Postpneumonectomy Bronchopleural Fistula 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.

Novel method for bronchial stump coverage for prevents postpneumonectomy bronchopleural fistula: pedicled thymopericardial fat flap

BackgroundBronchopleural fistula (BPF) is a serious complication with high mortality and morbidity that can be seen after lung resections. Although several methods have been described to prevent postoperative BPF it is still unclear which method is the best. In this study, we have used tymopericardial fat flap (TPFF) to cover the bronchial stump in patients after pneumonectomy and aim to show its feasibility and efficacy to prevent BPF.MethodsBetween January 2013 and June 2021, 187 patients with lung cancer underwent pneumonectomy at our institution. Among them, 53 patients underwent bronchial stump coverage with TPFF. In other 134 patients there wasn’t used any coverage method. Patient characteristics, preoperative status, surgical procedures, perioperative course, pathological findings, and long-term prognoses were evaluated retrospectively.ResultsPostoperative BPF was observed in 16 (%8.5) patients. It was observed that TPFF was applied in only 1 of the patients who developed BPF. A statistically significant difference was detected between TPFF-coverage with non-coverage groups in terms of postoperative BPF rates (p = 0.044). Other factors associated with the development of postoperative BPF in univariate analysis were right sided pneumonectomy, and re-operation.ConclusionBronchial stump coverage with TPFF is a feasible and effective method to prevent postpneumonectomy BPF.

The technique of stump closure has no impact on post-pneumonectomy bronchopleural fistula in the non-small cell lung cancer-a cross-sectional study.

BackgroundPneumonectomy is a high-risk radical resection procedure, with bronchopleural fistula (BPF) being its most challenging and severe complication. This study aimed to assess the surgical risk factors and the impact of the bronchial stump closure technique on the incidence of the BPF.MethodsThis is a single-center, cross-sectional study of the medical records of 455 post-pneumonectomy patients operated due to non-small cell lung cancer (NSCLC) in 2006–2017. We analyzed the following variables and their influence on the occurrence of the BPF: operation side, surgical techniques (i.e., manual suture or the stapler), stump buttressing, the extension of pneumonectomy, comorbidities, and postoperative complications.ResultsBPF occurred in 7.47% of post-pneumonectomy patients. BPF was more prevalent in right-sided pneumonectomy versus left-sided (10.98% vs. 5.32%; P=0.026). The use of a stapler or manual suture was not associated with the incidence of the BPF (7.96% vs.7.09%, P=0.72). There were no significant differences in the occurrence of BPF among bronchial stump buttressing with the parietal pleura (P=0.80), intercostal muscle flap (IMF) (P=0.46), and pericardial fat pad (P=0.88). When comparing data from 2006–2012 with those from 2013–2017, we found a steady decrease in the number of performed stump reinforcements, but this was not associated with a higher risk of BPF.ConclusionsThe method used for stump closure, additional tissue buttressing of the bronchial stump and year of the surgery had no significant impact on the occurrence of BPF. Only right-sided pneumonectomy was associated with higher BPF occurrence.

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.
 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.
 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.
 Conclusion: Omentoplasty has low complication and high success rates and can be used safely for the treatment of BPF.

Management of postpneumonectomy empyema and bronchopleural fistula

: Although the number of pneumonectomies performed worldwide is decreasing due to epidemiological changes in lung cancer, increased awareness of postoperative complications of pneumonectomy plays a major role in the proper clinical management and ultimately in the quality of life and survival rate of patients. Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. The prognosis of postpneumonectomy empyema patients mainly depends on when the complication appears and the presence or absence of a bronchopleural fistula (BPF). The majority of empyema will occur within the first 3 months after surgery. The management of postpneumonectomy empyema is a challenge to thoracic surgeons due to the number of surgical approaches available and a lack of consensus as to the best approach. It can vary from a simple rib resection and open drainage to a complete thoracoplasty. Unfortunately, after pneumonectomy, patients who develop BPF and empyema will present prolonged hospitalization and are at risk of high morbidity and mortality rates. Consequently, successful therapy might be difficult to achieve, that is why is so important to well select your strategy. Though this remains an area of controversy in the field of thoracic surgery, accurate and expedited diagnosis is critical to achieve a cure. Regardless of the technique adopted for treatment, adequate pleural drainage, definitive closure of the BPF, sterilization of the pleural cavity, and obliteration of residual space are the key factors to favorable outcomes. In this article, the authors aim to discuss in detail the management strategy based on the clinical evolution of patients with postpneumonectomy empyema and BPF.

Complications of thoracic surgery: post-pneumonectomy bronchopleural fistula

: Bronchopleural fistula (BPF) describes an abnormal connection between a bronchus (main, lobar or segmental) and the pleural cavity. BPF is a recognized complication after pneumonectomy and is associated with significant morbidity and mortality. The risk of post-pneumonectomy BPF (PP-BPF) is greater in right sided operations, male patients, residual tumor, barotrauma, previous TB and active infection. If suspected, diagnosis of BPF should be made expeditiously with computed tomography scanning and bronchoscopy. The management depends on the timing of presentation, the size of the fistula and the clinical status of the patient. All patients require drainage of the infected pleural space and intravenous antibiotics. In early presentations, re-do thoracotomy followed by stump closure and reinforcement with a pedicled muscle flap is recommended. If the fistula is small (<5 mm) or the patient is not fit enough for major surgery, bronchoscopic repair using fibrin glue application, stents or closure devices can be attempted. Minimally invasive techniques can also be used as a temporizing measure while optimizing a patient for a major intervention. There are multiple case reports describing novel bronchoscopic techniques for management of BPF. The risk of BPF should be reduced in high-risk patient groups by implementing bronchial stump coverage (BSC) at the time of pneumonectomy. Overall, the literature is limited by the relative rarity of the problem. Much of the literature is based on retrospective studies and case series which leads to inherent biases preventing true comparative studies in operative techniques and outcomes. Meta-analysis of case reports and new randomized controlled trials may give more evidence to support the current findings. While some simple principles should be followed, management of BPF needs to be individualized to each patient’s clinical picture.

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.

Commentary: An innovative, minimally-invasive approach to post-pneumonectomy bronchopleural fistula

Commentary: An innovative, minimally-invasive approach to post-pneumonectomy bronchopleural fistula

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

Transsternal Transpericardial Bronchopleural Fistula Repair

Postpneumonectomy bronchopleural fistula with empyema is a rare complication with devastating consequences that can occur at any time after pneumonectomy. Over the years multiple methods have been developed to treat this morbid condition. The most frequently utilized procedure to manage a bronchopleural fistula is a repeat thoracotomy with fistula repair and muscular flap coverage. However, this necessitates operating in densely fibrotic tissue planes, does not allow thorough dissection of the fistula, and has a high rate of recurrence. A less utilized technique, the transsternal transpericardial approach, allows the surgeon not only to enter the chest anteriorly and dissect in fresh tissue planes but also affords excellent exposure of the carina and fistula. This is an important approach with which all thoracic surgeons should be familiar as it offers an excellent option for large and recalcitrant postpneumonectomy bronchopleural fistulas.

EP1.17-23 Omentopexy for Post-Pneumonectomy Bronchopleural Fistula in Patients with Non-Small Cell Lung Cancer After Salvage Radiotherapy

Preoperative chemotherapy or radiotherapy could affect bronchial mucosa blood flow and also the normal healing process of bronchial stump after surgical resection. Otherwise, bronchopleural fistula (BPF) is the worst and time consuming complication in lung cancer surgery. Pneumonectomy is reported as a high risk surgery of BPF. Here, we report our successful treatment experience of BPF using omentum after salvage radiotherapy in NSCLC patient. Retrospective medical chart review A sixty-four years old male patient who had a history of chronic obstructive pulmonary disease diagnosed as squamous carcinoma in left upper lobe, clinical stage of T2aN1M0. Because interlobar artery invasion was suspicious, the patient was treated with radical radiotherapy. After 6600cGy of radiotherapy, the lesion showed marked response. Thus we decided to perform curative surgical resection, pneumonectomy. The patient had discharged in postoperative day 11 and the pathologic report was ypT1aN0M0. But after 1 week from discharge, the patient readmitted and complained of dyspnea and profound sputum. In bronchoscopy, fistula was seen. We performed the second operation. Due to hard fibrosis, direct closure of bronchial stump was not possible. Thus, we covered the stump site with omental flap in multilayers. The patient discharged uneventfully and now in disease free status almost after 2 years from initial operation.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Neoadjuvant radiation therapy and pneumonectomy are risk factors for post-operative BPF. Direct closure with buttressing biocompatible flap is the treatment of choice. But if direct closure is not possible, double-layered omentopexy could be an alternative treatment strategy.

Postpneumonectomy bronchopleural fistula: analysis of risk factors and the role of bronchial stump coverage.

Bronchopleural fistula (BPF) is a potentially fatal complication of pneumonectomy. We analyze its occurrence rate, risk factors, and the methods used for its prevention. We reviewed the medical records of patients who underwent pneumonectomy at our Institution between January, 1990 and March, 2016. The risk factors for postoperative BPF were analyzed by univariate analysis and multiple logistic regression. Over the study period, 511 patients underwent pneumonectomy for non-small cell lung cancer (NSCLC) and had the bronchus closed by manual suturing. BPF developed in 23 patients (4.5%). Multiple logistic regression identified no coverage of the bronchial stump, right-sided pneumonectomy, residual tumor in the bronchial stump, postoperative ventilatory support, and completion pneumonectomy, as independent risk factors for BPF. The cumulative rate of BPF decreased significantly over time from 18% between 1990 and 1995 to 1% between 2011 and 2016 (p < 0.001). Concurrently, the data of several patients showed a significant positive trend over time, including bronchial stump coverage (BSC). Several known risk factors for BPF were confirmed. The more frequent usage of tissue flaps for coverage of the bronchial stump may have contributed to the reduction in the rate of postoperative BPF over time.

Multimodal Treatment for Post-Pneumonectomy Bronchopleural Fistula Associated With Empyema

Post-pneumonectomy bronchopleural fistula associated with empyema still remains a dreaded complication in thoracic surgery. A variety of surgical and endoscopic procedures have been proposed over the years, but none of these has been suitable for all patients. Herein, we report a new multimodal approach, including the insertion of tracheobronchial conical stent, the open pleural packing, and the closure of bronchial stump with omentoplasty. This procedure was successfully applied in 11 patients with post-pneumonectomy bronchopleural fistula with empyema.

GW29-e1886 Percutaneous transcatheter closure of postpneumonectomy bronchial pleural fistula with the atrial septal occluder

Postpneumonectomy bronchopleural fistulas (BPFs) remain difficult management problems associated with considerable morbidity and mortality. Traditional therapies included primary repair or delayed closure with the creation of an Eloesser cavity and tissue flap reinforcement. We describe an less

A novel approach for the treatment of post-pneumonectomy bronchopleural fistula by using an autologous corticocancellous bone graft.

Post-pneumonectomy bronchopleural fistula (PPBPF) is a devastating complication in thoracic surgery, with reported incidences varying from 3.1% to 20% (1-3). The diversity of incidence depends on a number of factors including malignancy or benign conditions and the extent of the resection and the resection technique used (4).

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.

Emergency drain for post pneumonectomy bronchopleural fistula: a drain placement technique based on the siphon principle.

Post pneumonectomy bronchopleural fistula (BPF) is a life-threatening complication requiring pleural cavity drainage to avoid acute mediastinal shift and contralateral aspiration pneumonia. Chest drain insertion in this situation may be technically difficult because of drastic anatomical changes such as mediastinal dislocation, diaphragm elevation and, sometimes, massive subcutaneous emphysema. In addition, the most important part of the pleural cavity to be drained is the costophrenic recess that is scarcely drained by a standard chest tube with its tip aiming high and upwards. We propose a safe, simple and effective technique based on the siphon principle to drain the lowest part of the pleural cavity.

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.

Pedicled and free flaps for intrathoracic fistula management.

Intrathoracic fistulae are among the potential sequelae of radiation therapy, empyema and abscess clearance and surgical tumour resections. Interdisciplinary plastic-reconstructive flap surgery is a helpful tool for the successful treatment of intrathoracic fistulae. From February 2006 to April 2016, 13 patients (3 females and 10 males) underwent flap surgery for bronchial (n = 5), tracheal (n = 2), oesophageal (n = 2), post-pneumonectomy bronchopleural fistula (n = 2), tracheo-oesophageal (n = 1), gastrobronchial (n = 1) and oesophagobronchial (n = 1) fistulae. Patient characteristics, identified pathogenic micro-organisms, treatment and decision criteria, long-term outcome and postoperative complications were evaluated by analysing patient charts and surgical reports. The mean age of the 13 patients who underwent reconstructive surgery was 55.5 years (range: 42-66 years). The median follow-up time was 31.4 months (range: 2-96 months). American Society of Anaesthesiologists classification was II for 1 patient, III for 8 patients and IV for 4 patients. In total, 18 flaps were performed (7 latissimus dorsi pedicled flaps, 7 pectoralis major pedicled flaps, 2 rectus abdominis myocutaneous flaps, 1 free temporo-parietal fascia flap and 1 intercostal muscle flap). A second flap was indicated in 5 cases (38.5%) due to fistula recurrence; of these, 1 patient developed a bronchial fistula after successful reconstruction of a gastrobronchial fistula. Eight of the 13 patients (61.5%) were evaluated postoperatively at regular intervals for at least 1 year and showed no signs of fistula recurrence. Our study showed that plastic-reconstructive flap surgery, although associated with significant morbidity and mortality, can be a life-saving tool for intrathoracic fistula reconstruction. DRKS00010447.

Surgical approaches for bronchopleural fistula

Bronchopleural fistula (BPF) is defined as a direct communication between the bronchus and the pleural space. The low incidence of tuberculosis added to the development of technical and surgical thoracic equipment has greatly decreased its incidence. However, despite surgical refinement, postpneumonectomy BPF is still a severe postoperative complication with high rates of morbidity and mortality. Postlobectomy BPF, however, occurs in less than 1% of patients and has a much lower mortality rate. The clinical suspicion of BPF obligates an urgent and objective investigation that allows proper decision-making for the management of this highly morbid complication. Despite all medical and technical advances, BPF remains a challenge to the thoracic surgeon. The focus of this chapter is to review the surgical approaches to BPF.