Prophylactic flap coverage and the incidence of bronchopleural fistulae after pneumonectomy

Intraoperative Determination of Bronchus Stump and Anastomosis Perfusion with Hyperspectral Imaging

BACKGROUND

The intraoperative evaluation of bronchus perfusion is limited. Hyperspectral Imaging (HSI) is a newly established intraoperative imaging technique that enables a non-invasive, real-time perfusion analysis. Therefore, the purpose of this study was to determine the intraoperative perfusion of bronchus stump and anastomosis during pulmonary resections with HSI.

METHODS

In this prospective, IDEAL Stage 2a study (Clinicaltrials.gov: NCT04784884) HSI measurements were carried out before bronchial dissection and after bronchial stump formation or bronchial anastomosis, respectively. Tissue oxygenation (StO₂; upper tissue perfusion), organ hemoglobin index (OHI), near-infrared index (NIR; deeper tissue perfusion) and tissue water index (TWI) were calculated.

RESULTS

Bronchus stumps showed a reduced NIR (77.82 ± 10.27 vs 68.01 ± 8.95; P = 0,02158) and OHI (48.60 ± 1.39 vs 38.15 ± 9.74; P = <.0001), although the perfusion of the upper tissue layers was equivalent before and after resection (67.42% ± 12.53 vs 65.91% ± 10.40). In the sleeve resection group, we found both a significant decrease in StO 2 and NIR between central bronchus and anastomosis region (StO₂: 65.09% ± 12.57 vs 49.45 ± 9.94; P = .044; NIR: 83.73 ± 10.92 vs 58.62 ± 3.01; P = .0063). Additionally, NIR was decreased in the re-anastomosed bronchus compared to central bronchus region (83.73 ± 10.92 vs 55.15 ± 17.56; P = .0029).

CONCLUSIONS

Although both bronchus stumps and anastomosis show an intraoperative reduction of tissue perfusion, there is no difference of tissue hemoglobin level in bronchus anastomosis.

Short-Term Outcomes of Fiberoptic Bronchoscopy-guided Resection and Anastomosis Control in Thoracic Surgery

BACKGROUND

In thoracic surgery practice, bronchial closure and anastomosis are relatively easy in technical terms; however, it is also the procedure that is most open to the development of complications with high morbidity. This study aimed to investigate the effect of simultaneous evaluation of bronchial closure under fiberoptic bronchoscopy guidance during lung resection on the development of complications.

MATERIALS AND METHODS

Patients aged over 18 years who underwent elective lung resection in our clinic between 2017 and 2021 were included in the study. Postoperative complications were recorded and statistically analyzed.

RESULTS

The mean age of the patients was 61.4±10.4 years, and 267 patients were male (75.4%) and 87 (24.6%) were female. Thoracotomy was performed in 258 (72.9%) patients and lung resection with the video-assisted thoracoscopic surgery technique in 96 (27.1%) patients. During the follow-up, complications were observed during the first 30 days in 78 (22.0%) of the patients and later in 9 (2.5%). Surgical mortality occurred in 11 patients (3.1%), and the rate of readmission to the intensive care unit was 5.6% (n=20).

CONCLUSION

We consider that the control of the resection line with the active use of fiberoptic bronchoscopy during surgery is important for the prevention of the development of bronchial morbidity. Complications in the early period can be reduced by ensuring that the remaining bronchus is not narrowed, there are no residual stump structures that may disrupt the bronchial line, such as cartilage, and bronchial washing is frequently undertaken.

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.

[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.

Surgical ligation level of the bronchial artery influences tissue oxygen saturation of the bronchus and the incidence of postoperative bronchofistula after pulmonary lobectomy

Background

Lobectomy, or the removal of a lobe of the lung, is the most commonly performed lung cancer surgery. One of the most severe postoperative complications is a bronchial stump fistula, which often occurs following a right lower lobectomy. During lymph node dissection, the bronchial arteries, which supply blood to the bronchus, are cut. Subsequently, reduced blood supply to the bronchus may result in bronchofistula. We investigated the relationship between the level of the surgical ligation of the bronchial arteries and the decrease in blood flow at the bronchial stump during a right lower lobectomy. This study aimed to clarify the relationship between the anatomical amputation level of the bronchial artery and the decrease in tissue oxygen saturation at the bronchial stump, allowing us to identify a surgical procedure that reduces the risk of a bronchopleural fistula following pulmonary lobectomy and an appropriate bronchial artery amputation site that could be used in future lobectomies.

Methods

We developed a new system (micro-tissue oxygen saturation) that enabled the semi-quantification of the oxygen saturation of thin tissues in pinpoint during video-assisted thoracic surgery. Changes in the blood flow at the bronchial stump were examined during lymph node dissection and bronchial artery amputation using a biological pig lobectomy model.

Results

The regional oxygen saturation level at the bronchial wall was 95.5%±1.0% in normal conditions. A gradual decrease in regional oxygen saturation was observed, as the cutting point of the bronchial artery was moved higher. When the bronchial artery coursing into the middle lobe bronchus was preserved, the blood flow in the bronchus was preserved at 82.8%±1.3%. When the branches of the bronchial arteries running both inside and outside of the intermediate bronchial trunk were cut at high positions, regional oxygen saturation level decreased to 55.7%±1.2%.

Conclusions

The preservation of at least one bronchial artery at the level of the middle lobe bronchus minimizes the reduction of tissue oxygen saturation at the lower lobe bronchial stump. The ligation of bronchial arteries at a higher position results in desaturation <60%, which may increase the risk of bronchial stump fistula.

[Pneumonectomy for Non-small Cell Lung Cancer: Predictors of Operative Mortality and Survival]

外科手术是目前根治非小细胞肺癌（non-small cell lung cancer, NSCLC）的最有效方式。全肺切除作为一种术式被应用于临床中。对于中央型肺癌，袖式肺叶切除术因其术后肺功能丧失少、术后并发症及死亡率低逐渐取代全肺切除术成为主流。然而为保证肿瘤学效果，当其他术式无法完全切除时，全肺切除术式仍是必要的。全肺切除术后主要发生心肺并发症，充分了解全肺切除术后相关并发症能帮助临床医师及时做出诊断，并进一步采取相关措施降低术后并发症对患者的不良影响。充分了解预后相关危险因素可帮助临床医师提前采取措施尽可能规避风险，从而改善患者预后。

Current indications for the intrathoracic transposition of the omentum

Background

The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications.

Methodology and review

This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery.

Conclusions

OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.

Intensive care in thoracic oncology

The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.

Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.

For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.

Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.

Transverse rectus abdominis myocutaneous flap for postpneumonectomy bronchopleural fistula: A case report

RATIONALE

Numerous types of flap coverage have been reported to prevent or to repair bronchopleural fistulas. Most of the flaps were harvested from chest area. However, these pedicled flaps might not be optimal for the patient who has undergone previous radiotherapy on pulmonary parenchyma because the pedicle artery of the flap might have been injured by irradiation. Therefore, an alternative flap outside of the chest area is necessary.

PATIENT CONCERNS

A 61-year-old male was diagnosed of squamous cell carcinoma in right upper lobe lung (cT3N2M0, stage IIIa). After completing the neoadjuvant chemoradiotherapy, he underwent video-assisted thoracoscopic surgery with right side intrapericardial pneumonectomy.

DIAGNOSIS

Persistent air leak due to postpneumonectomy bronchopleural fistula.

INTERVENTIONS

Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was used to repair the bronchial stump.

OUTCOMES

The bronchial stump was repaired successfully, the bronchopleural fistula was obliterated, and the patient was free from air leak after following for 12 months.

LESSONS

This case demonstrated that pedicled TRAM flap is a feasible alternative to repair bronchopleural fistula.

[Tracheal injuries, fistulae from bronchial stump and bronchial anastomoses and recurrent laryngeal nerve paralysis : management of complications in thoracic surgery]

BACKGROUND

Complications cannot always be avoided and their treatment is an integral component of a high quality medical treatment. Complications of the central airways are rare but necessitate supportive treatment by an experienced thoracic surgeon.

OBJECTIVE

The reader should become acquainted with measures to prevent complications, to recognize and treat complications early and should understand the necessity for an interdisciplinary approach.

MATERIAL AND METHODS

A selective literature research was supplemented by personal experiences and complemented with prospectively collected photographs.

RESULTS

There are risk constellations for the appearance of all the mentioned complications which the surgeon needs to know in order to be able to take measures for early detection of complications. Iatrogenic tracheal injuries and bronchial stump fistulae are rare (< 5 %) whereas recurrent laryngeal nerve palsy after left-sided pneumonectomy occurs in up to 30 % of cases.

DISCUSSION

After the occurrence of complications at the latest, it is very important to include experienced thoracic surgeons and other specialists when necessary to protect the patient from further damage.

A late visceral hernia after diaphragmatic flap coverage of the bronchial stump

A 54-year-old man presented with sudden and severe abdominal pain, and vomiting. He had underwent a right pneumonectomy with bronchial stump reinforcement using diaphragmatic muscle flap 9 years ago, due to non-small cell lung cancer after neoadjuvant chemotherapy. A right partial visceral herniation had been detected 5 years ago during the follow-up which was not present at previous visits. He had refused any surgical intervention since he had been asymptomatic. The chest computed tomography demonstrated visceral herniation. The patient underwent an urgent operation via thoracoabdominal incision to repair the herniation. This type of late catastrophic complication of diaphragmatic muscle flap reinforcement is extremely rare.

Internal mammary artery pedicle: a solution for prophylactic flap coverage in high-risk trans-sternal thoracic surgery

Prophylactic use of vascularized flaps to buttress and reinforce bronchial or oesophageal closure is nowadays the preferred approach in high-risk cases, especially for extended resections with tracheobronchial reconstructions or after neoadjuvant chemoradiotherapy. However, the majority of these options and techniques are described for an approach through a thoracotomy. Due to anatomical restrictions, these options are less suitable when a trans-sternal approach is used. We emphasize the use of an internal mammary artery pedicle as prophylactic flap coverage in 3 high-risk cases, all operated on through a median sternotomy.