Postoperative pulmonary function of patients with lung cancer and interstitial lung abnormalities.

OBJECTIVE: We investigated the impact of radiological interstitial lung abnormalities on the postoperative pulmonary functions of patients with non-small cell lung cancer. METHODS: A total of 1191 patients with clinical stage IA non-small cell lung cancer who underwent lung resections and pulmonary function tests ≥ 6 months postoperatively were retrospectively reviewed. Postoperative pulmonary function reduction rates were compared between patients with and without interstitial lung abnormalities and according to the radiological interstitial lung abnormality classifications. Surgical procedures were divided into wedge resection, 1-2 segment resection, and 3-5 segment resection groups. RESULTS: No significant differences in postoperative pulmonary function reduction rates 6 months after wedge resection were observed between the interstitial lung abnormality [n = 202] and non-interstitial lung abnormality groups [n = 989] [vital capacity [VC]: 6.82% vs. 5.00%; forced expiratory volume in 1 s [FEV1]: 7.05% vs. 7.14%]. After anatomical resection, these values were significantly lower in the interstitial lung abnormality group than in the non-interstitial lung abnormality group [VC: 1-2 segments, 12.50% vs. 9.93%; 3-5 segments, 17.42% vs. 14.23%; FEV1: 1-2 segments: 13.36% vs. 10.27%; 3-5 segments: 17.36% vs. 14.39%]. No significant differences in postoperative pulmonary function reduction rates according to the radiological interstitial lung abnormality classifications were observed. CONCLUSIONS: The presence of interstitial lung abnormalities had a minimal effect on postoperative pulmonary functions after wedge resections; however, pulmonary functions significantly worsened after segmentectomy or lobectomy, regardless of the radiological interstitial lung abnormality classification in early-stage non-small cell lung cancer.

Lessons from short chest drain management for primary spontaneous pneumothorax.

OBJECTIVES: Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain. METHODS: The current study included patients aged < 30 years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10 cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups. RESULTS: Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003). CONCLUSION: In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Clinical Significance of Preserving Pulmonary Function After Lung Resection in Early-Stage Non-Small-Cell Lung Cancer.

INTRODUCTION: To determine the association between changes in pulmonary function before and after surgery, and the subsequent prognosis, of patients with early-stage non-small-cell lung cancer (NSCLC). METHODS: A total of 485 patients who underwent lobectomy or segmentectomy for NSCLC with whole tumor size ≤2 cm and clinical stage IA at 2 institutions were retrospectively reviewed. The relationship between the postoperative reduction rate in vital capacity (VC), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) and overall survival (OS) was investigated. OS determined the cut-off value of the reduction rate, according to the reduction rate of every 10% in pulmonary function. RESULTS: Multivariable Cox regression analysis showed that a reduction rate in VC at 12 months postoperatively was an independent prognostic factor for OS (hazard ratio, 1.05; 95% confidence interval [CI], 1.02-1.07; P < .001) but those in FVC and FEV1 were not. OS was classified into good and poor with 20% reduction rate in VC. OS and recurrence-free survival (RFS) in a higher than 20% reduction rate in VC were worse than those in ≤20% reduction rate in VC (5 year-OS; 82.0% vs. 93.4%; P = .0004. Five year-RFS; 80.3% vs. 89.8%; P = .0018, respectively). Multivariable logistic analysis showed that lobectomy was a risk factor for the higher than 20% reduction rate in VC (odds ratio, 1.61; 95% CI, 1.01-2.56; P = .045). CONCLUSIONS: Postoperative decrease in VC was significantly associated with the prognosis. Preserving pulmonary function is important for survival of patients with early-stage NSCLC.

Utility of 4 K three-dimensional endoscopic system in performing video-assisted thoracoscopic surgery lobectomy: initial results of the first year after installation.

OBJECTIVES: With the evolution of technology in the field of thoracoscopy, three-dimensional (3D) endoscopic systems with 4 K resolution have recently come into use. This study aimed to determine perioperative outcomes of video-assisted thoracoscopic surgery (VATS) lobectomy performed a year after the 4 K three-dimensional (3D) endoscopic system installation and compare them with those of the high-definition (HD) 3D endoscopic system. METHODS: We included patients who underwent complete VATS (cVATS) lobectomy for primary lung cancer using an HD3D endoscopic system (HD3D group, June 2015-September 2021, n = 251) or 4K3D endoscopic system (4K3D group, October 2021-September 2022, n = 47). The perioperative outcomes were compared between the two groups. RESULTS: The operation time was significantly shorter in the 4K3D group (mean, 189.5 min) than in the HD3D group (208.5 min; p = 0.021), and the 4K3D group did not require conversion to thoracotomy or transfusion. The 4K3D group had less blood loss volume (4K3D group: mean, 24.0 mL vs. HD3D group: 43.3 mL; p = 0.105) and shorter chest drainage duration (4K3D group: mean, 2.3 days vs. HD3D group: 3.1 days; p = 0.115) and hospitalization period (4K3D group: mean, 7.9 days vs. HD3D group:10.0 days; p = 0.226) than the HD3D group, with no significant difference. No difference was observed in the incidence of ≥ Grade IIIa complications (p = 0.634). CONCLUSION: The 4K3D endoscopic system significantly shortened the duration of cVATS lobectomy. It is useful for lung resection and may replace other endoscopy systems.

Significance of the Goddard Score in Predicting Complications Related to Air Leak After Lobectomy.

BACKGROUND: Postoperative air leakage is a frequent complication after lung resection, and emphysema is a risk factor. However, no study has investigated the relationship between emphysema severity and postoperative complications related to air leak by the Goddard score (GS), a visual evaluation method of radiologic emphysema using computed tomography. METHODS: This study included patients who underwent lobectomy for non-small cell lung cancer between April 2009 and March 2022. The utility of GS in predicting complications related to air leak (air leak prolonged for ≥5 days, pleurodesis, and reoperation for air leak) was investigated by receiver operating characteristic curve analysis and multivariable analysis with a logistic regression model. RESULTS: This study included 477 patients. The GS was a significant predictor of complications related to air leak (area under the curve, 0.696; P < .001). Based on the receiver operating characteristic curve analysis, GS of 6 points was used as the cutoff point for multivariable analysis. In the multivariable analysis, GS of ≥6 points was a significant predictor of complications related to air leak (odds ratio, 2.719; P = .007). In the subgroup analysis of patients with emphysema, GS of ≥6 points was a significant predictor of complications related to air leak (P = .014). CONCLUSIONS: The GS was useful in predicting complications related to air leak. Patients with radiologic findings of emphysema with GS of ≥6 points should be recognized as a high-risk group for complications related to air leak.

Successful conservative treatment for massive tracheal necrosis after lung segmentectomy.

BACKGROUND: Tracheal necrosis, which is rare because the trachea has rich in blood supply, can be a serious condition. Herein, we report the case of extensive tracheal necrosis that developed after right apical segmentectomy for a metastatic lung tumor of esophageal cancer. CASE PRESENTATION: A 74-year-old man who had undergone thoracoscopic subtotal esophagectomy and gastric tube reconstruction via the posterior sternal route for esophageal adenocarcinoma 2 years previously was referred to our department with an enlarging nodal lesion in the right upper lung lobe. Computed tomography revealed a 30-mm tumor in the right apical segment with no lymph node enhancement, suggesting primary lung cancer or a metastatic lung tumor. The patient underwent right apical segmentectomy. The upper lobe was adherent to the chest wall and mediastinal fat from the apex of the lung to the dorsal side, with particularly strong adhesion at the esophagectomy site. After dissecting the adhesions, right apical segmentectomy was performed via complete video-assisted thoracic surgery. The patient was discharged on the 9th day after surgery without any complications. Pathologic findings revealed a metastatic lung tumor originating from the patient's esophageal cancer. On the 26th day after surgery, the patient returned with dyspnea and increased sputum. Computed tomography images revealed that the posterior wall of the trachea was missing an area of 16 × 42 mm and was connected to the dead space after the right apical segmentectomy, with no effusion. We diagnosed extensive tracheal necrosis. Considering that the patient's status was very well despite the extensive tracheal necrosis, we chose conservative treatment. After receiving 12 days of intravenous antibiotic treatment, his symptoms improved, and he was discharged on day 26 after admission. CONCLUSIONS: Right upper lung lobe resection after esophagectomy has a risk of tracheal necrosis. Conservative treatment is one approach to manage massive tracheal necrosis in patients with stable respiratory conditions.

Pleural plaque identification in computed tomography and intraoperative thoracic findings: Correspondence and prognosis comparison in patients with resection of non-small cell lung cancer.

BACKGROUND: We previously reported that intraoperative findings of pleural plaques were worse prognostic factors of resected non-small cell lung cancer (NSCLC). However, differences in the presence of pleural plaques detected either intraoperatively or by CT findings have not been addressed. METHOD: We included 121 patients who underwent resection for NSCLC with intraoperatively detected pleural plaques. We investigated preoperative CT findings and compared the prognosis between patients with or without evidence of pleural plaque on CT. RESULTS: Only 43% of patients with pleural plaques on intrathoracic findings had pleural plaques detected on preoperative CT. There were no differences in prognosis between patients with or without pleural plaque evidences on preoperative CT. CONCLUSION: The rate of detection of pleural plaques on preoperative CT is low even if they are present intraoperatively, and patients with intraoperative findings of pleural plaques have equally poor prognosis regardless of their evidences on preoperative CT.

The mitigating effect of exogenous carbon monoxide on chronic allograft rejection and fibrosis post-lung transplantation.

BACKGROUND: Small airway inflammation and fibrosis or bronchiolitis obliterans (BO) is the predominant presentation of chronic lung allograft dysfunction (CLAD) post-lung transplantation. Carbon monoxide (CO) is a critical endogenous signaling transducer with known anti-inflammatory and anti-fibrotic effects but its therapeutic potential in CLAD remains to be fully elucidated. METHODS: Here we investigate the effect of inhaled CO in modulating chronic lung allograft rejection pathology in a murine orthotopic lung transplant model of BO (B6D2F1/J→DBA/2J). Additionally, the effects of CO on the activated phenotype of mesenchymal cells isolated from human lung transplant recipients with CLAD were studied. RESULTS: Murine lung allografts treated with CO (250 ppm × 30 minutes twice daily from days 7 to 40 post-transplantation) demonstrated decreased immune cell infiltration, fibrosis, and airway obliteration by flow cytometry, trichrome staining, and morphometric analysis, respectively. Decreased total collagen, with levels comparable to isografts, was noted in CO-treated allografts by quantitative hydroxyproline assay. In vitro, CO (250 ppm × 16h) was effective in reversing the fibrotic phenotype of human CLAD mesenchymal cells with decreased collagen I and ß-catenin expression as well as an inhibitory effect on ERK1/2 MAPK, and mTORC1/2 signaling. Sildenafil, a phosphodiesterase 5 inhibitor, partially mimicked the effects of CO on CLAD mesenchymal cells and was partially effective in decreasing collagen deposition in murine allografts, suggesting the contribution of cGMP-dependent and -independent mechanisms in mediating the effect of CO. CONCLUSION: These results suggest a potential role for CO in alleviating allograft fibrosis and mitigating chronic rejection pathology post-lung transplant.

Risk factors for long-term decline in post-operative pulmonary function after lung resection.

OBJECTIVES: The study aimed to examine the risk factors for long-term decline in pulmonary function after anatomical resection for lung cancer and the effects of the decrease on survival. METHODS: We retrospectively examined 489 patients who underwent anatomical resection for lung cancer between 2010 and 2020. Pulmonary function tests were performed preoperatively and at 1, 3, 6 and 12 months after surgery. The lower interquartile medians of the reduction rates of forced expiratory volume in 1 s and vital capacity at 12 months after surgery were taken as the cut-off values of risk factors for the decrease in post-operative pulmonary function. RESULTS: Forced expiratory volume in 1 s and vital capacity decreased the most in the first month after surgery and then gradually recovered. Vital capacity continued to increase even after 6 months post-surgery, whereas forced expiratory volume in 1 s stabilized. Multivariable logistic analysis showed that the number of resected segments (odds ratio, 2.09; 95% confidence interval, 1.12-3.89; P = 0.019) was a risk factor for the decrease in forced expiratory volume in 1 s at 12 months, and the numbers of resected segments (odds ratio, 1.36; 95% confidence interval, 1.13-1.63; P < 0.001) and post-operative complications (odds ratio, 2.32; 95% confidence interval, 1.01-5.35; P = 0.047) were independent risk factors for decrease in vital capacity. Multivariate cox regression analysis showed that the decrease in vital capacity at 12 months was significantly associated with overall survival (hazard ratio, 2.02; 95% confidence interval, 1.24-3.67; P = 0.004). CONCLUSIONS: Long-term decrease in vital capacity, which was influenced by the number of resected segments and post-operative complications, adversely affected survival.

Histopathology and Cytology of Pulmonary Myoepithelial Neoplasms: 2 Cases.

Myoepithelial neoplasms (MNs) of the lung are extremely rare tumors. Approximately 40 cases of pulmonary MNs have been reported to date. Herein, we report extremely rare cases of different types of pulmonary MN, including cytological features. Case 1 is an 18-year-old female, and case 2 is a 73-year-old female patient. They presented to our hospital with nodules of the lung. Histological examination revealed tumor cells with round to oval nuclei and acidophilic cytoplasm that formed nests or fascicles with mild hyalinized stroma in case 1 and tumors containing the bi-phasic components of a nest-like and fascicle pattern with pleomorphism in case 2. Immunohistochemically, these tumors were positive for cytokeratin (CK) AE1/AE3, CK5/6, vimentin, calponin, and EMA, and focal positive for S-100a protein and alpha smooth muscle actin. The pathological diagnoses in cases 1 and 2 were myoepithelioma and myoepithelial carcinoma, respectively. In conclusion, we encountered two cases of extremely rare MNs that occurred in the lung. This disease can be diagnosed by collecting appropriate cytological and histological findings and should be listed as a differential diagnosis.

Classification based on skeletal muscle mass and the severity of lung emphysema impacts on clinical outcomes after anatomical resection for lung cancer.

OBJECTIVES: Both sarcopenia and lung emphysema are prognostic factors in lung cancer and can be easily assessed using the psoas muscle index and Goddard score, respectively. We investigated the clinical significance of the classification based on psoas muscle index and Goddard score in non-small cell lung cancer. METHODS: A total of 303 consecutive patients who underwent anatomical resection for non-small cell lung cancer were retrospectively analyzed. The psoas muscle at the level of the third lumbar vertebrae and Goddard score were measured on preoperative computed tomography. The psoas muscle was adjusted by height as the psoas muscle index (cm2/m2). We divided patients into three groups: low-, middle- and high-risk, using cut-off values of psoas muscle index < 6.36 cm2/m2 for males and 3.92 cm2/m2 for females and Goddard score higher than 7. The predictors of postoperative complications and prognosis were examined. RESULTS: High-, middle- and low-risk were present in 30 (10%), 164 (54%) and 109 (36%) patients, respectively. High risk was significantly associated with male sex, low pulmonary function, more comorbidities and increased postoperative complications. High-risk patients showed poorer overall survival than middle- and low-risk patients (P < 0.001). Multivariable analysis revealed that high risk was an independent risk factor for postoperative complications and unfavorable prognostic factors (P = 0.011, P = 0.014, respectively). CONCLUSIONS: Classification based on psoas muscle index and Goddard score is significantly associated with short- and long-term outcomes in patients with lung cancer. This method can be easily assessed for patients and may help select patients for nutritional support and rehabilitation before surgery.

Prognosis of resected non-small cell lung cancer with pleural plaques on intrathoracic findings.

BACKGROUND: The prognosis of patients with lung cancer who demonstrate pleural plaques intraoperatively, which may be associated with exposure to asbestos, is unclear. Here, we compared the clinicopathological characteristics and prognosis of these patients to those of patients without pleural plaques. METHODS: We included patients who underwent curative-intent resection for non-small cell lung cancer. We retrospectively investigated the relationship of intrathoracic findings of pleural plaques with clinicopathological features and prognosis. RESULTS: Pleural plaques were found in 121/701 patients (17.3%) during surgery. The incidence of squamous cell carcinoma (P < 0.001) and the pathological stage (P = 0.021) were higher in patients with pleural plaques. Overall survival was significantly worse in patients with pleural plaques (5-year rate; 64.5% vs. 79.3%; P < 0.001), and the same finding was noted in clinical stage I patients (5-year rate; 64.8% vs. 83.4%; P < 0.001). In multivariable analysis, the presence of pleural plaques was a significant predictor of overall survival in patients with clinical stage I (hazard ratio, 1.643; P = 0.036). In the analysis among patients with emphysema more severe than Goddard score 5 points or interstitial pneumonia, overall survival was significantly worse in those with pleural plaques than in those without pleural plaques (5-year rate; 66.3% vs. 49.5%; P < 0.001). CONCLUSIONS: Patients with non-small cell lung cancer who underwent resection and demonstrated pleural plaques intraoperatively had a significantly worse prognosis. It is important to recognize the presence of pleural plaques intraoperatively, and our findings will be useful in determining the treatment and follow-up strategy for such patients with lung cancer and pleural plaques on intrathoracic examination.

Thrombocytopaenia successfully treated by a multilocular thymic cyst resection.

The multilocular thymic cyst (MTC) is a rare, acquired disease caused by inflammatory changes in the thymus, and is associated with autoimmune diseases. We report a case of MTC with thrombocytopaenia, which improved following surgical resection. A 45-year-old man developed thrombocytopaenia with an anterior mediastinal tumour. Thrombocytopaenia due to an autoimmune mechanism, associated with thymoma or thymus-related disease, was suspected. Pathologic analysis following thoracoscopic thymectomy confirmed MTC. The platelet level recovered postoperatively. Our findings suggested a relationship between the acquired formation of MTC and the development of autoimmune antibodies. However, further investigation is needed to obtain more information.

Novel microwave surgical instrument for use in various lung resection situations.

A novel surgical energy device with high sealing ability using microwave technology has been developed. This novel microwave surgical instrument (MSI) is capable of sealing and dissecting a vessel ≤ 5 mm in diameter. The high sealing ability of the MSI enables fine dissection of the lung parenchyma by a scissor-type blade. This device is particularly useful in situations wherein the use of an automatic suturing instrument is difficult. Here, we describe the dissection of the lung parenchyma using this device in three patients (cases 1-3). This device was used for wedge resection of a tumor located close to the pulmonary hilum, for subsegmentectomy, and for dividing incomplete interlobar fissure (cases 1-3, respectively). In all the cases, the postoperative course was uneventful. This MSI is effective for resection of the lung parenchyma, allowing fine tissue dissection and excellent tissue sealing. This technique could assist surgeons in various lung resection cases.

[Rapid Growing Anterior Mediastinal Leiomyosarcoma with Pericardial Infiltration:Report of a Case].

Primary mediastinal leiomyosarcoma is extremely rare, and few reports in the literature have described the clinical features of this malignancy. We report a case of a small anterior mediastinal leiomyosarcoma that showed rapid growth within a short period. An 85-year-old woman showed a small anterior mediastinal tumor on chest computed tomography (CT), three months prior to presentation. Contrast-enhanced chest CT revealed rapid tumor growth, and positron emission tomography/CT revealed significant 18-fluorodeoxyglucose uptake, suggestive of malignancy. Thoracoscopic tumor resection was performed via the left thoracic approach. In addition to the tumor and surrounding anterior mediastinal tissue, we resected an area of pericardial infiltration. The tumor was diagnosed as a primary mediastinal leiomyosarcoma based on histopathological and immunohistochemical findings.

Systemic Inflammatory Score Predicts Response and Prognosis in Patients With Lung Cancer Treated With Immunotherapy.

AIM: This study aimed to investigate useful prognostic factors of immunotherapy in patients with lung cancer. PATIENTS AND METHODS: We retrospectively observed 73 patients who underwent immunotherapy (nivolumab, pembrolizumab, and atezolizumab) for lung cancer. The systemic inflammatory score (SIS) was calculated as the sum of the following factors scored one point each: Hemoglobin <12.5 g/dl and serum albumin <3.6 g/dl, resulting in scores of 0-2. We examined the correlation between the SIS and initial tumor response and progression-free and overall survival with other existing markers, namely tumor programmed death-ligand 1 (PD-L1) expression level; neutrophil-to-lymphocyte ratio (NLR); modified Glasgow prognostic score; and prognostic nutritional index, etc. Results: SIS ≤1 was significantly associated with better initial tumor response. In multivariate analysis, PD-L1 expression ≥50% (p=0.010), SIS ≤1 (p=0.028) and NLR <5.6 (p=0.047) were significantly associated with longer progression-free survival, and SIS ≤1 (p=0.030) and NLR <5.6 (p=0.037) were associated with longer overall survival. CONCLUSION: SIS is a useful marker of the efficacy of immunotherapy that can be obtained via routine blood tests.

A survived case of penetrating neck injury with intrathoracic organ damage.

BACKGROUND: Thoracic surgeons rarely encounter stab wounds with injury to the intrathoracic organs. However, such sudden and urgent situations could arise; therefore, experiences in managing such cases are invaluable. CASE PRESENTATION: An 84-year-old woman with depression who had a stab injury in the neck caused by a broad-bladed kitchen knife was brought to our facility by ambulance. She was stable in the emergency room; however, a computed tomography scan revealed that the blade had penetrated the right thoracic cavity. A right hemopneumothorax was seen. Considering the possibility of injury to the major vessels, a median sternotomy was performed. During the dissection around the blade, the patient started bleeding profusely, which required repair of an injury to the right internal jugular vein. The blade tip had penetrated the dorsal right upper lung lobe; however, it did not reach the hilum, and the knife was carefully removed. The damaged area of the lung was removed by wedge resection. CONCLUSION: Patients with deep stab wounds from knives are often hemodynamically stable because the blade acts as tamponade and prevents hemorrhage. Therefore, a surgical approach that allows for good visualization should be considered for the extraction of the blade.

Anterior Mediastinal Leiomyosarcoma: A Case Report and Literature Review.

Primary mediastinal sarcomas are extremely rare. Additionally, mediastinal leiomyosarcomas account for approximately 9% of mediastinal sarcoma cases. Until date, only few cases of anterior mediastinal leiomyosarcomas have been reported. Herein, we report a case of an 85-year-old female with an anterior mediastinal mass of 15 mm. Histological examination revealed spindle tumor cells showing a fascicular growth pattern. Immunohistochemically, the tumor cells were focal positive for desmin, calponin, and α-smooth muscle actin. The pathological diagnosis was leiomyosarcoma. In conclusion, we encountered a case of a very rare leiomyosarcoma that occurred in the anterior mediastinum, and our report may contribute to the understanding of this disease.

Lung segmentectomy with novel microwave surgical instrument (Acrosurg. Revo).

A novel model of a microwave surgical instrument (Acrosurg. Revo) which is an energy device using microwave technology and 2450 MHz microwave has recently been developed for endoscopic surgery. Herein, we describe the technique of pulmonary segmentectomy with a novel device.

Negative pressure wound therapy for broncho-pleural fistula with collapsed lung.

We present a case of the broncho-pleural fistula with a collapsed lung that was developed 2 weeks after right lower lobectomy. The patient urgently underwent open-window thoracostomy. However, the residual lung remained collapsed. To expand the lung and close the broncho-pleural fistula, negative pressure wound therapy was initiated 20 days after the procedure. The lung expanded within a few days, and the residual thoracic cavity gradually contracted. Subsequently, 2.5 months later, the remaining thoracic cavity was successfully closed using omentoplasty. No recurrence of the broncho-pleural fistula was observed for 1 year. If the lung could be inflated to reduce dead space in the thoracic cavity, broncho-pleural fistula with collapsed lung may be treated with bronchial stump coverage and negative pressure wound therapy.