Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

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.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BACKGROUND

Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.

CASE PRESENTATION

This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.

CONCLUSIONS

After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Clinical impact of vaping on cardiopulmonary function and lung cancer development: an update

The word 'vaping' is used to define the usage of electronic cigarettes or other instruments to inhale a wide variety of heated and aerosolized substances. Although proposed as a less dangerous and oncogenic alternative than standard nicotine products, e-cigarettes and vaping devices are quite far from being considered benign. In fact, although vaping devices do not generate carcinogenic agents as polycyclic aromatic hydrocarbons produced by the combustion of standard cigarettes and their liquids do not present tobacco-related carcinogens like nitrosamines, there is nowadays clear evidence that they produce dangerous products during their use. Several different molecular mechanisms have been proposed for the oncogenic impact of vaping fluids - by means of their direct chemical action or derivative products generated by pyrolysis and combustion ranging from epithelial-mesenchymal transition, redox stress and mitochondrial toxicity to DNA breaks and fragmentation. In this review we focus on vaping devices, their potential impact on lung carcinogenesis, vaping-associated lung injury and other clinical implications on cardiovascular, cerebrovascular and respiratory diseases, as well as on the psychological implication of e-cigarettes both on heavy smokers trying to quit smoking and on younger non-smokers approaching vaping devices because they are considered as a less dangerous alternative to tobacco cigarettes.

Prevalence and treatment outcome of bronchopleural fistula: a multi-center study in Ethiopia

PURPOSE

The study aimed to assess the magnitude, risk factors, and management outcome of patients with a bronchopleural fistula at multiple centres in Ethiopia.

METHOD AND MATERIALS

A ten years (September 2012 - August 2021) institution-based multicenter retrospective cohort study was conducted from September 13 to September 30, 2021. we surveyed the cards of all patients having a diagnosis of bronchopleural fistula for the last 10 years. The document was reviewed using an extraction checklist. Descriptive statistics (mean, standard deviation, frequency, percentages) and crosstabulation were used to describe the outcome variable.

RESULT

A total of 52(2%) patients were diagnosed to have bronchopleural fistula out of 2546 patients admitted to the cardiothoracic unit in three hospitals from September 2012 - August 2021 and 69% of study participants were male. The mean age of study participants was 33.42 years with SD = 12.5. Thirty-one (60%) of the cases spontaneously developed a bronchopleural fistula and 20 (38%) were post-surgical and 1(2%) was a post-traumatic fistula. Of the total of post-surgical bronchopleural fistula, 14 (26.9%) of them were lung resection, 4 (7.7%) were hydatid cystectomy and 1(1.9%) are decortications, and bullectomy respectively. of the total post-lung resection, 8 (57%) were pneumonectomies followed by 3 (21.5%) Lobectomy, 2 (14.5%) wedge resection and 1(7%) bilobectomy respectively. Fifty patients were managed surgically and two patients were managed conservatively. Bronchopleural fistula (BPF) was closed in 40 (85.4%) and there were two (3.9%) deaths, and the cause of death was sepsis secondary to pneumonia of the contralateral lung in one case.

CONCLUSION

Having thoracic surgery is a risk factor for the development of bronchopleural fistula. Management of bronchopleural fistula needs to be individualized.

Pulmonary sleeve resection complications and management

In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.

Stage III Non-Small-Cell Lung Cancer: An Overview of Treatment Options

Lung cancer is the second-most commonly diagnosed cancer and the leading cause of cancer death worldwide. The most common histological type is non-small-cell lung cancer, accounting for 85% of all lung cancer cases. About one out of three new cases of non-small-cell lung cancer are diagnosed at a locally advanced stage—mainly stage III—consisting of a widely heterogeneous group of patients presenting significant differences in terms of tumor volume, local diffusion, and lymph nodal involvement. Stage III NSCLC therapy is based on the pivotal role of multimodal treatment, including surgery, radiotherapy, and a wide-ranging option of systemic treatments. Radical surgery is indicated in the case of hilar lymphnodal involvement or single station mediastinal ipsilateral involvement, possibly after neoadjuvant chemotherapy; the best appropriate treatment for multistation mediastinal lymph node involvement still represents a matter of debate. Although the main scope of treatments in this setting is potentially curative, the overall survival rates are still poor, ranging from 36% to 26% and 13% in stages IIIA, IIIB, and IIIC, respectively. The aim of this article is to provide an up-to-date, comprehensive overview of the state-of-the-art treatments for stage III non-small-cell lung cancer.

Perpendicular implantation of porcine trachea extracellular matrix for enhanced xenogeneic scaffold surface epithelialization in a canine model

Objective

The availability of clinically applied medical materials in thoracic surgery remains insufficient, especially materials for treating tracheal defects. Herein, the potential of porcine extracellular matrix (P-ECM) as a new airway reconstruction material was explored by xenotransplanting it into a canine trachea.

Methods

P-ECM was first transplanted into the buttocks of Narc Beagle dogs (n = 3) and its overall immuno-induced effects were evaluated. Subsequently, nine dogs underwent surgery to create a tracheal defect that was 1 × 2 cm. In group A, the P-ECM was implanted parallel to the tracheal axis (n = 3), whereas in group B the P-ECM was implanted perpendicular to the tracheal axis (n = 6). The grafts were periodically observed by bronchoscopy and evaluated postoperatively at 1 and 3 months through macroscopic and microscopic examinations. Immunosuppressants were not administered. Statistical evaluation was performed for Bronchoscopic stenosis rate, graft epithelialization rate, shrinkage rate and ECM live-implantation rate.

Results

No sign of P-ECM rejection was observed after its implantation in the buttocks. Bronchoscopic findings showed no improvement concerning stenosis in group A until 3 months after surgery; epithelialization of the graft site was not evident, and the ECM site appeared scarred and faded. In contrast, stenosis gradually improved in group B, with continuous epithelium within the host tissues and P-ECM. Histologically, the graft site contracted longitudinally and no epithelialization was observed in group A, whereas full epithelialization was observed on the P-ECM in group B. No sign of cartilage regeneration was confirmed in both groups. No statistically significant differences were found in bronchoscopic stenosis rate, shrinkage rate and ECM live-implantation rate, but graft epithelialization rate showed a statistically significant difference (G-A; sporadic (25%) 3, vs. G-B; full covered (100%) 3; p = 0.047).

Conclusions

P-ECM can support full re-epithelialization without chondrocyte regeneration, with perpendicular implantation facilitating epithelialization of the ECM. Our results showed that our decellularized tracheal matrix holds clinical potential as a biological xenogeneic material for airway defect repair.

ARDS after Pneumonectomy: How to Prevent It? Development of a Nomogram to Predict the Risk of ARDS after Pneumonectomy for Lung Cancer

(1) Background: The cause of ARDS after pneumonectomy is still unclear, and the study of risk factors is a subject of debate. (2) Methods: We reviewed a large panel of pre-, peri- and postoperative data of 211 patients who underwent pneumonectomy during the period 2014−2021. Univariable and multivariable logistic regression was used to quantify the association between preoperative parameters and the risk of developing ARDS, in addition to odds ratios and their respective 95% confidence intervals. A backward stepwise selection approach was used to limit the number of variables in the final multivariable model to significant independent predictors of ARDS. A nomogram was constructed based on the results of the final multivariable model, making it possible to estimate the probability of developing ARDS. Statistical significance was defined by a two-tailed p-value < 0.05. (3) Results: Out of 211 patients (13.3%), 28 developed ARDS. In the univariate analysis, increasing age, Charlson Comorbidity Index and ASA scores, DLCO < 75% predicted, preoperative C-reactive protein (CRP), lung perfusion and duration of surgery were associated with ARDS; a significant increase in ARDS was also observed with decreasing VO2max level. Multivariable analysis confirmed the role of ASA score, DLCO < 75% predicted, preoperative C-reactive protein and lung perfusion. Using the nomogram, we classified patients into four classes with rates of ARDS ranking from 2.0% to 34.0%. (4) Conclusions: Classification in four classes of growing risk allows a correct preoperative stratification of these patients in order to quantify the postoperative risk of ARDS and facilitate their global management.

From Diagnosis to Treatment of Lung Cancer: An Update in "Cancers" in 2021

After its successful launch in January 2021 by Cancers, the topic collection "Diagnosis and Treatment of Primary and Secondary Lung Cancers" experienced a productive first full year [...].

Cover always the bronchial stump! A flap could prevent catastrophic complications even in complete broncho-pleural fistula

Broncho-pleural fistula after pneumonectomy is a life-threatening condition with very high mortality rate, even if detected early. All symptomatic patients should be treated immediately. The diagnosis in the absence of symptoms poses the real difficulties of management. Early detection of asymptomatic post-pneumonectomy broncho-pleural fistula is usually fortuitous. The use of bronchoscopy allows direct and accurate evaluation of the stump. This reported case allows us to make several considerations on the treatment of fistulas, but above all to consider that the systematic bronchial stump coverage is fundamental not only for preventing fistulas, but also for limiting their enlargement and communication with the residual cavity, in order to prevent catastrophic complications.

Unplanned Return to the Operating Room after Elective Oncologic Thoracic Surgery: A Further Quality Indicator in Surgical Oncology

Background: An unplanned return to the operating room (UROR) is defined as a readmission to the operating room because of a complication or an untoward outcome related to the initial surgery. The aim of the present report is to evaluate the role of URORs after elective oncologic thoracic surgery. Methods: In the study, 4012 consecutive patients were enrolled; among them, 71 patients (1.76%) had an unplanned return to the operating room. Age, sex, Charlson comorbidity index, induction treatments, type of the first operation, indication to readmission to the operating room and type of second operation, length of stay, complication after reoperation and outcomes were collected. Results: The mean age was 63.3 (SD: 13.0); there were 53 male patients (74.6%); the type of the first procedure was: lower lobectomy (11.3%), middle lobectomy (1.4%), upper lobectomy (22.5%), metastasectomy (5.6%), extrapleural pneumonectomy (4.2%), pneumonectomy (40.9%), pleural biopsy (5.6%) and other procedures (8.5%). Patients presenting complications after UROR had undergone a significantly longer first procedure (p < 0.02), had a longer length of stay (p < 0.001) and had higher post-operative mortality (p < 0.001). Conclusions: The patients experiencing UROR after elective oncologic thoracic surgery have significantly higher morbidity and mortality rates when compared to standard thoracic surgery. Bronchopleural fistula remains the most lethal complication in patients undergoing UROR.

Pneumonectomy and broncho-pleural fistula: predicting factors and stratification of the risk

The goal of the study is to evaluate the different risk factors and stratify the patients, before the surgery, into distinct risk classes. We retrospectively reviewed pre, peri, and postoperative outcomes of 366 consecutive patients who underwent pneumonectomy for lung cancer between the last 10 years (2009-2019). We classified the patients into four classes, depending on preoperative assessments. Differences between groups were assessed with the log-rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent prognostic significance of the variables associated with the development of BPF at univariate analysis. Finally, we performed non-linear [artificial neural network (ANN)] multiple regression analyses. All tests were two-sided, and p values < 0.05 were considered significant. Fifty-one patients (13.9%) out of 366 developed BPF. Male sex (p = 0.048), right side (p = 0.015), postoperative pulmonary complications (p = 0.0139) and adjuvant treatments (p = 0.0169) were the independent predicting factors of fistulas in multivariate analysis. The right side (p = 0.043) and adjuvant treatments (p = 0.032) were the independent predicting factors of BPF after the ANN analysis. Based on multivariate and artificial neural network analysis and our experience, we observed a trend of growing risk of BPF in the first 4 weeks (early fistula), considering the four classes. Preoperative differentiation of the patients into four risk classes could allow a correct stratification of the growing risk of developing early BPF. This information could be significant to share with patients and the other physicians during the decision-making process, to minimise the risk of BPF.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Preserving the eponym: Klinkenbergh technique for bronchial stump suturing

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas.

Successful use of bio plugs for delayed bronchial closure after pneumonectomy in experimental settings

OBJECTIVES

Cell therapies, such as stem cell suspension injection, are used to treat bronchopleural fistula. Although it is safe and effective, injected cells cannot remain within the bronchioles of the fistula due to cell leakage into the thoracic cavity. Here, we inserted a 'bio plug' into the fistula, produced using cells and a bio-3D printer, to examine the effectiveness of bio plugs for the closure of bronchopleural fistulas, the optimal cell source and the closure mechanism.

METHODS

Bio plugs were made with mesenchymal stem (stromal) cells derived from bone marrow (MSCBM), fibroblasts and rat lung micro-vessel endothelial cells using a bio-3D printer with different cell mixing ratios. Six groups, according to the presence or absence and the type of bio plugs, were compared. The plugs were inserted into the bronchi of F344 rats. The obstruction ratio and histological and immunohistochemical findings were evaluated.

RESULTS

MSCBM+ rat lung micro-vessel endothelial cell group exhibited a higher obstruction ratio among all groups excluding the MSCBM group (P = 0.039). This group had fibrosis and CD31-positive cells and fewer CD68-positive cells than MSCBM and MSCBM+ fibroblast groups.

CONCLUSIONS

Bio plugs with mixed cells, including stem cells, contribute to bronchial closure in the current experimental setting. Endothelial cells effectively maintain the structure in this model. Although bronchial closure for bronchopleural fistula could not be described as clinical conditions were not reproduced, we collected essential data on bronchial closure; however, further experiments are warranted.

Management of Complications Following Lung Resection

Lung resections are associated with a variety of potential postoperative complications. Not surprisingly, pulmonary complications are most frequent after lung surgery. Cardiac and thromboembolic complications are also important. It is essential that surgeons anticipate the possibility of these complications and take preventative measures whenever possible. When complications do occur, prompt recognition and treatment is required to assure optimal patient outcomes.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

A Multiple-Center Nomogram to Predict Pneumonectomy Complication Risk for Non-Small Cell Lung Cancer Patients

OBJECTIVE

This study aimed to construct a nomogram to quantitatively predict pneumonectomy complication risks for non-small cell lung cancer (NSCLC) patients.

METHODS

Data from 1052 NSCLC patients who underwent pneumonectomy were retrospectively retrieved from the databases of three thoracic centers. Multivariable logistic regression was used to investigate postoperative morbidity predictors. Clinical parameters and operative features were analyzed using univariable and multivariable logistic regression analyses, and a nomogram to predict the risk of postoperative complications was constructed using bootstrap resampling. A receiver operating characteristic (ROC) curve was used to estimate the discrimination power for the nomogram.

RESULTS

A total of 212 patients (20.2%) had major complications. After regression analysis, forced expiratory volume in 1 s, Charlson Comorbidity Index score, male sex, and right-sided pneumonectomy were identified and entered into the nomogram. The nomogram showed a robust discrimination, with an area under the ROC curve of 0.753 (95% confidence interval 0.604-0.818). The calibration curves for the probability of postoperative complications showed optimal agreement between the nomogram and the actual probability.

CONCLUSIONS

Based on preoperative data, we developed a nomogram for predicting complication risks after pneumonectomy. This model may be helpful for thoracic surgeons in selecting appropriate patients for adopting prophylactic measures after surgery.

Innovative method for Amplatzer device implantation in patients with bronchopleural fistulas

Background

Bronchopleural fistula (BPF) is a relatively rare complication after various types of pulmonary resection. The double-sided mushroom-shaped occluder (Amplatzer device, AD) has been gradually used for BPF blocking due to its reliable blocking effect. We have improved the existing AD implantation methods to facilitate clinical use and named the new approach Sheath-free method (SFM). The aim of the present report was to explore the reliability and advantages of the SFM in AD implantation.

Methods

We improved the existing implantation methods by abandoning the sheath of the AD and using the working channel of the bronchoscope to directly store or release the AD without general anesthesia, rigid bronchoscopy, fluoroscopy, or bronchography. A total of 6 patients (5 men and 1 woman, aged 66.67 ± 6.19 years [mean ± SD]) had BPF blocking and underwent the SFM in AD implantation.

Results

AD implantation was successfully performed in all 6 patients with the SFM, 4 persons had a successful closure of the fistula, one person died after few days and one person did not have a successful closure of the fistula. The average duration of operation was 16.17 min (16.17 ± 4.67 min [mean ± SD]). No patients died due to operation complications or BPF recurrence. The average follow-up time was 13.2 months (range 10–17 months).

Conclusion

We observed that the SFM for AD implantation—with accurate device positioning and a clear field of vision—is efficient and convenient. The AD is effective in BPF blocking, and could contribute to significantly improved symptoms of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01493-8.

Drug Regimen for Patients after a Pneumonectomy

Pneumonectomy is an entire lung removal and is indicated for both malignant and benign diseases. Due to its invasiveness and postoperative complications, pneumonectomy is still associated with high mortality and morbidity. Appropriate postoperative management is crucial in pneumonectomy patients to improve quality of life and overall survival rates. Diverse drug regimens are under development to be used in adjuvant chemotherapy or to improve respiratory health after a pneumonectomy. The most common causes for a pneumonectomy are non-small cell lung cancer, malignant pleural mesothelioma, and tuberculosis; thus, an appropriate drug regimen is necessary. The uncommon incidence of pneumonectomy cases remains the major obstacle in studies of postoperative drug regimens. As the majority of current studies include post-lobectomy and post-segmentectomy patients, it is highly recommended that further research of postoperative drug regimens be focused on post-pneumonectomy patients.

Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience

OBJECTIVES

Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina.

METHODS

All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice.

RESULTS

A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days.

CONCLUSIONS

Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula

Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.

Endoscopic Lipofilling for the Treatment of Bronchopleural Fistulas After Anatomic Lung Resection

A bronchopleural fistula is a potentially fatal complication of anatomic lung resection surgery. Bronchoscopy has been described in the treatment of small-caliber fistulas. An endoscopic procedure based on instillation of mesenchymal stem cells for the treatment of bronchopleural fistula has recently been successful. Fat tissue is rich in mesenchymal stem cells, and we describe a technique based on the instillation of autologous fat (lipofilling) for the treatment of bronchopleural fistulas. The procedure was applied to 8 subjects affected by bronchopleural fistulas that were greater than 8 mm in diameter, and saw resolution in all cases.

Treat bronchopleural fistula after right lower lobectomy by extra right middle lobectomy-a neglected approach

OBJECTIVES

Bronchopleural fistula (BPF) after right lower lobectomy (RLL), although uncommon, is associated with high mortality rates. This study was aimed at evaluating the therapeutic effect of extra right middle lobectomy (ERML) in the management of BPF after RLL.

METHODS

We investigated 12 consecutive patients who were treated at our hospital for BPF occurring after RLL. The diagnosis of BPF was established by bronchoscopy in all cases and BPFs were treated by ERML. All patients were followed up for at least 1 year after ERML to assess treatment outcomes.

RESULTS

The severity of infection and malnutrition after BPF was different for different patients. All patients agreed to undergo ERML. The procedure was uneventful in all cases, and there were no cases of perioperative complications or death. The median duration of hospitalization after ERML was 10.5 (range 6-21) days. Postoperative pathological examination showed the presence of hyperaemia and oedema in the BPF stump, and inflammatory cell infiltration in the stroma. The fresh stump of the bronchus intermedius was well structured. Patients were followed up for a median duration of 27 (range 12-41) months. The BPFs were successfully treated in all patients, and a new BPF did not develop in the new fresh stump in any of the cases.

CONCLUSIONS

ERML aimed at creating a fresh stump for quick healing could be alternative for treating BPF after RLL.

Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula

INTRODUCTION

This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula.

MATERIALS AND METHODS

The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated.

RESULTS

The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence.

CONCLUSIONS

The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Is low serum albumin associated with postoperative bronchopleural fistula in patients undergoing pulmonary resections?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether low serum albumin (sAlb) was associated with postoperative bronchopleural fistula (BPF) in patients undergoing pulmonary resections. Altogether 660 papers were found using the reported search, of which 5 retrospective cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four of the 5 cohort studies showed that the preoperative sAlb level in patients who experience a BPF was significantly lower than that in patients who did not experience a BPF. One of the 5 studies also reported that the incidence of BPF in patients with a lower sAlb (13.6%) was found to be significantly higher than that in patients with a higher sAlb (7.0%). The level of hypoalbuminaemia is not defined, but it may be <3.5 g/dl. This cut-off value of sAlb is assumed from the currently available retrospective data. No prospective study has been reported to address this issue. In summary, low preoperative sAlb can serve as a significant risk factor for postoperative BPF in patients undergoing pulmonary resections.

Simple chest closure of open window thoracostomy for postpneumonectomy empyema: a case report

BACKGROUND

Management of postpneumonectomy empyema requires comprehensive strategies, especially when the condition is associated with large bronchopleural fistulae. We report a case involving the simple chest closure of open window thoracostomy with remaining residual space.

CASE PRESENTATION

We performed open window thoracostomy for empyema with a huge bronchial stump dehiscence after right pneumonectomy for a large lung cancer. We definitively closed the chest window infected with chronic persistent Pseudomonas aeruginosa via a simple chest closure technique with the remaining residual space, after repairing the bronchial dehiscence using an omental flap and the appearance of healthy granulation tissue throughout the cavity. The patient died of recurrent cancer 10 months after the definitive chest closure. Until the patient died, there were no symptoms or signs suggestive of recurrent empyema.

CONCLUSION

This simple chest closure technique allows "silent empyema" to be observed carefully, is less invasive, and can even be applied to cases of recurrent cancer.

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.