Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures.

OBJECTIVE: The method used to achieve bronchial closure, especially the relative merits of sutured versus stapled closure, remains an important topic among thoracic surgeons who seek the best way to prevent postoperative bronchopleural fistula (BPF) formation. METHODS: Bronchial closure in 533 consecutive stumps in pulmonary resection from 1995 to 1997 at the National Cancer Center Hospital, Tokyo, was reviewed in terms of the incidence of troubles related to mechanical stapling (stapling failure) and to BPF formation. Fifty stumps (9%) were closed by manual suturing and 483 (91%) by mechanical stapling. For stapling, endostaplers were used for 313 stumps (65%), and other types of conventional staplers for 170 stumps (35%). RESULTS: There were 18 stapling failures (a 3.7% overall incidence, 4.8% for endostaplers, 1.8% for other types of staplers). However, of these 18 patients only one developed BPF after surgery. Seven BPFs developed postoperatively among the 533 closures (overall incidence, 1.3%): two after manual suturing (4%) and five after stapling (1%), and this difference was not statistically significant. Of seven patients with BPF, four died of BPF-related complications. CONCLUSIONS: Although bronchial closure by stapling was accompanied by failure, its incidence was acceptable and was not directly associated with the development of BPF postoperatively, as long as properly repaired. Newly developed endostaplers had similar incidence of stapling failure and BPF formation compared with other types of conventional staplers. These results suggest endostaplers can be used safely for various types of bronchial closure. The advantage of such devices could be the least chance of pollution of the operative field, simultaneous performance of stapling and division by one motion, and subsequently great saving of time.     

Videothoracoscopy and muscle flaps in the treatment of bronchial stump fistula.

The aim of the paper is to report our surgical technique applied for treatment of broncho-pleural fistula (BPF) as well as the results of the treatment. From 1992 to 1998 we performed 127 pneumonectomies for lung cancer. In 5 cases (3.9%) bronchial stump insufficiency developed postoperatively. Three patients were treated by means of videothoracoscopy (the Multifire Endo Hernia Stapler was used to clipped the fistula). Rethoracotomy with myoplasty was performed four times in 3 patients. In one patient both the methods were employed. In 2 out of 3 cases videothoracoscopic treatment was successful and the patients were discharged without signs of BPF and pleural empyema. In one case the recurrence of the fistula occurred and the stump of the bronchus was successfully covered with the pectoral musce flap 3 days later. In two cases after rethoracotomy and myoplasty (one of them was reoperated twice) the recurrence of BPF occurred and both the patients died due to cardiopulmonary failure. Despite the limited experience, we think videothoracoscopy is worth considering as a tool for treatment of BPF.     

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

Surgery Today - 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...     

Experience with thoracoscopic surgery for primary bronchial stump fistula after pneumonectomy

After a left pneumonectomy, thoracoscopic closure with fibrin glue was performed for a fistula on the bronchial stump and the postoperative state progressed favorably thereafter. In this paper, we report on this successful case.Case: A 61 year-old male, who underwent a left pneumonectomy on January 17, 1996 for pulmonary carcinoma (T 3 N 1M 0 stage III A). The bronchial stump was covered with anterior serratus muscle flap. On April 1 (the 76th postoperative day), after two courses of Carboplatin and Vindesine treatment, the patient suddenly developed a fistula on the bronchial stump. Bronchofiberscopic closure with fibrin glue was attempted, but failed to close the fistula. Thoracoscopic surgery was then performed on May 15 (the 45th day after the onset of the fistula). After the intrathoracic opening of the fistula was found with a contrast medium, fibrin glue was injected to fill up to the bronchial stump, and communication with the thoracic cavity was blocked. Owing to coverage with a myocutaneous flap, the patient’s general postoperative state remained relatively stable. Thoracoscopic surgery is useful as a treatment for some cases of bronchial stump fistula after pneumonectomy.     

The role of inflammation in bronchial stump healing.

The roles of inflammatory response and closure technique in the development of bronchopleural fistula were evaluated. Canine bronchial stumps closed with 3-0 silk and studied 14 days later were characterized by a dense inflammatory infiltrate. Stumps closed with 3-0 chromic catgut suture showed a moderate inflammatory response with disintegration of suture material. However, stumps closed with the automatic stapling device (TA-30) showed the best healing and a minimal degree of inflammation. These findings correlated well with leakage pressures. The average leakage pressure for the silk closed stumps was 139.44 mm Hg plus or minus 78.9 SD. This was significantly lower (P less than 0.02) than the average leakage pressure for staple closed stumps (251.25 mm Hg plus or minus 82.9 SD). It is concluded that the minimal amount of inflammation following staple closure will be associated with improved bronchial stump healing and a lower incidence of bronchopleural fistula.     

Bronchopleural fistula after pneumonectomy: a major challenge.

OBJECTIVE: Bronchopleural fistula (BPF) is a life-threatening complication of pneumonectomy. Its treatment still challenges the thoracic surgeon. We present our 10-year experience in the management of this entity. MATERIAL: From 1986 to 1997, 8 patients with BPF, representing 2.5% of the 315 pneumonectomies performed in the same period, were treated in our Department. All were male, aged 52-74 (mean: 62.5) years. Pneumonectomy (right: 5, left: 3) was undertaken due to lung cancer. BPF occurred within one month postoperatively. RESULTS: No difference in BPF incidence was observed comparing hand suturing and stapling of the bronchial stump. BPF was associated with empyema thoracis (ET) in 5 patients. Methods of management included prolonged chest tube drainage (n = 5), open thoracostomy (n = 3), bronchoscopical injection of fibrin sealant (n = 2), BPF closure through the previous thoracotomy with autologous tissue buttress (n = 2), transternal transpericardial closure of the BPF (n = 1). Two patients died (mortality 25%): one patient treated with chest tube drainage due to myocardial infarction, and the other undergone transternal BPF closure due to sepsis. In the rest 6 patients closure of the BPF was achieved. CONCLUSION: BPF after pneumonectomy continues to be a problem without definite solution at present. Prevention has not been achieved with the use of staples for bronchial stump closure. Small leaks may be scaled endoscopically with fibrin glue. Otherwise, early surgical closure is mandatory, especially when empyema thoracis coexists.     

全肺切除术后支气管残端瘘的原因与治疗

目的 探讨肺癌全肺切除术后支气管残端瘘的因素,并寻找其预防与治疗方法.方法 回顾性分析1987年5月至2007年5月965例因肺癌行全肺切除术患者中32例术后发生支气管残端瘘患者的临床资料.对全肺切除术后支气管残端瘘的风险因素进行分析.结果 全肺切除术后支气管残端瘘的发生率为3.3%(32/965),左侧12.5%(4/32),右侧87.5%(28/32).单因素分析显示,全肺切除术后支气管残端瘘的风险因素包括右全肺切除、术前接受放疗、延长机械通气、支气管残端长度>2 cm和血清白蛋白<30 g/L.Logistic回归证实右全肺切除、术前接受放疗和血清白蛋白<30 g/L是全肺切除术后支气管残端瘘的危险因素.对直径≤3 mm的瘘口行生物胶粘堵,治愈率为83.3%(5/6).对直径＞3 mm的瘘口行大网膜加固残端,治愈率为83.3%(5/6).结论 右全肺切除、术前接受放疗和血清白蛋白水平低于3 g/L是全肺切除术后支气管残端瘘的危险因素.对直径≤3 mm的瘘口,可应用生物胶粘堵;对直径>3 mm的瘘口,可利用转移大网膜加固残端.     

The posterior membranous flap technique for bronchial closure after pneumonectomy

Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients - 89%), small cell lung cancer (one patient - 2.2%), mixed and other types of cancer (two patients - 4.4%), and non-neoplastic etiology (one patient - 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.     

Suture closure versus stapling of bronchial stump in 304 lung cancer operations.

Suture closure of the bronchial stump was compared with staple closure after 304 operations for bronchogenic carcinoma over an 8-year period. In 154 cases (112 lobectomies and 42 pneumonectomies) the bronchial stump was closed with interrupted sutures of 000 polyester, and in 150 cases (120 lobectomies and 30 pneumonectomies) an autosuture stapler was used. The time for suture closure ranged from 5-15 minutes, whereas stapling was accomplished uniformly in c. 90 seconds. Bronchopleural fistula developed after suture closure in seven cases (4.5%), but in none after stapling closure. Stapling of the bronchial stump after lobectomy or pneumonectomy for lung cancer is safer and quicker than suture closure, and is recommended as the method of choice.     

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

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

肺切除术后支气管胸膜瘘的外科治疗

从1976年至1996年，我科对11例肺切除术后发生支气管胸膜瘘的病人进行了外科治疗。治愈10人，治愈率91％，1例经过3次手术后复发的病人死于与手术无关的晚期肺癌。治疗支气管胸膜瘘的方法很多，以胸改（局部或扩大）加胸部带蒂肌瓣胸内转移方法最有效。肩胂骨次全切除（一种扩大胸改的新术式）加肩胂下肌及冈下肌胸内转移对那些顽固性支气管胸膜瘘病人有良好的效果。作者认为治疗支气管胸膜瘘的关键是：①充分地胸腔引流及感染的控制；②有效地封闭支气管瘘口；③彻底地消除患侧胸膜残腔。     

Combined transthoracic and transtracheal closure of large bronchopleural fistulae

PURPOSE: Postoperative central bronchopleural fistulae (BPF) are difficult to close using percutaneous or endoscopic techniques. We devised an alternative method to treat BPF using a combined transthoracic and transtracheal approach with the use of a multifilamented polypropylene (Prolene) mesh patch. METHODS: Two patients with large, central BPF after thoracic surgery and lobar resection had minimally invasive BPF closure using a transtracheal approach with catheterization of the fistula and thoracoscopically guided Prolene mesh placement over the bronchial stump defect. This technique was adopted after conservative management and multiple endobronchial interventions had failed in both patients. RESULTS: One patient had closure of his BPF within one week and remains symptom-free one year after chest tube removal. The other patient had a BPF and chest tube for two years prior to our procedure. His BPF initially closed, but recannalized 2 weeks later. He subsequently had two thoracotomies and continues to suffer a BPF which remains externalized to his chest wall. CONCLUSIONS: Post-thoracotomy central BPF that is resistant to nonsurgical treatments can be closed with a combined thoracoscopic and transtracheal placement of a polypropylene patch. The success of this repair seems to depend on early intervention and aggressive sterilization of the pleural space.     

Simultaneous bronchopleural and esophagopleural fistulas after pneumonectomy

The simultaneous occurrence of bronchopleural fistula (BPF) and esophagopleural fistula (EPF) after pneumonectomy is very rare. We describe a 60-year-old man who developed empyema associated with bronchopleural fistula as a complication of a right pneumonectomy. Initial chest tube drainage and antibiotic therapy were ineffective. Five months later ingested food particles appeared in the drainage fluid. Esophagoscopy revealed an esophageal fistula of 10 mm in diameter. After nutritional support by feeding jejunostomy both BPF and EPF were repaired by subscapular muscle myoplasty and extensive thoracoplasty through a right thoracotomy. Endoscopic examination performed 1 month after surgery showed complete closure of both fistulas and 9 months after surgery the patient was eating and gaining weight. The patient's death was due to aspiration pneumonia of another origin.     

A safe and effective method for an immediate bronchopleural fistula repair

Bronchopleural fistula (BPF) is a well recognized and potentially fatal complication of major thoracic surgery and several strategies regarding its prevention and subsequent management have been described. An immediate BPF occurring intraoperatively after bronchial closure is a rare event and is usually treated by bronchial stump reamputation and/or hand-suture reinforcement by mattress suture, or myoplasty. We report a simple and successful technique, using azygous vein flaps, to repair an intraoperative BPF associated to a small bronchial dehiscence occurred after a right pneumonectomy in a 70-year-old diabetic man receiving induction chemotherapy treatment.     

Comparison of two automatic staplers for closing the bronchial stump after pulmonary resection

The incidence of complications following pulmonary resection using an automatic stapler was studied in 348 consecutive patients. A parallel-jaw stapler with two staple lines was used in group A (133 males, 101 females, mean age 66 years) between 1990 and 1995, and a hinged-jaw stapler with three staple lines in group B (70 males, 44 females, mean age 67 years) in 1995-1997. The incidence of bronchopleural fistula was 0.4% (1 patient) in group A and nil in group B. The incidence of intraoperative air leak requiring interrupted suture closure was 4.7% (11 patients) in group A and nil in group B (p < 0.05). Postoperative bronchopleural fistula did not develop in any of the cases, and there was no mortality. For management of the bronchial stump after pulmonary resection, the newer device firing three rows of staples is superior to the two-row device.     

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer.

OBJECTIVE: Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS: Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS: The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS: Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.     

Postoperative bronchial stump fistula after lobectomy: response to occlusion with polyglycolic acid mesh and fibrin glue via bronchoscopy

Bronchial stump fistula after resection of lung cancer is an extremely difficult to treat postoperative complication. Endoscopic fistula closure is a favorable alternative, potentially avoiding major surgical intervention. an 80-year-old man underwent curative resection of squamous cell carcinoma by left upper lobectomy of the lung. The patient suddenly developed massive subcutaneous emphysema on postoperative day 10. Bronchoscopy revealed a fistula about 3 mm in diameter at the lateral edge of the bronchial stump. Concentrated fibrinogen 0.5 ml (fluid A) was sprinkled on the bronchial fistula initially, and then pieces of polyglycolic acid mesh presoaked in fluid A or fluid B (thrombin) of the fibrin glue were pushed with biopsy forceps into the fistula in an alternating fashion (A→B→A→B) under endotracheal local anesthesia. Air leakage was stopped, and the patient did not develop empyema. Particularly for patients in poor general condition, our noninvasive technique seems to serve as a therapy of first choice.     

Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report.

An 80-year-old man underwent middle and lower lobectomy of the right lung to treat squamous cell carcinoma (SCC) (4 cm in diameter) originating from the right B4 bronchus. On the 4th postoperative day, a massive air leak from the thoracic drain was noted. At that time, a diagnosis of bronchial stump fistula was made on the basis of the bronchoscopic findings. Continuous thoracic drainage, aspiration of sputum via a tracheostomy and intravenous administration of antibiotics were performed immediately after the diagnosis. However, the patient's condition was complicated by aspiration pneumonia. On the 11th postoperative day, bronchoscopic procedure to close the bronchial fistula was performed via the tracheostomy. During this procedure, metallic coils were first inserted into the fistula to serve as the core for occlusion. Then, instead of directly infusing fibrin glue, several small beans-sized pieces of Surgicell cotton (Johnson & Johnson Co., Cincinnati, OH) soaked in fluid A (concentrated fibrinogen) and the same number of Surgicell cotton pieces soaked in fluid B (thrombin) were alternately inserted into the fistula, to allow closure of the bronchial fistula. After this procedure, the embolus created remained in place without being expectorated, and the aspiration pneumonia entered remission, allowing the patient to be discharged from the hospital on the 24th postoperative day. At preset, 14 months after surgery, the patient is in good condition. This technique allows simple and reliable closure of a fistula if a tracheostomy is available. It should be selected as a therapy of first choice when dealing with patients with a postoperative bronchial stump fistula in poor general condition. Patients undergoing right pneumonectomy or middle and lower lobectomy of the right lung should be considered as belonging to a high risk group for bronchial fistula and as requiring preventable measures (e.g., covering the stump with an intercostal muscle flap).     

Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy.

Postpneumonectomy bronchopleural fistula (BPF) remains a serious and often life-threatening complication. Over a seven-year period, seven cases of BPF occurred in a series of 100 consecutive pneumonectomies performed for lung carcinoma by the same surgical team. The incidence increased from 3% (1/33) prior to 1993 to 9% (6/67) thereafter. The presence of tumour within the main stem bronchus and the need for postoperative mechanical ventilation correlated significantly with the occurrence of BPF. However, it is likely that other risk factors, such as the introduction of systematic mediastinal lymph nodes dissection since 1992 and bronchial stapling since 1993, were involved. In four patients, closure of BPF was achieved by transposition of pedicled latissimus dorsi (LD) muscle flap and closed-chest irrigaiton of the pleural cavity. Patients were discharged after a median stay of 19 d; fistula recurred in one case and was successfully treated with an omental flap. No complications related to the LD division were observed. In conclusion, mediastinal lymph node dissection may increase the risk of post-pneumonectomy BPF. Systematic bronchial stapling should be used cautiously, especially if the tumour is present within the main stem bronchus. Treatment with predicted LD muscle flap or omental flap associated with closed-chest irrigation proved to be simple, time-saving and efficient.     

栓塞治疗顽固性咯血患者支气管动脉-肺动脉瘘

目的观察顽固性咯血患者的支气管动脉-肺动脉瘘(BPF)血管造影征象,探讨对不同类型BPF患者采用聚乙烯醇(PVA)颗粒和明胶海绵条行支气管动脉栓塞(BAE)的安全性及疗效。方法回顾性分析15例接受BAE治疗且存在BPF的顽固性咯血患者资料。均采用Seldinger法股动脉穿刺入路,行主动脉及支气管动脉造影,观察BPF的表现,采用医用PVA颗粒、明胶海绵条行栓塞治疗。术后严密监测并发症的发生,评价BAE术后疗效及随访咯血复发情况。结果对15例患者均采用PVA颗粒栓塞瘘口、病变区末梢供血动脉,明胶海绵条栓塞支气管动脉主干,BAE治疗成功率为100%(15/15),共成功栓塞21支病变动脉,影像学表现为瀑布型3支,枯枝型6支,斑片型12支。无异位栓塞、感染等严重并发症发生。治疗后随访1~3年,1年内3例复发,其中2例为肺癌患者,再次栓塞新病灶区后咯血停止,分别于15、17个月后死亡;另1例为肺结核患者,为痰中少量带血,经临床对症止血治疗一周后出院,未再发生咯血症状。结论支气管动脉-肺动脉瘘血管造影表现形式多样,采用PVA颗粒和明胶海绵条的栓塞均安全、有效。