2009. The average patient’s age was 60.1 ± 7.9 years (range from 34 to 76). Patients according to postoperative staging: stage IIA – 30 patients, IIB – 80, IIIA – 320, IIIB – 96, IV – 54. The most common tumor histology was planocellular carcinoma – 301, adenocarcinoma – 108, small-cell carcinoma – 76. Results. There were 327 (56.4%) right and 253 (43.6%) left pneumonectomies. Mediastinal lymph node dissection (LND) was performed to 387 (66.7%) and lymph node sampling (LNS) to 193 (33.3%) patients. The bronchial stump was covered in 285 (49.1%) patients. Bronchopleural fistula after pneumonectomy developed in 48 (8.3%) patients (bronchial dehiscence was confirmed by bronchoscopy), and 7 patients with BPF died (14.5%). BPF after right pneumonectomy occurred in 30 cases (9.5%) and after left pneumonectomy in 18 cases (7.1%), the difference was not statistically significant (p &gt; 0.05). BPF after LND occurred in 38 cases (9.82%) and after LNS in 10 cases (5.18%), the dif­f erence was statistically significant (p

Pneumonectomy for Non-Small Cell Lung Cancer: Predictors of Early Mortality and Morbidity

Background: The aim of this study was to determine independent risk factors affecting postoperative morbidity and mortality after pneumonectomy for non-small cell lung cancer (NSCLC).Methods: A review of 329 patients having pneumonectomy for NSCLC between January 1, 1998 and July 31, 2012 was undertaken. Factors affecting morbidity and mortality were analyzed by univariate and multivariate analyses. Results: The overall 30-day mortality rate was 5.1%. Smoking habits, chronic obstructive pulmonary disease (COPD) status, neoadjuvant therapy and obesity had no statistical influence on the short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p < 0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increased the incidence of bronchopleural fistula (p < 0.01).Conclusions: Pneumonectomy for NSCLC carries an acceptable operative morbidity and mortality. Coronary artery disease, right pneumonectomy and respiratory failure adversely affect morbidity and mortality after this procedure.

Reply to Terzi et al.

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

Surgery for the treatment of the tuberculosis-destroyed lung: to protect or not to protect the bronchial stump?

We read with interest the paper by Bai et al. [1] regarding the efficacy of surgery, mainly pneumonectomies, in the treatment of tuberculosis (TB)-destroyed lungs and we congratulate them on their results. One of the most dreaded complications after pneumonectomy is the bronchopleural fistula (BPF), and this is particularly true for pneumonectomies performed for infectious diseases including TB. The authors report a very low incidence of BPF, but they do not give information about the method, if any, they use to reinforce the bronchial stump. It should be of great interest to know whether or not they protect the stump and to know which criteria they use to decide who can benefit from the bronchial stump coverage. For Wang et al. [2], the incidence of BPF was 9% when parietal pleura or the pericardium were used to protect the bronchial stump, and it was as high as 36% when they were not. According to Pomerantz [3], positive sputum at the time of surgery and polymicrobial contamination increases the risk of BPF, and he suggests using muscle flaps to protect the bronchial stump. In our experience, we used with satisfaction a muscle flap of the serratus anterior or a split latissimus dorsi flap [4] in all sputum-positive patients, most of whom also had a polymicrobial contamination of the destroyed lung. Both these flaps can be easily and quickly harvested and add only a minimal morbidity to the operation.

Right-sided approach for management of left-main-bronchial stump problems

Although the incidence of bronchopleural fistula (BPF) has decreased in the past decades, it remains a serious complication following pulmonary resection. The management of left-sided bronchial stump fistulas is difficult and depends on the choice of the approach. In contrast to several surgical procedures published in the past, herein we report our experience managing five left-main-bronchial stump (LMBS) problems through a right thoracotomy route. Five women, who underwent left pneumonectomy and later developed BPF, were managed with this novel procedure at our Institution. BPF appeared between 12 days and 24 years after pneumonectomy. Diagnosis of BPF or bronchoesophageal fistula (BEF) was made by computed tomography (CT) scan and fiberoptic bronchoscopy. Through a right posterolateral thoracotomy incision, the LMBS was re-stapled and covered with pedicled flaps in all cases. In patient #4, carinal resection was performed also, with temporary extracorporeal membrane oxygenation (ECMO) application. The main results are depicted in the table. In all cases, encircling of the LMBS and stapling at the level of the carina was performed without difficulties. In patients #1, #2 and #3, resection of the bronchial stump remnant was also done and, in patient #4, carinal resection was also performed. All patients are doing well, with no evidence of recurrence of fistula. We advocate the right posterolateral thoracotomy route for the management of left-sided BPFs as an alternative to transternal transpericardial and transthoracic closures. It is a safe, feasible and time-efficient approach that provides control of central structures and avoids previously manipulated or infected operative fields.

Bronchopleural Fistula Treated With a Silicone-Covered Bronchial Occlusion Stent

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

Risk Factors for Early Mortality and Morbidity After Pneumonectomy: A Reappraisal

Pneumonectomy remains a high-risk procedure. Comprehensive patient selection should be based on analysis of proven risk factors. The records of 323 pneumonectomy patients were retrospectively reviewed. Multiple demographic data were collected. End points were operative mortality at 30 and at 90 days, major procedurally related complications, and cardiovascular events. Univariate and multivariate statistical analyses were performed. Smoking habits, chronic obstructive pulmonary disease (COPD) status, induction chemotherapy status, diabetes, and obesity had no statistical influence on short-term outcomes. After right pneumonectomy, 30-day mortality (p = 0.045) and the incidence of bronchopleural fistulas (p = 0.009) were increased. Multivariate analysis for postoperative bronchopleural fistulas discovered that right pneumonectomies are the sole risk factor (p = 0.015). Univariate analysis for postoperative atrial fibrillation showed that male gender, age 70 and older, hypertension, and dyslipidemia are risk factors. Multivariate analysis found no definite risk factor. Patients with coronary artery disease had more postoperative cardiovascular events (p = 0.003). Among patients free of coronary artery disease, COPD led to an increased 90-day mortality rate (p = 0.028). Patients with right pneumonectomies are at increased risk. Postoperative cardiovascular events are more frequent in coronary artery disease patients. COPD is a risk factor in patients free of coronary disease.

Does chemotherapy increase morbidity and mortality after pneumonectomy?

The impact of chemotherapy on postoperative complications after pneumonectomy remains unclear, and the procedure is often considered as potentially dangerous. This retrospective review of prospectively collected data included 269 patients operated from January 1, 1998 through December 31, 2007. Group 1 included patients those who received preoperative chemotherapy (PCT) and pneumonectomy (54 patients, 20%), and group 2 included patients who underwent pneumonectomy alone (215 patients, 80%). Overall 30- and 90-day mortality rates were 5.9% and 8.9%, respectively. Postoperative mortality at 30 days was 5.6% in group 1 and 6% in group 2 (P = 0.16), and 11.1% for group 1 and 8.3% in group 2 at 90 days (P = 0.8). Incidence of postoperative respiratory failure was 3.7% in group 1 and 3.2% in group 2 (P = 0.62); incidence of empyema was 5.5% in group 1 and 2.8% in group 2 (P = 0.1). Incidence of bronchopleural fistula (BPF) was 3.7% in group 1 and 2.8% in group 2 (P = 0.55); risk of BPF was higher following right pneumonectomy (6.1%) versus left pneumonectomy (0%, P = 0.003). PCT does not significantly increase postoperative morbidity and early mortality after pneumonectomy in our experience.

Pericardial flap for bronchial stump coverage after extrapleural pneumonectomy; is it feasible?

Bronchial stump reinforcement with viable tissue after pneumonectomy is an important prophylactic measure against the development of bronchopleural fistula. We present our technique of utilizing the pericardium on the posterior wall of the left atrium as a flap to cover the bronchial stump after extrapleural pneumonectomy. From January 1999 to March 2008, we used this technique in 50 patients (29 on the right side and 21 on the left side) with no incidence of bronchopleural fistula or empyema. This technique is proved to be feasible, safe and effective; also it does not increase operative time or surgical trauma.