[Bronchoscopic treatment of bronchopleural fistula]

Bronchopleural fistula is an uncommon complication occurring especially following lung resection (pneumonectomy) and associated with high morbidity and mortality rates. The treatment is surgical but some studies reported bronchoscopic treatment. Localization and size of the fistula may indicate different endoscopic procedures. This overview described the different endoscopic procedures and their benefits.

[Bronchial fistulae after pneumonectomy for lung cancer]

Fistula of bronchial stump developed in 246 (9.4%) cases of 2614 patients who were underwent pneumonectomy for lung cancer in 1964-2013. Mortality rate in case of bronchial fistulae was 17.9%. It was analyzed causes of this complication, an important role of infection for its development was emphasized. So prevention of wound infection is main prophylactic action. Postoperative pneumonia and bleeding are considerable risk factors. Clinico-anatomical type of tumor, stage and technique of bronchial stump treating don't affect incidence of fistulae. Bronchial stump covering is important intraoperative preventive measure. Treatment of this complication includes early drainage and pleural cavity sanitation and isolation of fistula from pleural cavity. Endoscopic procedures (impact with silver nitrate, trichloroacetic acid, laser) are preferred to solve the last problem. It allowed to achieve fistulae healing in 58.1% of cases.

[Bilio-bronchial fistula due to hydatic disease: case report and review of the literature]

Bilio-bronchial fistula due to hydatid disease is a rare but severe condition. Three levels, abdominal, diaphragmatic and thoracic, may be involved, with high perioperative mortality. We report a case of bilio-bronchial fistula successfully managed by thoracotomy. Thoracotomy is the best approach for surgical treatment at all three levels.

[Treatment and prevention of bronchus-pleural fistula after pneumonectomy for lung cancer]

OBJECTIVE

To explore the methods of the treatment and the principles of the prevention of bronchus-pleural fistula (BPF) after pneumonectomy.

METHODS

The clinical data of 15 cases of BPF after pneumonectomy in 815 lung cancer cases treated from July 1999 to June 2006 were analyzed retrospectively.

RESULTS

The occurrence rate of BPF after right pneumonectomy was 3.9% (12/310), higher than 0.6% (3/505) of left pneumonectomy (P < 0.01). The occurrence rate of BPF in cases with positive cancer residues in stump of bronchus was 22.7% (5/22), higher than 1.3% (10/793) of the cases with negative stump of bronchus (P < 0.01). The occurrence rate of BPF in the cases received preoperative radio- or chemotherapy was 5.0% (6/119), higher than 1.3% (9/696) of the cases received operation only (P < 0.05). There were no BPF occurred in the 76 cases whose bronchial stump were covered with autogenous tissues. All of the cases diagnosed as BPF were undertaken either closed or open chest drainage. Two cases were cured by thoracentesis aspiration and infusion antibiotics repeatedly. Two cases were cured by blocking the fistula with fibrin glue after sufficient anti-inflammatory treatment and hypertonic saline flushing. Six cases were discharged with a stable condition after closed drainage only. One case was discharged with open drainage for long time and 1 case was cured by hypertonic saline flushing after failure to cover the BPF using muscle flaps. Three cases died of multi-organs functional failure.

CONCLUSIONS

BPF are related to the bronchial stump management and positive or negative residue of tumor at the bronchial stump. Autogenous tissues covering of the bronchial stump is a effective method for decrease the rate of BPF and especially for those patients received preoperative radio- or chemotherapy and right pneumonectomy. It should be performed for early mild cases with repeated thoracentesis aspirations or blocking the fistula with fibrin glue together with antibiotics. Chest closed drainage immediately and flushing with hypertonic saline repeatedly are effective methods for BPF.

[Use of endobronchial valve in postresection empyema and residual cavities with bronchopleural fistulas]

The results of treatment are analyzed in 78 patients with brochopleural fistilas after lung surgery. A method for imaging the draining bronchus under endoscopic guidance, by using the foamed dye administered into the residual cavity, has been developed. A valvular bronchial blocker for abolishing the function of bronchopleural fistular inserted into the lobular and segmental bronchus at bronchoscopy was designed and clinically tested. This procedure allows resurgery to be avoided in 91.7% of cases.

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies

BACKGROUND

Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema.

METHODS

Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression.

RESULTS

One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis.

CONCLUSIONS

Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

Preoperative Serum Fibrinogen Level Predicts Postoperative Pulmonary Complications After Lung Cancer Resection

BACKGROUND

Patients undergoing pulmonary resection are thought to be at high risk for the development of postoperative pulmonary complications (PPCs), and these complications may lead to serious morbidity. The purpose of this study was to identify the factors associated with postoperative pulmonary complications in patients undergoing lung cancer resection and to determine the effect of PPCs on survival.

METHODS

The study involved a retrospective review of 635 patients who had undergone curative resection for lung cancer. The patient group included 504 males (79.4%), and the overall mean age was 61.3 years. Patients were classified as those who had experienced PPCs (PPCs group, n = 105, 16.5%) or those who had not (no-PPCs group, n = 530, 83.5%).

RESULTS

The surgical procedures performed were 101 pneumonectomies (15.9%), 505 lobectomies (79.5%), and 29 lesser resections (4.6%). Cancer types comprised 330 squamous cell carcinomas (52.0%), 255 adenocarcinomas (40.2%) and 50 others (7.8%). Univariate analysis showed that the following factors were predictors for PPCs: male sex, erythrocyte sedimentation rate, preoperative serum fibrinogen level, pulmonary function, chronic obstructive pulmonary disease, smoking, double primary cancer, and surgical duration. Multivariate logistic regression showed that preoperative serum fibrinogen level (p < 0.001), surgical duration (p < 0.0001) and being male (p = 0.02) were significant predictors of PPCs. Overall survival 3 years after surgery was 68.2% in no-PPCs group and 38.8% in PPCs group (p < 0.0001). Regardless of tumor staging, overall survival differed significantly between PPCs and no-PPCs groups, whereas disease-free survival did not.

CONCLUSIONS

Higher preoperative serum fibrinogen levels, longer surgical duration, and being male were the predictive factors for PPCs in surgical candidates. The development of PPCs was linked to a shortened overall survival.

Early Detection of Occult Bronchopleural Fistula After Routine Standard Pneumonectomy

OBJECTIVE

The aim of this study was to define symptoms and signs for early diagnosis of occult bronchopleural fistula (OBPF) after routine pneumonectomy.

PATIENTS AND METHOD

From 1999 to 2003, 301 pneumonectomies for malignancy were performed. The records of these patients were retrospectively analyzed for several clinicopathologic factors. All patients (group A) that presented postoperatively with one or more suspicious symptoms and signs were recorded. These cases were grouped according to bronchopleural fistula documentation (group A1) or not (group A2). Both groups were subjected to multivariate analysis.

RESULTS

In 10 cases (3.3%) bronchopleural communication was confirmed (group A1). The most frequent signs included the lack of contracture or even enlargement of postpneumonectomy space (52.7%), subcutaneous emphysema (33.3%), fever (27.7%), respiratory insufficiency (27.7%), and cough (22.2%). Multivariate analysis disclosed failure of the postpneumonectomy space to contract as an independent prodromal sign for bronchopleural communication (P=0.03, odds ratio 58.3, 95% CI: 1.45-2335.9).

CONCLUSION

Chest radiology proved to be the diagnostic modality of choice for early detection of bronchopleural fistula.

Analysis of Risk Factors for Postpneumonectomy Bronchopleural Fistulas in Patients with Lung Cancer

BACKGROUND

Bronchopleural fistula is a potentially fatal complication of pulmonary resections, especially pneumonectomy.

METHODS

Univariate and multivariate analyses of the development of bronchopleural fistula were performed in 12 patients with bronchopleural fistula and 102 patients without bronchopleural fistula who had undergone pneumonectomy from January 1983 through December 2005.

RESULTS

Bronchopleural fistula developed after pneumonectomy in 12 patients (8.5%). Seven (58.7%) of the 12 patients died of bronchopleural fistula. Univariate analysis showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease significantly contributed to the development of postpneumonectomy bronchopleural fistula (p=0.0002, p=0.0043, and p=0.0387, respectively). Multivariate analysis also showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease were significant risk factors for postpneumonectomy bronchopleural fistula.

CONCLUSIONS

Bronchopleural fistula is strongly associated with preoperative infection, right pneumonectomy, and pathological N2, 3 disease. Bronchial stump coverage with pedicled tissue flaps and preservation of the bronchial arteries during mediastinal lymph node dissection are recommended to maintain the blood supply to the bronchial stump in patients at risk.

Bronchopleural Fistulas

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

[Esophago-respiratory fistulas of tumorous origin]

Esophago-respiratory fistulas developing in malignant disease have serious consequences by continuous airway contamination. Between 1984 and 1999 in the 1st Department of Surgery of Semmelweis University 1439 patients were treated with esophageal cancer. During regular examinations esophago-respiratory fistulas were detected in 163 patients (11.3% incidence). By analyzing data about these patients, we examined the causes, the characteristics of the disease and the possibilities and the efficiency of treatment. The mean age of these 163 patients was 55 (21-83) years, the ratio between men and women 3.7:1. By analyzing data of these patients according to their age, history, degree of dysphagia, weight loss, tumor size and survival rate, it can be noticed that there are two specific peaks, which differs from the average patients with esophageal tumors. Presumably, patients with esophago-respiratory fistulas can be divided into two groups. One consists of relatively younger patients with biologically more aggressive carcinomas, while the other group is of older patients where the fistula formation is the end stage of the slower progressing tumor. Twenty eight patients received irradiation before the fistula developed, most likely the longer survival rate contributed to the rise of the number of the fistulas. Ninety-five patients underwent endoscopic endoprosthesis implantation, 24 had the position of a stent corrected, 44 patients received palliative therapy, gastrostomy was performed in 15 patients. The median survival period was 5.0 months (0-46 months). Patients with endoprosthesis, gastrostomy and palliative treatment only had mean survival periods of 6.2 (1-46), 1.7 (0-5) and 1.6 (0-5) months. By sealing off the fistula, a successful endoscopic stent can end the serious airway contamination and the dysphagia, improving the quality of life and length of survival. Endoscopic endoprosthesis implantation is a feasible method in the treatment of patients with esophago-respiratory fistula.

Completion pneumonectomy for chronic mycobacterial disease

OBJECTIVE

Patients with persistent pulmonary infections from mycobacterial disease present a difficult clinical challenge. These individuals typically have poor pulmonary function, malnutrition, and other comorbidities, and few guidelines exist regarding optimal therapy. We report our experience with completion pneumonectomy as part of a multidisciplinary treatment program for patients with recurrent, persistent mycobacterial disease.

METHODS

During a 9-year period, 26 consecutive patients underwent completion pneumonectomy for mycobacterial disease. All patients underwent intensive, guided preoperative antibiotic therapy and aggressive nutritional supplementation. Complete surgical resection of the remaining destroyed or infected lung tissue was performed, often through an extrapleural dissection with intrapericardial ligation of vessels. Vascularized tissue flaps were used whenever possible to buttress the bronchial stump closure. Postoperative management consisted of a multidisciplinary approach, with ongoing antibiotic and nutritional therapy.

RESULTS

The primary organisms were Mycobacterium avium complex (n = 15), Mycobacterium tuberculosis (n = 5), Mycobacterium abscessus (n = 3), Mycobacterium xenopi (n = 2), and Mycobacterium chelonae (n = 1). Operative mortality was 23% (6/26): respiratory failure or adult respiratory distress syndrome in 2 cases, sepsis in 2, bronchopleural fistula in 1, and pulmonary embolism in 1. Significant morbidity occurred in 46% (12/26). Among the 17 long-term survivors, sputum conversion or discontinuation of medications was achieved in 14 (82%). Mean length of follow-up was 45 months (range 4-105 months).

CONCLUSION

Completion pneumonectomy remains an important component of therapy in patients with mycobacterial disease who have had failure of previous therapy. Although associated with significant risks, successful outcomes can be achieved with an organized, multidisciplinary approach and careful postoperative follow-up.

Pneumonectomy for nontuberculous mycobacterial infections

BACKGROUND

Pneumonectomy is considered in the treatment of nontuberculous mycobacterial infections when an entire lung is affected. However, this procedure carries high morbidity. We report on our experience in using pneumonectomy for treating patients with nontuberculous mycobacterial infections.

METHODS

Between 1983 and 2002, 53 patients infected with nontuberculous mycobacteria underwent 55 pulmonary resections. Of these patients, 11 (3 men, 8 women) underwent pneumonectomy (5 right, 6 left). Median age was 57 years (range, 43 to 69 years). Mycobacterium avium complex disease occurred in 10 patients and Mycobacterium abscessus disease in 1. Indications for pneumonectomy included multiple cavities in one lung and destruction of an entire lung. The bronchial stump was covered with a latissimus dorsi muscle flap in 7 patients and with an intercostal pedicle flap in 2.

RESULTS

Operating time ranged from 142 to 477 minutes (median, 360 minutes). The median intraoperative blood loss was 555 mL (range, 130 to 1,245 mL). There was no operative mortality. Bronchopleural fistula occurred in 3 patients. All fistulas were observed after right pneumonectomy, and were treated by reclosure of the bronchus. Empyema occurred in 1 patient, who was treated with irrigation. All patients achieved sputum-negative status after surgery. Two late deaths occurred. One patient died of respiratory failure 11 months after surgery. A second patient, the only patient who had recurrent disease, died of respiratory failure 4 years postoperatively.

CONCLUSIONS

Despite bronchial stump protection, right pneumonectomy carries a risk for bronchopleural fistula. Nonetheless, pneumonectomy can result in high cure rates in patients with nontuberculous mycobacterial infections.

[Post-pneumonectomy empyemas: causes, clinical course, management]

Between 1984 and 2000 in the Thoracic Surgery Centre pneumonectomies were performed in 947 patients. Postpneumonectomy empyema (PE) occurred in 67 (7%) patients. The aim of this paper were: analysis the reasons of postpneumonectomy empyema appearance, defined bacterial flora, clinical course and optimal management. The causes of PE were: pleural cavity haematoma (20 patients-29.8%), wound suppuration (18 patients-26.8%), bronchial fistula (31 patients-46.2%). These complications appeared singly or together in 49 (73.1%) patients. In 2 (3.0%) patients a long treatment in the Intensive Care Unit because of postoperative shock was the cause of infection. In 3 (4.5%) cases the cause of empyema was associated with infection during the operation. In 13(19.4%) cases the cause of empyema was not established. In 55 patients infections of pleural cavities were diagnosed in the first 8 weeks after operations. In 12 patients empyemas were established later. 12 (17.9%) patients died during the analyzed 1 year period after operation. In 18 (26.9%) patients infections were caused by only one bacterial strain and in 49 (73.1%) by two or three bacterial strains. The different methods of treatment (thoracentesis, drainage, operation) depending on general condition of patient were done.

Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter

OBJECTIVE

Side- and sex-related differences were analysed to explain the occurrence of bronchopleural fistula (BPF) after pneumonectomy on the right-hand side in men.

PATIENTS AND METHODS

Surgical pathology reports on 209 patients (15 with BPF) were retrospectively reviewed regarding sex, age, side, TNM stage, outer diameter of the resection margin (mm) and intrabronchial distance between tumour and resection margin (mm). Patients without macroscopic bronchial invasion were categorised as peripheral tumours. The t-test, U-test (Mann-Whitney) and cross-tabulation using the chi 2-test were performed for univariate statistical analysis. A logistic stepwise backwards regression model was used for multivariate analysis.

RESULTS

Women were significantly younger than men, had a smaller resection margin and fewer central tumours. Stage 4 was overrepresented in women, stage 2 in men. On the right-hand side, the distance was significantly shorter, the resection margin longer and the patients younger. Fistula patients showed a longer resection margin and a shorter distance, men were dominant. Multivariate analysis only identified length of the resection margin as an independent risk factor for BPF (p = 0.024, OR 1.177 CI: 1.033 - 1.356). Gender and side significantly influenced the diameter of the resection margin (p = 0.00).

CONCLUSION

The diameter of the bronchial stump is a major risk factor in the occurrence of post-pneumonectomy BPF, and explains the predominance of the male sex, the right-hand side and pneumonectomy. Where it exceeds 25 mm, prophylactic stump coverage with viable tissue should be performed.

[Mediastinal tubercular lymphadenitis and adenobronchial fistulas (TABF) in the paediatric age. 1980-2001 case record]

The aim of this study is to assess the frequency and clinical importance of mediastinal tubercular lymphadenitis and adenobronchial fistulas (TABF) and to evaluate the role of fiberbronchoscopy and surgical bronchoscopy associated with antimicrobical chemotherapy. 136 cases of primary pulmonary TBC, admitted to the Unit of Infectious Diseases, Bambino Gesu Children Hospital in Rome, between 1980 and 2001, were enrolled in the study. We considered 56 patients with clinical and radiological evidence of mediastinal tubercular lymphadenitis and 28 patients with adenobronchial fistulas (TABF). The incidence of TABF was 20,58% of primary pulmonary TBC. All patients were treated by medical therapy combined with local endobronchial surgery. TABF emerges as a complication of pediatric primary pulmonary TBC. We suggest a clinical and radiological survey to decide the utility of a diagnostic and therapeutic surgical bronchoscopy

Bronchopleural fistula after pneumonectomy

BACKGROUND

Bronchopleural fistula (BPF) is an infrequent but life-threatening complication after lung resection. The incidence of BPF reported in the literature varies between 0 and 15%.

AIM

To evaluate the incidence of BPF after pneumonectomy for primary lung cancer in a single practice using a single technique.

METHODS

Hospital records of patients who underwent pneumonectomy from 1 January 1988 to 1 October 1998 were reviewed retrospectively. The bronchial stump was closed using a uniform hand suture technique. There was a total of 157 patients, including 118 males and 39 females with a mean age of 64 years (range 37-78). Sixty-two patients (39.5%) had a right pneumonectomy.

RESULTS

Three patients developed BPF (1.9%). All occurred within seven days of the operation. Two of the three patients died. Ventilation for more than 24 hours was found to be the only significant risk factor for the development of BPF (p < 0.001).

CONCLUSIONS

Hand suture closure of bronchial stump after pneumonectomy is a safe, reproducible and inexpensive technique, and a low incidence of BPF can be achieved.

Application of mechanical and manual sutures enclosing the bronchus

The mechanical suture was introduced into thoracic surgical procedures by Amonosow and Androsow, Soviet surgeons, in the late 50s. The aim of the paper is to compare the incidence of bronchopleural fistulae that develop after the mechanical suture has been applied in bronchus surgery with the corresponding figures for traditional manual sutures. In the period of January 1997-March 1999 a series of 524 anatomical lung parenchyma resections was performed at the Department of Thoracic Surgery, Medical Academy of Gdańsk. In 460 cases (87.8%) the indication for the procedure came from primary lung carcinoma, and in 64 cases (12.2%) from tuberculosis, hamartoma, arteriovenous fistula, inflammatory lesions, asperpilloma, and metastases to the lungs. Depending on the way the bronchus was surgically closed the patients were subgrouped as follows: group I comprised 209 subjects (40.6%) whose bronchus was closed with a mechanical TA Premium Auto Suture, and group II that embraced 306 subjects (59.4%) whose bronchus was closed with a manual PDS 3/0 or Maxon 3/0 suture. The bronchopleural fistula developed in 11 cases of which 5/216 (2.3%) had the bronchus stump closed with a mechanical suture, and 6/308 (2.0%) cases had it closed with a manual suture. Of 11 cases of bronchopleural fistula 10 cases were noted after pneumonectomy. After the right side pneumonectomy, one fistula was discovered following the application of mechanical suture and six fistulas were found when the manual suture was used. After the left side pneumonectomy, no fistulae were discovered when the manual suture was used, and 3 those found were exclusively present when the mechanical suture was applied.

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis

BACKGROUND

The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication.

METHODS

We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses.

RESULTS

Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation.

CONCLUSIONS

Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.

Successful closure of postpneumonectomy bronchopleural fistulae by latissimus dorsi island flap and closed-chest irrigation

Bronchopleural fistula after pneumonectomy is a dreaded complication, because of its high morbidity and mortality. We describe a successful technique using closed-chest irrigation of the pleural cavity continued with transposition of a latissimus dorsi island flap.

Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures

OBJECTIVE

The method used to achieve bronchial closure, especially the relative merits of sutured versus stapled closure, remains an important topic among thoracic surgeons who seek the best way to prevent postoperative bronchopleural fistula (BPF) formation.

METHODS

Bronchial closure in 533 consecutive stumps in pulmonary resection from 1995 to 1997 at the National Cancer Center Hospital, Tokyo, was reviewed in terms of the incidence of troubles related to mechanical stapling (stapling failure) and to BPF formation. Fifty stumps (9%) were closed by manual suturing and 483 (91%) by mechanical stapling. For stapling, endostaplers were used for 313 stumps (65%), and other types of conventional staplers for 170 stumps (35%).

RESULTS

There were 18 stapling failures (a 3.7% overall incidence, 4.8% for endostaplers, 1.8% for other types of staplers). However, of these 18 patients only one developed BPF after surgery. Seven BPFs developed postoperatively among the 533 closures (overall incidence, 1.3%): two after manual suturing (4%) and five after stapling (1%), and this difference was not statistically significant. Of seven patients with BPF, four died of BPF-related complications.

CONCLUSIONS

Although bronchial closure by stapling was accompanied by failure, its incidence was acceptable and was not directly associated with the development of BPF postoperatively, as long as properly repaired. Newly developed endostaplers had similar incidence of stapling failure and BPF formation compared with other types of conventional staplers. These results suggest endostaplers can be used safely for various types of bronchial closure. The advantage of such devices could be the least chance of pollution of the operative field, simultaneous performance of stapling and division by one motion, and subsequently great saving of time.

[Bronchopleural fistula following the use of automatic stapling devices for lung cancer]

We compared automatic stapling with hand suturing in the rate of bronchopleural fistula. Twenty two hundred forty one patients of 25 hospitals, who were performed lobectomy or pneumonectomy for lung cancer from the year of 1990 to 1992, were investigated about the occurrence of bronchopleural fistula. The rate of bronchopleural fistula following lobectomy were 0.9% (11/1,227 cases) in automatic stapling, and 1.1% (8/753 cases) in hand suturing; there was no difference. However, there was a higher rate of the fistula with the use of automatic stapling devices in pneumonectomy. The rate was 11.2% (11/98 cases) in automatic stapling, and 1.2% (2/166 cases) in hand suturing. Automatic stapling may lead to bronchopleural fistula in pneumonectomy. Moreover, addition of hand suturing to automatic stapling was thought to prevent the fistula.

Clinical efficacy of doxycycline for pleurodesis

To determine the efficacy of doxycycline as a pleural sclerosing agent, we examined the outcomes in 31 patients (aged 31 to 87 years) receiving doxycycline (500 to 1,000 mg) through a chest tube for malignant pleural effusions or persistent bronchopleural fistulae. Of the 27 patients with malignant pleural effusions, 21 patients had a complete short-term response (no fluid reaccumulation during the initial hospitalization); 5 of the 6 short-term nonresponders had partial control of effusions, with improvement in respiratory symptoms. Of the 23 patients who survived longer than 1 month, 15 patients did not have reaccumulation of fluid during follow-up. All four patients with persistent bronchopleural fistulae had resolution of their air leaks; one patient had recurrence with a partial pneumothorax. Pleural pain controllable with narcotic therapy was the only important complication. Thus, doxycycline is a suitable substitute for tetracycline as a pleural sclerosing agent.

Pulmonary hydatidosis in children

In the years 1963-1991 inclusive, 88 patients were operated on with a diagnosis of pulmonary hydatid disease. The cysts were intact in 69 and infected in 19 cases. It was possible to use a surgical technique that preserved the pulmonary parenchyma in 67 patients. In this technique, the cavity after removal of the mother membrane is left open and only the air leaks are sutured. Continuous postoperative drainage of the residual cavity and the ipsilateral hemithorax always resulted in complete inflation of the affected lung. Enucleation of the endocyst and extended resection of the sclerotic pulmonary parenchyma were performed in 15, enucleation and obliteration in three, lobectomy in two and Barrett's method was applicable in one patient. A bronchopleural fistula developed in 11 patients postoperatively and in four of these cases a second thoracotomy was necessary. Postoperative empyema developed in four cases. There were two postoperative deaths in the series. Eighty-six patients were symptom-free in the long-term postoperative follow-up. We conclude that in the surgical management of the disease it should not be necessary to obliterate the residual cavity with extensive suturing which always leads to extra fibrosis with loss of viable pulmonary parenchyma.

Delayed leaks and fistulas after esophagogastrectomy: radiologic evaluation

OBJECTIVE

Although breakdown of the esophagogastric anastomosis often occurs as a complication of esophagogastrectomy during the early postoperative period, it is not well recognized that anastomotic leaks and fistulas may occur during the late postoperative period (more than 1 month after surgery). The purpose of our study was to determine the radiologic appearance and clinical significance of these late leaks and fistulas.

MATERIALS AND METHODS

A review of radiology records at our hospital from 1985 to 1991 revealed 37 patients who had upper gastrointestinal contrast studies an average of 13.3 months after esophagogastrectomy.

RESULTS

Six patients (16%) had anastomotic leaks or fistulas that occurred during the late postoperative period. Four patients were asymptomatic; three had contrast studies that showed thin, blind-ending tracks extending from the anastomosis into the mediastinum, and the fourth had an esophagogastric fistula. One of the blind-ending tracks later progressed to a gastropleural fistula that was treated with antibiotics and drainage. One symptomatic patient had a gastropleural fistula, and the other had a gastrobronchial fistula. Both fistulas were surgically repaired. None of the leaks or fistulas was associated with recurrent tumor.

CONCLUSION

Anastomotic leaks or fistulas may be detected on contrast studies obtained more than 1 month after esophagogastrectomy. Some leaks appear as blind-ending tracks that have no clinical significance, but others may be manifested by life-threatening gastropleural or gastrobronchial fistulas that necessitate surgical intervention.

Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome

During a 28-year period, 52 bronchopleural fistulas developed after pulmonary resection of 49 primary and three recurrent lung cancers at the National Cancer Center Hospital, Tokyo. During the same period there were 2359 pulmonary resections for primary lung cancer; the prevalence of bronchopleural fistula was 2.1%. Multivariate analysis on 15 variables in the most recent 1360 resections revealed significant risk factors for bronchopleural fistula: wider resection such as pneumonectomy, residual carcinomatous tissue at the bronchial stump, preoperative irradiation, and diabetes. Univariate analysis further recognized a risk in preoperative bronchial arterial infusion and the postsurgical stage of lung cancer. Six patients were not treated. Apart from chest tube drainage in seven patients, surgical repair was attempted in 39, direct resuture of the stump in 16, wrapping in 25, thoracoplasty in 31, completion pneumonectomy in 6, and other treatments. Despite various treatments, 37 patients (71.2% mortality) died from fistula-related complications (such as regurgitation of infected pleural fluid through the fistula and airway/intrathoracic bleeding). Even for patients whose fistulas were cured and who were discharged, the average hospital stay was 189 days. Further investigation is necessary to answer whether prevention by flap coverage is of any benefit.

Congenital respiratory-esophageal fistula in the adult. Report of nine cases and review of the literature

Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.

[The diagnosis and treatment of hepatopulmonary fistulae of amebic etiology]

The author has analyzed results of treatment of 28 patients with hepato-thoracic complications of amebic abscesses of the liver. Different variations of operative interventions are proposed including the separate (subdiaphragmatic) draining of the cavity of the liver abscess and pleural cavity and in cases of the appearance of bilio-bronchial fistulas--resection of the lung.

[Bronchopleural fistula after pulmonary resection of lung cancer]

From 1977 to 1988, 390 cases of lung cancer were resected in our hospital. In 12 patients (3.1%) a postoperative bronchopleural fistula developed. This complication occurred more commonly after right pulmonary resection than left and most common after right pneumonectomy. Moreover, that had occurred following right pneumonectomy was most fatal. After right middle and lower lobectomy, this complication occurred at the same rate as after pneumonectomy and also caused a fatal result. On the other hand, after the resection of single lobe, the rate of the occurrence of a bronchopleural fistula was lower. And, even if it had developed, the fistula sometimes could be healed by a conservative treatment only. In one of our cases the fistula was successfully treated by intra-bronchial gluing through a bronchofiberscope.

[Bronchopleural fistula: a late complication of collapse therapy in pulmonary tuberculosis]

Bronchopleural fistula (BPF) is a late complication of collapse therapy for pulmonary tuberculosis which usually develops several decades after the procedure. A characteristic finding in the chest radiogram is a pleural hydroaerial level, which suggests the diagnosis when associated with gravitational chocolate-like sputum. As the treatment of these patients is difficult, we think it is appropriate that they should be controlled in a primary care setting by periodical radiological studies (posteroanterior chest radiograms) which may permit early detection of the condition so as to establish specific therapy.

[Course of the postoperative period in infants with suppurative lung diseases]

An analysis of postoperative complications in 167 infants, operated for suppurative lung diseases, indicated that these complications are mainly the result of the purulent-inflammatory process progression. Recommendations concerning the prophylaxis against these complications with the analysis of the results of their use are given.