Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis

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.

A rare cause of esophagopleural fistula due to intensity-modulated proton therapy: a case report and review of literature

Esophagopleural fistula (EPF), initially described in 1960, is an abnormal communication between the esophagus and the pleural cavity which can occur due to congenital malformation or acquired due to malignancy or iatrogenic treatment. The most common presenting symptoms are of a respiratory infection, such as fever, chest tenderness, cough and imaging findings consistent with pleural fluid consolidation. In this report, we present a 59-year-old man who exhibited shortness of breath, productive cough, and significant weight loss for 2 weeks. His medical history was significant for smoking-related lung disease and pulmonary squamous cell carcinoma (SCC). His SCC (T4N0) was diagnosed 6 years prior to this presentation and was treated with chemoradiotherapy. The cancer recurred a year ago and he was treated with intensity-modulated proton therapy (IMPT) and consolidation chemotherapy. During admission, he was found to have an EPF by CT scan after initially failing antibiotic treatment for suspected complicated pneumonia and pleural effusion. Multiple attempts of esophagopleural fistula closure were made using endoscopic self-expandable metallic stents and placement of an esophageal vacuum-assisted closure device. However, these measures ultimately failed and, therefore, he required an iliocostalis muscle flap (Clagett window) procedure for closure. Esophageal pulmonary fistulae should be suspected whenever patients have undergone thoracic IMPT and may present with acute pulmonary complications, particularly pneumonia refractory to antibiotic treatment. This case reviews the current literature, potential complications, and treatment options for esophagopleural fistulas.

A Stepwise Approach for Postlobectomy Bronchopleural Fistula

Although rare, bronchopleural fistula (BPF) following anatomic lung resection is a serious complication associated with high rates of mortality (25%-71%). Risk factors for BPF include surgical approach, neoadjuvant therapy, diabetes mellitus, and chronic obstructive pulmonary disease. As neoadjuvant treatment is increasingly being administered to patients with locally advanced lung cancer, and as more patients are being diagnosed with lung cancer at an older age-elderly patients present with a higher index of multiple comorbidities-the incidence of BPF among patients undergoing anatomic resection for lung cancer is expected to increase. In this manuscript, we detail risk factors and considerations for BPF and describe a stepwise approach to treat BPF following lobectomy for lung cancer.

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

PURPOSE

Bronchopleural fistula (BPF) is a potentially fatal complication of pneumonectomy. We analyze its occurrence rate, risk factors, and the methods used for its prevention.

METHODS

We reviewed the medical records of patients who underwent pneumonectomy at our Institution between January, 1990 and March, 2016. The risk factors for postoperative BPF were analyzed by univariate analysis and multiple logistic regression.

RESULTS

Over the study period, 511 patients underwent pneumonectomy for non-small cell lung cancer (NSCLC) and had the bronchus closed by manual suturing. BPF developed in 23 patients (4.5%). Multiple logistic regression identified no coverage of the bronchial stump, right-sided pneumonectomy, residual tumor in the bronchial stump, postoperative ventilatory support, and completion pneumonectomy, as independent risk factors for BPF. The cumulative rate of BPF decreased significantly over time from 18% between 1990 and 1995 to 1% between 2011 and 2016 (p < 0.001). Concurrently, the data of several patients showed a significant positive trend over time, including bronchial stump coverage (BSC).

DISCUSSION

Several known risk factors for BPF were confirmed. The more frequent usage of tissue flaps for coverage of the bronchial stump may have contributed to the reduction in the rate of postoperative BPF over time.

Body surface area is a novel predictor for surgical complications following video-assisted thoracoscopic surgery for lung adenocarcinoma: a retrospective cohort study

Background

Body surface area (BSA) is a biometric unit to measure the body size. Its clinical significance in video-assisted thoracoscopic surgery (VATS) was rarely understood. We aimed to estimate the predictive value of BSA for surgical complications following VATS anatomical resections for lung adenocarcinoma (LAC).

Methods

A single-center retrospective analysis was performed on the consecutive patients between July 2014 and January 2016 in our institution. The differences in mean BSA values were evaluated between groups of patients classified by the development of postoperative surgical complications (PSCs), overall morbidity and cardiopulmonary complications, respectively. Receiver operating characteristic (ROC) analysis was performed to determine a threshold value of BSA on prediction of PSC occurrence. A multivariate logistic-regression model involving this optimal cut-off value and other significant parameters was established to identify the predictors for PSCs.

Results

During the study period, a total of 442 patients undergoing VATS anatomical resections for LAC were enrolled in this study. There were 135 patients developed with one or more complications (rate = 30.5%). PSCs occupied the largest percentages of all these complications (n = 81, rate = 18.3%). The mean BSA in PSC group was significantly higher than that in non-PSC group (1.76 ± 0.15 m² vs 1.71 ± 0.16 m²; P = 0.016). No difference was found in mean BSA values between groups classified by any other complication. The ROC analysis determined a BSA value of 1.68 m² to be the threshold value with the maximum joint sensitivity of 72.8% and specificity of 48.5%. Compared to patients with BSA ≤ 1.68 m², patients with BSA > 1.68 m² had significantly higher incidences of prolonged air leak (P = 0.006) and chylothorax (P = 0.004). Further multivariate logistic-regression analysis indicated that BSA > 1.68 m² could be an independent risk factor for PSCs (odds ratio: 2.03; P = 0.025).

Conclusions

BSA is an excellent categorical predictor for surgical complications following VATS anatomical resections for LAC. It may be considered when informing patients about surgical risks and selecting cases in the early learning curve. Large-scale and multi-institutional studies are expected to confirm and modify our findings in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-017-0264-4) contains supplementary material, which is available to authorized users.

A systematic review and meta-analysis-does chronic obstructive pulmonary disease predispose to bronchopleural fistula formation in patients undergoing lung cancer surgery?

BACKGROUND

we conducted this systematic meta-analysis to determine the association between chronic obstructive pulmonary disease (COPD) and risk of bronchopleural fistula (BPF) in patients undergoing lung cancer surgery.

METHODS

Literature retrieval was performed in PubMed, Embase and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) served as the summarized statistics. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Sensitivity analysis was performed to further examine the stability of pooled OR. Publication bias was detected by both Begg's test and Egger's test.

RESULTS

Eight retrospective observational studies were included into this meta-analysis. The overall summarized OR was 2.03 (95% CI: 1.44-2.86; P<0.001), revealing that COPD was significantly associated with the risk of BPF after lung cancer surgery. In subgroup analysis, the relationship between COPD and BPF occurrence remained statistically prominent in the subgroups stratified by statistical analysis (univariate analysis, OR: 1.91; 95% CI: 1.35-2.69; P<0.001; multivariate analysis, OR: 3.18; 95% CI: 1.95-5.19; P<0.001), operative modes (pneumonectomy, OR: 2.11; 95% CI: 1.15-3.87; P=0.016) and in non-Asian populations (OR: 2.36; 95% CI: 1.18-4.73; P=0.016). No significant impact of COPD on BPF risk was observed in Asian patients (OR: 1.48; 95% CI: 0.85-2.57; P=0.16). No significant heterogeneity or publication bias was discovered across the included studies.

CONCLUSIONS

Our meta-analysis indicates that COPD can significantly predispose to BPF formation in patients undergoing lung cancer surgery. Because some limitations still exist in this meta-analysis, our findings should be further verified and modified in the future.