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

OBJECTIVE: To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. METHODS: Patients 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. RESULTS: During 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. CONCLUSIONS: Empiric 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.

[Risk Factors, Prevention, Diagnosis, and Treatment of Bronchopleural Fistula After Lung Resection].

Postoperative bronchopleural fistula (BPF) is a rare but severe and sometimes life-threatening complication that needs immediate and proper treatment. Thoracic surgeons should strictly manage the comorbidities such as diabetes mellitus for BPF prevention. Also, coverage of the bronchial stump with pericardial fat tissue will prevent BPF, or at least prevent the turning severe of BPF. However, when BPF occurs, we must promptly determine whether to perform conservative treatment or invasive treatment such as fenestration.

Postoperative changes in a bronchial stump following covering with free fat tissue in a rat model.

OBJECTIVES: Covering the bronchial stump with free fat tissue has been used as minimally invasive prophylaxis against bronchial stump fistulas; however, postoperative changes in the bronchial stump have not been well validated. Our goal was to examine changes in the bronchial stump in response to covering with free fat tissue in a rat model. METHODS: A left pneumonectomy was performed on 16 Wistar/ST rats, 12 of which had a bronchial stump covered with free subcutaneous fat tissue. Four rats that underwent a left pneumonectomy alone were sacrificed on postoperative day 7, and the 12 rats whose bronchial stumps were additionally covered with fat tissue were sacrificed on postoperative days 7, 14 and 56. Macroscopic and histological changes and pressure resistance of the bronchial stumps due to coverage with free fat tissue were examined. RESULTS: None of the rats showed macroscopic infection or necrosis in the thoracic cavity at the time of the rethoracotomy. The normal bronchial stumps remained mostly exposed, whereas the bronchial stumps covered with fat tissue were well-coated with tissue mass. Histologically, fibrous connective tissue containing microvessels gradually formed around the bronchial stump covered with fat tissue, and some of the tissue masses still had normal fat structures 56 days postoperatively. Covering with fat tissue significantly increased the pressure resistance of the bronchial stump 7 days postoperatively and further increased with time. CONCLUSIONS: Covering the bronchial stump with free fat tissue formed fibrous connective tissue around the bronchial stump and reinforced its closure.

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

BACKGROUND: Bronchopleural 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. METHODS: Between 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. RESULTS: Postoperative 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. CONCLUSION: Bronchial stump coverage with TPFF is a feasible and effective method to prevent postpneumonectomy BPF.

Prophylactic Bronchial Stump Support With Intrathoracic Muscle Flap Transposition.

BACKGROUND: Bronchopleural fistula (BPF) is a dreaded complication of pulmonary resection. For high-risk patients, bronchial stump coverage with vascularized tissue has been recommended. The goal of this study was to report our experience with intrathoracic muscle transposition for bronchial stump coverage. METHODS: A retrospective review of all patients who underwent intrathoracic muscle flap transposition as a prophylactic measure at our institution between 1990 and 2010 was conducted. Demographics, surgical characteristics, and complication rates were abstracted and analyzed. RESULTS: A total of 160 patients were identified. The most common lung resections performed were pneumonectomy (n = 69, 43%) and lobectomy (n = 60, 38%). A total of 168 flaps were used where serratus anterior was the most common flap (n = 136, 81%), followed by intercostal (n = 14, 8%), and latissimus dorsi (n = 12, 7%). Ten patients (6%) developed BPF, and empyema occurred in 13 patients (8%). Median survival was 20 months, and operative mortality occurred in 7 patients (4%). CONCLUSIONS: Reinforcement of the bronchial closure with vascularized muscle is a viable option for potentially decreasing the incidence of BPF in high-risk patients. Further randomized studies are needed to determine the efficacy of this technique for BPF prevention.

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

BACKGROUND/AIM: The 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. METHODS: This 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. RESULTS: Out 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. CONCLUSION: The 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.

The Influence of Airway Closure Technique for Right Pneumonectomy on Wall Tension During Positive Pressure Ventilation: An Experimental Study.

Bronchopleural fistula (BPF) remains a significant source of morbidity and mortality after right pneumonectomy (RPN). Postoperative mechanical ventilation represents a primary risk factor for BPF. We undertook an experiment to determine the influence of airway diameter on suture line tension during mechanical ventilation after RPN. RPN was performed in 6 fresh human adult cadavers. After initial standard bronchial stump closure (BSC), the airway suture lines were subjected to 5 cm H2O incremental increases in airway pressures beginning at 5-40 cm H2O. To minimize airway diameter, a carinal resection was then performed with trachea to left main bronchial anastomosis and the airway suture lines subjected to similar incremental airway pressures. Wall tension (N/m) at the suture lines was measured using piezoresistive sensors at each pressure point. As delivered airway pressure increased, there was a concomitant increase in wall tension after BSC and carinal resection. At every point of incremental positive pressure, wall tension was however significantly lower after carinal resection when compared to BSC (P < 0.05). Additionally the differences in airway tension became even more significant with higher delivered airway pressure (P < 0.001). Airway diverticulum after BSC leads to significantly increased tension on the bronchial closure with positive airway pressure as compared to a closure which minimize airway diameter after RPN. This supports the role of Laplacian Law where small increases in airway diameter result in significant increases on closure site tension. Techniques which reduce airway diameter at the airway closure will more reliably reduce the incidence of BPF following RPN.

[Clinical Effect of Pedicled Pericardial Fat Flap in Prevention of Bronchial Pleural Fistula in Bronchial Sleeve Lobectomy].

BACKGROUND: Bronchial sleeve lobectomy is essential surgical approach to treat centralized lung cancer. It is the best reflected the principle of lung cancer surgery, "remove tumor completely while minimize pulmonary function loss". Bronchial pleural fistula (BPF) is not common but very severe complication of bronchial sleeve lobectomy, that is usually fatal. Present article is to explore clinical effect on prevention of bronchial pleural fistula (BPF) in bronchial sleeve lobectomy, by wrapping brachial anastomosis with pedicled pericardial fat flap. METHODS: Clinical data of 39 non-small cell lung cancer (NSCLC) patients who underwent surgical resection during January 2016 to May 2019 in Lung Cancer Center of West China Hospital, Sichuan University were collected and retrospectively analyzed. All of the patients underwent bronchial sleeve lobectomy and a brachial anastomosis wrapping with pedicled pericardial fat flap. RESULTS: All patients recovered well and were discharged within 6 d-14 d after operation. No BPF occurred, nor other severe complications, such as reoperation needing intrathoracic bleeding, several pneumonia and respiratory failure, and life threatening cardiac arrhythmia. Only one patient (1/39) had several anastomotic stenosis and consequential atelectasis of residual lung in operative side 6 months after surgery. CONCLUSIONS: Wrapping bronchial anastomosis with pedicled pericardial fat flap in bronchial lobectomy for centralized NSCLC is a simple and effective approach to prevent BPF, thus safety of the operation could be significantly improved.

Pediculated Intercostal Muscle Flaps in Bronchiactasis Resectional Surgery for Bronchial Stump Reinforcement.

OBJECTIVE: To determine the outcome of muscle flap to cover the bronchial stump in the resectional surgery for bronchiectasis for prevention of bronchopleural fistula. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Combined Military Hospitals of Quetta, Lahore, and Rawalpindi from January 2006 to August 2017. METHODOLOGY: Patients with localised bronchiectatic changes were included. Patients with carcinoma and without flap resection were excluded. Resectional surgery was performed through posterolateral thoracotomy approach, under general anesthesia with one lung ventilation. Pediculated or bipediculated intercostal muscle flap (ICM) was used to reinforce the bronchial stump. Pediculated ICM flaps were utilised for reinforcement of bronchial stump and bipediculated flaps were used over lesser. RESULTS: Three hundred and ninety-eight cases of bronchiectasis with average age of patients 38.5 ±19.8 years and male to female ratio of 2:1 were included. Bronchiectasis was unilateral in 377 cases. Tuberculous was found in 278 of the cases. Thirty-five had poor lung function tests (FEV1 <1.5%). Eighty-two patients underwent pneumonectomy, 228 patients had lobectomy and 88 patients underwent segmentectomy. Posterior-based pediculated ICM flap was used in 365 patients, and bipediculated ICM flaps in 30 cases. The most common complication was post-thoracotomy neuralgia 53. Bronchopleural fistula, despite transposition of intercostal muscle flap on bronchial stump, was present in 4 patients. CONCLUSION: Application of muscle flap over bronchial stump after resection surgery for bronchiectasis, is simple, safe and effective surgical option to avoid complication of bronchopleural fistula.

Investigation of surgical technique for bronchial stump closure after lobectomy in animal model.

OBJECTIVE: Bronchial fistulae following lung surgery are associated with high mortality. We examined the histological effects of mucosal ablation as a technique for closing bronchial stumps to prevent bronchial fistulae in an animal model. METHODS: Left lower lobectomy was performed in beagles under general anesthesia. The bronchial stumps were closed using one of the following four methods: (A) manual suturing using 3-0 absorbable sutures, (B) ablation of bronchial mucosa with electric cautery and manual sutures, (C) stapling and reinforcement with manual sutures, or (D) ablation and stapling followed by reinforcement with manual sutures. Bronchial stumps were histologically evaluated on postoperative day 14. RESULTS: No bronchial fistulae were noted in the animals during the observation period. Histologically, there were no adhesions between the bronchial mucosae at the suture and staple lesions in groups A and C. The bronchial mucosae were adherent at the ablation sites in groups B and D. Inflammatory cells, myofibroblasts, and neovascular vessels were abundant around the ablated lesions. CONCLUSIONS: Bronchial mucosal ablation may play a key role in mucosal adhesion and tight union of the bronchial stump.

Management of Postpneumonectomy Bronchopleural Fistula: From Thoracoplasty to Transsternal Closure.

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.

An Innovative Solution for Prolonged Air Leaks: The Customized Endobronchial Silicone Blocker.

BACKGROUND: Prolonged air leak (PAL) is a life-threatening condition that can present either as bronchopleural fistula, or alveolar-pleural fistula (APF). Although numerous bronchoscopic treatments are described, they are either expensive, not widely available in the developing world or have limited success. We describe our experience with a novel customized endobronchial silicone blocker (CESB) for PAL treatment. METHODS: This is a retrospective study of PAL patients who underwent CESB placement. The air leak was localized using a balloon occlusion test. The CESB was uniquely designed by molding silicone stent pieces into a conical shape, deployed with rigid bronchoscopy into the appropriate segment, and reinforced with cyanoacrylate glue to prevent migration. In patients with APF, pleurodesis was performed after leak resolution to prevent recurrence. Following this, the CESB was removed after 6 weeks. RESULTS: Forty-nine CESBs were placed in 31 patients (25 male individuals, 6 female individuals) with mean age of 49.7±19.7 years. The PALs included APF (n=16), bronchopleural fistula (n=14), and airway-mediastinal fistula (n=1). The average diameter of the CESB used was 7.9±2.9 mm. There was resolution of the PAL in 26 of 31 patients (84%). The CESB migrated in 5 patients with no adverse events. Pleurodesis was performed in 13 of 16 patients with APF, to prevent recurrence. No other significant complications were observed. CONCLUSIONS: CESBs represent a safe, effective, and innovative approach in the management of PAL. They should be considered in patients who are not surgical candidates, fail surgery, or those who have a recurrence following surgery.

[Bronchopleural Fistula;Intraoperative Prevention and Postoperative Treatment].

Postoperative bronchopleural fistula( BPF) is a life-threatening complication requiring immediate and proper treatments. Now days, the main method for closure of the bronchial stump after lung resection is mechanical stapling because of prevailing of commonly performed video-assisted thoracoscopic surgery. The frequencies of BPF seem to be decreased compared with the age of manual sutures under open thoracotomy, probably due to improvement of the stapling instruments. However, if once BPF occurs, the severity of the disease does not differ between these 2 closing methods. Thoracic surgeons should well understand the etiology, prevention, diagnosis, and treatment of the postoperative BPF.

Clinical results of bronchial stump coverage using free pericardial fat pad.

OBJECTIVES: Bronchial fistula is a severe complication after thoracic surgery. Although many methods of coverage using various autologous tissues including pedicled pericardial fat pad have been reported to be useful for the prevention of bronchial fistula, the ideal roles of these approaches and the coverage techniques yielding the best results still remain unclear. The clinical use of an autologous free fat graft has been reported in the various surgical fields including otolaryngology, orthopaedics and plastic surgery. Therefore, we have used a free pericardial fat pad (FPFP) as the material for covering the bronchial stump instead of a pedicled pericardial fat pad. METHODS: Between January 2009 and December 2013, 1134 patients with lung cancer underwent pneumonectomy or lobectomy without bronchoplasty at our institution. Among them, 46 patients underwent bronchial stump coverage using a FPFP and we investigated the clinical results obtained retrospectively. RESULTS: Bronchial fistula occurred in 5 patients during the study period. Although we performed bronchial stump coverage mainly in patients with several risk factors for bronchial fistula, no bronchial fistula developed in this group. To investigate the viability of the FPFP, we examined the fat tissue around the bronchial stump demonstrated by chest computed tomography retrospectively. Although fat tissue at the bronchial stump gradually decreased in size, it remained evident for 5 months and was identified in almost half of the patients even at 1 year after surgery. CONCLUSIONS: No bronchial fistula developed in the FPFP group. Although the FPFP is a free flap, it remains viable for many months after surgery and may contribute to good wound healing of the bronchial stump by offering a wet environment. A pericardial fat pad is easy to make, can be used anywhere in the thoracic cavity and may be useful for bronchial stump reinforcement.

Is the Isolated Pericardial Fat Pad Sufficient to Cover the Bronchial Stump and Separate the Pulmonary Artery in Order to Prevent Bronchopleural Fistula in Patients with Lung Cancer?

BACKGROUND: The development of a bronchopleural fistula (BPF) is the most serious postoperative complication of thoracic surgery. All surgical techniques that have been reported as preventive measures against BPF have disadvantages. PATIENTS AND METHODS: We herein introduce a new technique (Yatsuhashi method) for covering the bronchial stump after right lower lobectomy using isolated pericardial fat tissue (PFT). Between 2012 and 2015, 878 consecutive patients with lung disease underwent surgery at our Institution. Among these patients, 26 underwent right lower lobectomy. Their clinical records were retrospectively reviewed to identify the presence of residual fat, in patients in whom the traditional pedicle method was applied and in those in whom an isolated PFT method was applied. The data on the characteristics, surgical details, and perioperative outcomes were analyzed. RESULTS: There were no cases of BPF and the 90-day mortality rate was 0%. The mean period of time from the day of surgery until the computed tomographic examination was 207 days. There were no significant differences in the age, gender, clinical stage, pathological stage, the presence of comorbidities or complications, the duration until computed tomography, nor the presence of residual fat between the patients in whom the isolated PFT (n=17) and the standard pedicle (n=9) methods were applied. Furthermore, no postoperative complications due to the use of isolated PFT itself were observed in the patients who were treated using this method. The existence of residual isolated PFT was also confirmed in five out of six cases who underwent surgical treatment with the novel Yatsuhashi method. CONCLUSION: The simple technique using PFT for covering the bronchial stump after right lower lobectomy was satisfactorily effective and was not associated with any complications.

[Tracheal injuries, fistulae from bronchial stump and bronchial anastomoses and recurrent laryngeal nerve paralysis : management of complications in thoracic surgery]. / Tracheaverletzungen, Insuffizienz von Bronchusstumpf/-anastomose und Rekurrensparese : Management der Komplikationen in der Thoraxchirurgie.

BACKGROUND: Complications cannot always be avoided and their treatment is an integral component of a high quality medical treatment. Complications of the central airways are rare but necessitate supportive treatment by an experienced thoracic surgeon. OBJECTIVE: The reader should become acquainted with measures to prevent complications, to recognize and treat complications early and should understand the necessity for an interdisciplinary approach. MATERIAL AND METHODS: A selective literature research was supplemented by personal experiences and complemented with prospectively collected photographs. RESULTS: There are risk constellations for the appearance of all the mentioned complications which the surgeon needs to know in order to be able to take measures for early detection of complications. Iatrogenic tracheal injuries and bronchial stump fistulae are rare (< 5 %) whereas recurrent laryngeal nerve palsy after left-sided pneumonectomy occurs in up to 30 % of cases. DISCUSSION: After the occurrence of complications at the latest, it is very important to include experienced thoracic surgeons and other specialists when necessary to protect the patient from further damage.

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.

Use of previously divided latissimus dorsi muscle for bronchopleural fistula.

Management of postpneumonectomy bronchopleural fistula remains a major challenge for thoracic surgeons. Successful closure of a postpneumonectomy bronchopleural fistula was performed in a 60-year-old man, using a flap made by a combination of serratus anterior and latissimus dorsi muscle which had been divided during the pneumonectomy operation. The flap was prepared on the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle.