Bronchial stump coverage with fibrin glue-coated collagen fleece in lung cancer patients who underwent pneumonectomy

Bronchial mucosal ablation for bronchial stump closure in right pneumonectomy: a case report

Background

Bronchial fistula is a severe complication of pneumonectomy with a high mortality rate. We previously reported a technique for bronchial closure to prevent bronchial fistula in a canine model. We described that mucosal ablation could result in primary wound healing and involve mucosal tight adhesions histologically. In this paper, the pathologic findings of one patient, who underwent autopsy 4 years after surgery, were reviewed.

Case presentation

A 70-year-old Japanese man was diagnosed with malignant pleural mesothelioma and underwent right extra-pleural pneumonectomy. The right main bronchus was cut using a scalpel. When closing the bronchial stump, the bronchial mucosa was ablated by electric cautery and sutured manually using 3-0 absorbable sutures. The bronchial fistula was not found after pneumonectomy. Four years after surgery, the patient died of recurrent malignant pleural mesothelioma and underwent autopsy. Macroscopic evaluation showed tight adhesions and white scars on the bronchial stump. Microscopic findings showed few inflammatory cells and α-smooth muscle actin (α-SMA)-positive cells.

Conclusions

The results from this case suggested that bronchial mucosal ablation leads to robust agglutination of bronchial stump over years. This technique is not only simple but also reliable to prevent bronchial fistula.

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.

Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization

Background

During anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula.

Methods

Before reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared.

Results

ICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula.

Conclusions

ICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.