[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.

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.

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.

Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial.

Importance: An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. Objective: To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. Design, Setting, and Participants: Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. Interventions: Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. Main Outcomes and Measures: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute). Results: Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P < .001). Conclusions and Relevance: Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications. Trial Registration: ClinicalTrials.gov Identifier: NCT02148692.

The everlasting issue of prolonged air leaks after lobectomy for non-small cell lung cancer: A data-driven prevention planning model in the era of minimally invasive approaches.

BACKGROUND AND OBJECTIVES: Prolonged air leaks (PAL) are the most frequent complication after lobectomy for non-small cell lung cancer, even in case of minimally invasive approaches. We developed a novel score to identify high-risk patients for PAL during minimally invasive lobectomy. METHODS: A dedicated database was created. We investigated preoperative candidate features and specific intraoperative variables. Univariate and subsequent logistic regression analysis with bootstrap resampling have been used. Model performance has been assessed by reckoning the area under the receiver operating characteristics curve and the Hosmer-Lemeshow goodness of fit. RESULTS: PAL (>5 days) occurred in 72 (15.69%) patients. Five variables emerged from the model. Each one was assigned a score to provide a cumulative scoring system: forced expiratory volume in 1 second below 86% (P = 0.004, 1.5 points), body mass index <24 ( P = 0.002, 1 point), active smoking ( P = 0.001, 1.5 points), incomplete fissures ( P = 0.004, 1.5 points), and adhesions ( P = 0.0001, 1 point). The new score provided a stratification into four risk classes. CONCLUSIONS: The risk score incorporates either general or more specific variables, providing a risk stratification that could be readily applied intra- and postoperatively. Henceforth, specific technical and management measures could be properly allocated to curb PAL.

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.

Effective new membrane for preventing postthoracotomy pleural adhesion by surface water induction technology.

BACKGROUND: After thoracic surgery, adhesions between the pleura can cause substantial complications. This study investigated the effectiveness of a novel membrane utilizing surface water induction technology to prevent adhesions. METHODS: Eight beagles were divided into an experimental group (five males) and a control group (three females). The experimental group underwent thoracotomy on both the left and right sides of the chest. Both sides received the membrane, and the membrane on one side was glued to the pleura using tissue adhesive. The control group underwent thoracotomy only on the left side. Two weeks postoperatively, all dogs were sacrificed and adhesions were evaluated macroscopically and microscopically. RESULTS: Severe adhesion was seen between the parietal and visceral pleura in all control dogs, whereas the experimental group showed minor adhesion in only one dog on one side. CONCLUSIONS: Our novel anti-adhesive membrane appeared highly effective in preventing postthoracotomy pleural adhesions.

Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory.

The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.

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.

Complications of thoracentesis: incidence, risk factors, and strategies for prevention.

PURPOSE OF REVIEW: Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. RECENT FINDINGS: Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. SUMMARY: Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

The Prevention and Management of Air Leaks Following Pulmonary Resection.

Alveolar air leaks are a common problem in the daily practice of thoracic surgeons. Prolonged air leak following pulmonary resection is associated with increased morbidity, increased length of hospital stay, and increased costs. This article reviews the evidence for the various intraoperative and postoperative options to prevent and manage postoperative air leak.

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.

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.

A synthetic bioabsorbable sheet may prevent postoperative intrapleural adhesions following thoracotomy: a canine model.

OBJECTIVES: Intrapleural adhesions following thoracotomy may be associated with prolonged operating time or a higher complication rate at reoperation. The aim of this experimental study was to investigate the anti-adhesion property of a bioabsorbable sheet following thoracotomy in a canine model. METHODS: Ten adult beagle dogs underwent bilateral muscle-sparing thoracotomies with single ribs resected under general anaesthesia. A bioabsorbable sheet composed of poly-L-lactide copolymer (45 wt%) and ε-caprolactone (45 wt%) layered with polyglycolic acid (10 wt%) was sutured intrapleurally on the parietal pleura to cover the defect on the left, but not placed on the right side as a control. All the dogs were followed up with chest computed tomography until being sacrificed (6 months at the maximum). Thoracoscopic evaluations were performed at 1, 3 and 6 months for intrapleural adhesions at the thoracotomy site and absorption of the bioabsorbable sheet. The incidences of intrapleural adhesions were compared between the experimental side and the control side by the χ(2) test. Histological (macroscopic and microscopic) analyses of regenerated chest wall tissue were also performed at 1, 3 and 6 months. RESULTS: All the dogs survived uneventfully until being sacrificed without any postoperative complications or significant radiological findings. The bioabsorbable sheet prevented intrapleural adhesions in all subjects. There were statistically significant differences in the incidence of intrapleural adhesions between the experimental side and the control side at the thoracotomy incision (0 vs 80%, P = 0.0014) at 1 month, (0 vs 66.7%, P = 0.014) at 3 months and (0 vs 75%, P = 0.028) at 6 months. The bioabsorbable sheet was found residual at 1, 3 and 6 months in all subjects. Histological analyses confirmed regenerated chest wall layers with significantly more capillary vessels at 1 month (P = 0.015), but not at 3 and 6 months (P = 0.84 and 0.41, respectively), in the regenerated mucosal and submucosal layers on the experimental side. CONCLUSIONS: Our findings suggest that the bioabsorbable sheet may prevent intrapleural adhesions with parietal pleurae regenerated with more vascularization at 1 month following thoracotomy. No adverse findings were noted with the sheet.