CLOSURE OF THE BRONCHUS FOLLOWING TOTAL PNEUMONECTOMY: EXPERIMENTAL AND CLINICAL OBSERVATIONS

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.

Prophylaxis and management of postoperative complications after tracheobronchial surgery

Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.

Investigation of surgical technique for bronchial stump closure after lobectomy in animal model

OBJECTIVE

Bronchial fistulae following lung surgery are associated with high mortality. We examined the histological effects of mucosal ablation as a technique for closing bronchial stumps to prevent bronchial fistulae in an animal model.

METHODS

Left lower lobectomy was performed in beagles under general anesthesia. The bronchial stumps were closed using one of the following four methods: (A) manual suturing using 3-0 absorbable sutures, (B) ablation of bronchial mucosa with electric cautery and manual sutures, (C) stapling and reinforcement with manual sutures, or (D) ablation and stapling followed by reinforcement with manual sutures. Bronchial stumps were histologically evaluated on postoperative day 14.

RESULTS

No bronchial fistulae were noted in the animals during the observation period. Histologically, there were no adhesions between the bronchial mucosae at the suture and staple lesions in groups A and C. The bronchial mucosae were adherent at the ablation sites in groups B and D. Inflammatory cells, myofibroblasts, and neovascular vessels were abundant around the ablated lesions.

CONCLUSIONS

Bronchial mucosal ablation may play a key role in mucosal adhesion and tight union of the bronchial stump.

Obstructive pneumonia owing to migration of a Teflon pledget at 8 years after surgery for a pulmonary carcinoid tumor: a case report

Background

It is uncommon for a bronchial stump-related complication to develop during the remote postoperative period in a case of obstructive pneumonia owing to migration of the suture material. Here, we describe a case of bronchial obstructive pneumonia that developed owing to migration of the suture material in the airway 8 years after pulmonary resection.

Case presentation

A 34-year-old woman underwent left lower lobectomy for a pulmonary carcinoid tumor (pT1bN0M0-stage IA) in 2010. She experienced obstructive pneumonia, and chest computed tomography revealed a mass protruding from the bronchial stump to the bronchial lumen in 2018. After treatment for pneumonia, flexible bronchoscopy showed the presence of a fibrous suture material (Teflon pledget) completely obstructing the left second carina. A week later, the Teflon pledget obstructing the bronchial lumen was removed using a flexible bronchoscope with the patient under general anesthesia. The procedure was completed without removing the small amount of granulation tissue because the bronchial lumen opened after removing the Teflon pledget. She has remained asymptomatic for 1 year after removal.

Conclusions

In this case, the complication of obstructive pneumonia developed owing to migration of the non-absorbable suture materials used to suture the bronchial stump. Bronchoscopic management of this rare complication comprised endobronchial removal with the patient under general anesthesia. Given our experience with this case, we believe that such conservative management should allow for excellent results in most instances and avoid the need for reoperation.

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.

William Francis Rienhoff, Jr., MD - Halsted's Last Resident

: William Francis Rienhoff Jr. was a skilled and innovative surgeon whose career spanned over 4 decades of patient care, clinical investigative research, and surgical education. He was an unforgettable character for those who knew him. Colleagues, coworkers, and friends developed strong and divergent opinions of him. His professional life coincided with the early development of general and thoracic surgery to which he contributed.

Management Strategies for Complex Bronchopleural Fistula

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.

Techniques of protection and revascularization of the bronchial anastomosis

Airway anastomosis has been traditionally considered at risk for the onset of complications, particularly dehiscence with consequent infection and erosion in the adjacent vessels. Although the modifications and improvements of the surgical technique has contributed to reduce the incidence of complications, the protection and revascularization of the anastomotic site is still considered mandatory at many centers Many techniques have been proposed for encircling the bronchial anastomosis.

Modified method for bronchial suture by Ramirez Gama compared to separate stitches suture: experimental study

OBJECTIVE

To experimentally compare two classic techniques described for manual suture of the bronchial stump.

METHODS

We used organs of pigs, with isolated trachea and lungs, preserved by refrigeration. We dissected 30 bronchi, which were divided into three groups of ten bronchi each, of 3mm, 5mm, and 7mm, respectively. In each, we performed the suture with simple, separated, extramucosal stitches in five other bronchi, and the technique proposed by Ramirez and modified by Santos et al in the other five. Once the sutures were finished, the anastomoses were tested using compressed air ventilation, applying an endotracheal pressure of 20mmHg.

RESULTS

the Ramirez Gama suture was more effective in the bronchi of 3, 5 and 7 mm, and there was no air leak even after subjecting them to a tracheal pressure of 20mmHg. The simple interrupted sutures were less effective, with extravasation in six of the 15 tested bronchi, especially in the angles of the sutures. These figures were not significant (p = 0.08).

CONCLUSION

manual sutures of the bronchial stumps were more effective when the modified Ramirez Gama suture was used in the caliber bronchi arms when tested with increased endotracheal pressure.

Granulation tissue formation at the bronchial stump is reduced after stapler closure in comparison to suture closure in dogs

The aim of this study was to compare the morphology of the bronchial stump after lobectomy between mechanical stapler closure and manual suture closure. The effect of fibrin glue application on each method of closure was also observed. Right upper lobectomy was performed in beagles (n=31) using staplers (ST group) or sutures (SU group). In a separate experiment, fibrin glue was sprayed onto the stump after each respective method of closure. After one week, the stump region was examined macroscopically, and also by histology. chi(2)-Test and Mann-Whitney test were used for comparative analysis. The incidence of adhesion formation between the surrounding tissues was significantly reduced in the ST group in comparison to the SU group (22 vs. 80%, P=0.04). The thickness of granulation tissue over the stump was significantly reduced in the ST group in comparison to the SU group (0.8+/-0.2 vs. 2.5+/-0.3 mm, P<0.0001). Vessel density in the granulation tissue was also significantly reduced in the ST group in comparison to the SU group (6+/-2 vs. 16+/-2, P=0.003). Fibrin glue application after stapler closure significantly increased the incidence of adhesion formation, granulation tissue thickness, and vessel density in the granulation tissue over the stump.

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula

PURPOSE

Recurrent tracheoesophageal fistula (RTF) complicates 5-11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences.

METHODS

From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF).

RESULTS

There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months-5 years) demonstrated no evidence of recurrences.

CONCLUSION

Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences.

Postpneumonectomy and Postlobectomy Empyema

Although similar strategies are used in the management of PPE and PLE, these conditions need to be viewed as two separate entities. For the purpose of devising the appropriate management strategy, PPE should be divided into early and late, with and without mediastinal induration and extensive pleural space contamination. If at all possible, PLE should be managed as a postpneumonic empyema with prolonged chest tube drainage. The key to these conditions is prevention.

Reconstitution of Blood Supply of the Denuded Bronchial Stump

BACKGROUND

Our aim was to study the process of microcirculatory reconstitution in the bronchial stump after pneumonectomy.

METHODS

Eighteen juvenile pigs (median weight 40.6 kg) were randomly assigned to three groups. In all animals left pneumonectomy was performed and the stapled bronchial stump (median length 3.8 cm) carefully denuded. Group I animals received coverage of the stump by intercostal flap. In group II, the stump was covered with TachoComb, an impermeable hemostatic fleece; and group III served as a control without any coverage of the stump. Animals were sacrificed at day 14 after surgery. Vascular density was evaluated in serial histologic sections at multiple levels stained with CD-31 antibody. One-way analysis of variance and the Wilcoxon test were used for data analysis.

RESULTS

At autopsy, stumps of group III animals were totally covered by adjacent mediastinal structures. In group I, intercostal flaps were viable and completely healed to the bronchial stumps. There were no signs of infection or stump insufficiency in these groups. In all group II animals, empyema developed, and stumps were found necrotic at macroscopic and histologic evaluation. Statistical analysis revealed significantly lower vascular density of mature vessels in the area of the bronchial stump in group II compared with both other groups.

CONCLUSIONS

Reconstitution of microcirculation of the denuded bronchial stump after pneumonectomy takes place in a centripetal way from adjacent viable tissue. Hence, the purpose of covering the bronchial stump is the improvement of blood supply rather than mechanical reinforcement.

Extrapericardial pneumonectomy

Presentation of the technique of extrapericardial left and right standard pneumonectomy. After insertion of a disposable double-lumen endotracheal tube, the patient is positioned in lateral decubitus and a lateral thoracotomy is performed. One-lung ventilation is started after a thorough identification is performed followed by systematic nodal dissection. Centrally, the pulmonary artery and veins are encircled, cut on clamps and sewed. Alternatively, the vessels can be stapled. Next, the bronchus is dissected toward the trachea and transected by stapling or interrupted sutures as close to the trachea as possible. When there is a high risk of bronchopleural fistula, as after induction chemotherapy or radiotherapy, the bronchial stump is covered with viable tissue (as azygos vein, pericardial fat, intercostal muscle or pleural flap, omentum, or muscle flaps from the thoracic wall).

The history of tracheal surgery

Tracheal surgery, which did not exist in a coherent, systematic fashion 45 years ago, has developed techniques that allow resection of approximately half of the adult trachea with primary reconstruction, largely by anatomic mobilization procedures. Dependable methods have also been developed for laryngotracheal and carinal resection and reconstruction. The daunting problem of long congenital tracheal stenosis appears to be largely solved by slide tracheoplasty. In the past four decades much has also been learned about the etiology, natural history, pathology, and (in some cases) prevention of tracheal diseases including primary and secondary tumors, postintubation injuries, and idiopathic stenosis.

Special article: a brief history of pneumonectomy. 1999

The ineluctable conclusion to be drawn from this article is that thoracic surgery could not develop without endotracheal ventilation. What is astounding is that this technique, known since the 16th century and perfected in the late 19th century, was ignored and in fact rejected by surgeons [4]. The negative effect that Sauerbruch had on the development of thoracic anesthesia was well stated by Comroe: "An impressive piece of hardware, backed by a highly prestigious designer, can hold back progress for decades" [49]. Before the formation of the AATS, there was no forum for the discussion of methods for solving the problems of pulmonary resection and anesthesia. Experience gained in the animal laboratory was largely ignored and not applied to pneumonectomy in humans. Ligation of the pulmonary artery does not initiate the clinical course of massive pulmonary embolism. In the absence of infection, concern about the postpneumonectomy space is groundless. Preresection phrenic nerve crush and pneumothorax are unnecessary, as are attempts to stabilize the postpneumonectomy mediastinum by adjusting intrapleural pressure or by thoracoplasty. It behooves thoracic surgeons to heed Comroe's comment: "Finally, what are we, with our infinite wisdom and magnificent technical advances, doing today that will appear primitive, curious or even stupid 50 years from now?"

Management of empyema after lung resections (pneumonectomy/lobectomy)

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.

Experimental study of the effects of different stapling devices in healing of the mechanically sutured bronchial stump

OBJECTIVE

The invention of the mechanical suture of the bronchial stump resulted in the significant decrease of the incidence of bronchial fistulas. Bronchial fistula constitutes the most dangerous complication of the pulmonary resection. In connection with some negative opinions in world literature regarding the safety of applying some types of mechanical suture, the multi-factor analysis of efficacy of bronchial stump closure following the total pneumonectomy by two different types of stapling devices was performed.

METHODS

The experimental study was performed on 22 sheep. Each sheep underwent left pneumonectomy. In group I the bronchus was closed by the hinged-jaw stapling device (TA-Premium, Auto-Suture). In group II the bronchus was closed by the stapling device of parallel pattern (RLV 30 Ethicon). The macroscopic parameters (i.e. linear structure of staples, degree of staples closure, the symmetry of staples closure in the medial and lateral part of bronchial stump) as well as microscopic parameters (i.e. degree of inflammatory reaction, degree disorder in collagen fibers system, degree of disorders in cartilaginous system, degree of vascular proliferation and nervous regeneration) were evaluated.

RESULTS

In three cases of group I the serious abnormalities in staples closure in the medial part of the bronchial stump were revealed. Abnormalities were found also in microscopic evaluation of the specimens. In the whole group the inflammatory reaction predominated in the medial part of bronchial stump near the hinge of the cartridge (P value <0.05). The disorder in the collagen fibers system as well as in the stratified structure of muscular fibers and cartilaginous system was proved. On the other hand, in group II all staples were properly closed in adequate linear structure, without any symmetry in both medial and lateral end of the bronchial stump. The microscopic findings were only the subtle inflammatory process and a slight disarrangement in muscular, collagen and cartilaginous systems.

CONCLUSION

The listed abnormalities of mechanical, hinged-jaw suture of bronchial stump seem to be due to the inaccurate placement of staples, their incomplete closure, and excessive damage to the sutured tissues. We conclude that the application of the hinged-jaw mechanical suture of the bronchial stump might result in higher incidence of bronchial fistula after pneumonectomy.

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.

Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management

OBJECTIVE

Postpneumonectomy bronchopleural fistula remains a morbid complication after pneumonectomy. The incidence, risk factors, and management of postpneumonectomy bronchopleural fistula were evaluated in 256 consecutive patients who underwent pneumonectomy with a standardized suture closure of the bronchus.

METHODS

Pneumonectomy was performed for lung cancer in 198 cases, for other malignancy in 20 cases, and for benign causes in 38 cases. The bronchial stump was closed with interrupted simple sutures to emphasize a long, membranous wall flap. All stumps were covered by autologous tissue.

RESULTS

The incidence of postpneumonectomy bronchopleural fistula was 3.1%. Risk factors for bronchopleural fistula were the need for postoperative ventilation (p = 0.0001) and right pneumonectomy (p = 0.04). Five patients had bronchopleural fistulas as a result of pulmonary complications necessitating ventilation; the cause in the remaining three cases appeared to be technical. Reclosure was successful in five cases (mean postoperative day 12); in one case a pinhole fistula was healed by drainage alone. Two (25%) of the eight patients who had bronchopleural fistulas died.

CONCLUSIONS

Careful, sutured closure of the main bronchus with a tissue buttress after pneumonectomy yields excellent results. The most significant risk factor for bronchopleural fistula is a pulmonary complication necessitating ventilation. Contrary to previous reports, reclosure is usually successful even if performed late.

Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery

Desmoplastic reactions secondary to adjuvant chemotherapy and radiation in stage IIIA lung cancer, plus advances in complex tracheobronchial surgery, have rejuvenated an interest for augmenting bronchial stump coverage and suture line reinforcement. We present the techniques and applications of harvesting pleural, azygos vein, pericardial flaps, and fat pad grafts, and intrathoracic transposition of chest wall muscle flaps.

Endobronchial suture. A foreign body causing chronic cough

Although rarely considered in series of lower airway foreign bodies, endobronchial sutures can cause chronic cough or hemoptysis years after thoracic surgery. Eight endobronchial sutures were found in six patients who had undergone surgery four to 30 years prior to admission. Symptoms began two to 25 years after surgery and lasted from two to six years prior to diagnosis. Cough had been attributed to chronic bronchitis or bronchiectasis in five patients and to tracheal narrowing secondary to surgical repair of tracheomalacia in the sixth. Bronchoscopy was diagnostic in all cases. Suture removal was performed with either forceps or endoscopic suture scissors to cut the suture followed by extraction with forceps. Symptoms resolved within three days and granulation tissue by two to four weeks after suture removal. This series suggests that endobronchial suture should be considered in patients with a history (even remote) of previous thoracic surgery who present with chronic, persistent cough unresponsive to specific therapy for any underlying pulmonary disease.

[Extra-pleural approaches in the management of bronchial stump insufficiency following pneumonectomy]

Insufficiency of the bronchial stump is still a dreaded complication. The treatment with the use of extrapleural accesses led to a significant improvement of the therapeutical results. We have to distinguish between transpericardial techniques and the contralateral thoracotomy with transpleural or extrapleural access. If the pleural cavity is still sterile, immediate or four week postoperative insufficiency may be treated using rethoracotomy with resuturing the stump. Coverage of the stump with pedicled muscle tissue provides a rather good method for a secondary treatment of the bronchial stump. When the pleural cavity is already infected, extrapleural treatment of the bronchial stump should be undertaken immediately. In addition, all late insufficiencies are treated extrapleurally. If only a very small opening of a fistula is found, an endoscopical closure of the fistula should be attempted using acryl glue or fibrin glue. Our own therapeutic results concerning four right hand and one left hand stump insufficiency after pneumonectomy are presented in this study and we have classified the up to now published therapeutical results.

[Stapler and manual bronchial anastomosis--results of a consecutive trial series]

After lobectomy and pneumonectomy in experimental evaluations stapled bronchial closures showed the lowest incidence of inflammatory reaction and the highest strength determined by leakage pressure compared with other suture material. A total of 233 lung resections-performed at Surgical University Clinic Köln-Lindenthal and the Clinic for General and Abdominal Surgery of the Johannes-Gutenberg-Universität Mainz--were reviewed. Mechanical stapling reduced the rate of bronchopleural fistulas to 2.0% compared with 7.1% after manual suturing. In parallel, mortality related to bronchial stump leakage decreased to 0.7%. Main advantages of bronchial closure with staplers are the simplicity of their use, the speed and the uniformity of the closure. Thereby stapling devices are valuable completions in pulmonary surgery.

Use of staplers in pulmonary surgery

Stapling devices have helped reduce the incidence of bronchopleural fistulas after pulmonary resection. They have also simplified the resection of lung parenchyma and the closure of large-caliber blood vessels in the hilum of the lung.

Management of bronchopleural fistula following pneumonectomy

Bronchopleural fistula developed in 28 (12.5%) of 225 pneumonectomies performed for pulmonary carcinoma of non-small cell types during a 10-year period. The incidence of fistula apparently decreased significantly when chromic catgut was replaced by Dexon for closure of the bronchial stump. The fistula presented as an emergency in nine cases and was subacute in 19. The overall mortality from bronchopleural fistula was 28.6%. Conservative treatment, i.e. bronchoscopic application of silver nitrate to destroy the epithelium in the bronchial stump and induce granulation, achieved closure of fistula in all the surviving patients. In the seven patients with sterile pleural cavity the pleura was not drained. The results justified our principle of conservative management when a bronchopleural fistula does not present as an emergency. In emergency situations, however, or if the pleural fluid is purulent, pleural drainage should be instituted.

Brochial stump closure techniques following pneumonectomy: A serial comparative study

Three methods of closing bronchial stumps were evaluated in 90 dogs undergoing left pneumonectomy:interrupted 3-0 silk sutures, interrupted 3-0 nylon sutures, and stapling with an automatic device. The dogs were sacrificed at 24 hours, 3, 5, 7, 10, and 14 days after pneumonectomy. Brochial stump leakage pressures and histological studies were performed on all specimens. Differences in the exudative reaction between silk and staple closures were significant on day 5(238.19+/- 23.28 SD PMN's/HPF in silk closures, 34.95+/- 20.37 SD PMN's/HPF in staple closures) and therafter(P less than 0.001). The reaction to nylon was intermediate between silk and staple. Collagen levels were highest at all periods for staple closures. Staple leakage pressures were greater than silk or nylon(day 5: 145.3 mm Hg +/- 64.9 SD in staple closures, 40.2 mm Hg +/- 15.4 SD in silk closures). These results have clinical relevance to the selection of suture materials for stump closures.

Bronchopleural fistula: a review of 86 cases

A review of all the bronchopleural fistulas which developed following pulmonary resection in the Department of Cardio-Vascular and Thoracic Surgery of The London Hospital between 1953 and 1973 is presented. During this period 3150 pulmonary resections were performed for various conditions and 86 fistulas occurred, an incidence of 2-7 per cent. The aetiology, diagnosis and treatment of these fistulas are discussed.

Postoperative bronchopleural fistula: clinical and experimental study

It is a well-known fact that in pulmonary tuberculosis patients treated by resection, the quality of the suture material used for closing the bronchial stump plays an important role in the pathogenesis of postoperative bronchopleural fistula. Of 426 cases treated surgically and in whom silk suture thread was used, 23 developed bronchopleural fistula, whereas none of the 220 cases sutured with nylon monofilament developed abnormality. Statistical analysis of 100 surgical cases with silk thread suture and of 100 cases with nylon monofilament suture showed that the two groups had no marked differences as to background factors. Howevers, as compared with the silk-thread suture group, the nylon-monofilament suture group revealed more consistently favorable postoperative bronchoscopic findings. Experimental studies with dogs showed a similar lack of complications when the monofilament suture material was used, as contrasted were conducted in hospital by the same surgical personnel using the same procedures, it can be said that, to insure prevention of complications, the suture material for bronchial stump closure should be of non-irritating nature and preferably of monofilament strength and quality, such as nylon monofilament.

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.

Use of pectoralis skin pedicle flap for closure of large bronchial fistula connected with postpneumonectomy empyema

In 4 patients, the postpneumonectomy empyema was connected with a large bronchopleural fistula. The empyema was in all cases treated by a permanent open window thoracostoma. The fistulae were closed later with pedicle flaps made of the pectoralis muscle and the adjoining skin. In 2 patients the closing of the bronchial fistula was successful, and the treatment of one patient is not completed. In one patient the open pneural cavity was covered completely by skin using an additional pedicle flap and free skin transplantation. The surgical technique of the pedicle flap operation is described and the cases are reported.