Bronchial closure methods and risks for bronchopleural fistula in pulmonary resections: how a surgeon may choose the optimum method?

Abstract

There is debate about which bronchial closure technique is the best to prevent bronchopleural fistulas (BPFs). We aim to assess the effect of bronchial closure procedures and patients' characteristics on BPF occurrence in pulmonary resections. Bronchial closures in 625 consecutive patients were assessed. Stumps were closed by manual suturing in 204 and by mechanical stapling in 421 cases. In the mechanical stapling group, stapling supported by manual suture was performed in 170 cases. BPFs occurred in 3.8%. Of these, stapling was used in 5.0%, whereas manual suturing was used in 1.5% (P=0.04). BPFs were more prevalent among patients who had undergone pneumonectomy (P<0.01), right pneumonectomy (P<0.01), stapler closure (P<0.01), patients with co-factors (P<0.01), and patients who had undergone preoperative neo-adjuvant (P=0.01) or postoperative adjuvant therapy (P=0.03). There was no difference in the frequency of BPF between patients with and without adjuvant support in the stapling group. The optimum bronchial closure method has to be chosen by considering the patient and bronchus based characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in risky patients. An additive support suture on the bronchial stump does not decrease the risk of BPF.

Neoadjuvant therapy and risk of bronchopleural fistula after lung cancer surgery: a systematic meta-analysis of 14 912 patients

“…Finally, a total of 30 studies (21-50) were included into our meta-analysis after quantitative estimations. The reasons for exclusion of the six lastly filtrated studies (51)(52)(53)(54)(55)(56) are briefly summarized in the Supplementary Data 3.…”

Management options for the complicated pleural space

“…BPF is more common after right compared with left-sided pneumonectomy (13.2-17.4 % versus 5.0 %) [26,27]. Other risk factors include use of staple closure and preoperative neoadjuvant or postoperative adjuvant chemotherapy [26]. Predisposing factors for spontaneous development of pneumothorax include underlying bullae or cysts, pulmonary infection, malignancy, necrosis from radiation or chemotherapy, acute respiratory distress syndrome, and disease states resulting in elevated intrathoracic pressure, for example exacerbation of obstructive lung disease and Boerhaave syndrome [29,75].…”

“…Many of these cases are further complicated by the development of prolonged bronchopleural fistulas (BPF) [25][26][27]. Open thoracostomy uses a vertical chest incision with rib resection and large bore chest tube insertion, enabling drainage of the pleural space.…”

“…Development of a BPF is a particularly deleterious complication of surgical lung resection with occurrence ranging from 0.5-0.7 % for lobectomy and 7.1-10.2 % for pneumonectomy [25][26][27]. BPF is more common after right compared with left-sided pneumonectomy (13.2-17.4 % versus 5.0 %) [26,27].…”

Pneumonectomy for Non–Small Cell Lung Cancer

“…If no leak is seen, the bronchus is covered with vascularized tissue. Whether an omental flap, a pericardial fat pad, a vascularized pericardium, or an intercostal muscle is used, it should be sutured either to the bronchus itself or to the tissues around the bronchus [46][47][48][49] (Fig. 8).…”