Ann Thorac Surg 2007;84:971-972
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Kemp Howard Kernstine, MD, PhD
Department of Thoracic Surgery, Lung Cancer and Thoracic Oncology Program, City of Hope Medical Center, 1500 E Duarte Rd, Warsaw MOB, Duarte, CA 91010-3000
(Email: kkernstine{at}coh.org).
Post-pneumonectomy bronchial stump fistula (BPF) is relatively uncommon. When BPF occurs, there is a high risk of morbidity and mortality, and usually requires a long hospital stay, often with poor, long-term outcome. Efforts to prevent BPF have been the subject of many articles and book chapters. Adherence to the principles attributed to Professor Richard Sweet decades ago minimize and potentially eliminate the occurrence of BPF (ie, avoiding long bronchial stumps so that the closure is adjacent to the blood supply and minimizes the pooling of endobronchial secretions, avoiding injury to the posterior bronchial arterial blood supply, avoiding the injury to bronchial tissue, avoiding tension of the bronchial closure [eg, by selectively using staplers, stapler thickness, or avoiding staplers and performing a hand sewn closure], avoiding tumor at the bronchial stump, and avoiding closure of the stump adjacent to infection or inflammation). Furthermore, we know that patients with comorbid problems such as malnutrition, diabetes (especially poorly controlled diabetes prior to surgery, during surgery, or after surgery), heart failure, liver failure, extensive preoperative radiation therapy, chemotherapy, and severe chronic obstructive pulmonary disease have all been implicated in the occurrence of BPF. The development of postoperative pneumonia and adult respiratory distress syndrome are also risk factors for BPF, as are patients who require postoperative intubation, likely from the continuous positive pressure on the bronchial stump and other confounding factors. Bronchial stump fistula is often a multifactorial problem that may not have a single cause. Probably the most important thing that we can do to prevent BPF is to avoid a pneumonectomy.
The article by Sfyridis and colleagues [1], from the Metaxa Cancer Hospital in Piraeus, Greece, in this issue of The Annals of Thoracic Surgery is interesting and unique in that it addresses BPF in a prospective fashion. The authors designed a randomized trial to assess the role of using a pedicled-intercostal muscle flap to prevent the endpoint, BPF, and postpneumonectomy empyema. They identified a high-risk group, diabetics, and they report a 0% rate of BPF and empyema in the patients that had an intercostal muscle flap performed at the time of pneumonectomy compared with an 8.8% and 7.4%, respectively for the two complications, in the control group. The authors are congratulated for their work and their attempt to improve patient care.
There are a few issues regarding this article that warrant comment. First, there were 70 pneumonectomies during a 3-year time period, which is quite a large number. Because there is a high short-term and long-term mortality attributed to pneumonectomy, and because there may be less cancer survival advantage [2], a better strategy would be to avoid pneumonectomy. Second, it is very difficult to standardize a surgical procedure (ie, the method of pneumonectomy), given the many surgeons involved and the types of patients with many different presenting problems and anatomy. Control of these details is necessary to study an intervention into the performance of pneumonectomy. However, the intercostal flap was standardized. In addition, bronchopleural fistula and empyema were not clearly defined, and the surveillance for these end points was not provided. By not having strict definitions, it allows for observer bias. Finally, the readers should be reminded that many other vascular-pedicled tissue flaps have been used to cover bronchial stumps that include parietal and mediastinal pleura, as stated in the article (ie, the intact azygous vein, pericardium, pericardial fat and thymic tissue, pedicled chest wall musculature, pedicled diaphragmatic flap, and pedicled omentum). When there is significant concern for bronchial breakdown or healing, the omentum may be superior.
Bronchial stump fistula and post-pneumonectomy empyema have a significant morbidity and mortality. Attention to detail and careful consideration of stump coverage, especially in high-risk patients, may hopefully reduce the likelihood of this dreaded complication. Although it intuitively makes sense to bring in extra blood supply and healthy tissue, we must temper our enthusiasm concerning the exciting results as it relates to this article, and we must perform good science to demonstrate to the rest of our profession the need for extra bronchial stump protection for our high-risk pneumonectomy patients.
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References
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- Sfyridis PG, Kapetanakis EI, Baltayiannis NE, et al. Bronchial stump buttressing with an intercostal muscle flap in diabetic patients Ann Thorac Surg 2007;84:967-972.[Abstract/Free Full Text]
- Albain KS, Swann RS, Rusch VR, et al. North American Lung Cancer Intergroup Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA(pN2) non-small cell lung cancer (NSCLC): outcomes update of North American Intergroup 0139 (RTOG 9309)2005 ASCO Annual Meeting Proceedings, Vol 23, No. 16S, Part I of II (June 1 Supplement). J Clin Oncol 2005:7014.
Related Article
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Bronchial Stump Buttressing With an Intercostal Muscle Flap in Diabetic Patients
- Panagiotis G. Sfyridis, Emmanouil I. Kapetanakis, Nikolaos E. Baltayiannis, Nikolaos V. Bolanos, Dimitrios S. Anagnostopoulos, Antonios Markogiannakis, and Antonios Chatzimichalis
Ann. Thorac. Surg. 2007 84: 967-971.
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