Advertisement

Postpneumonectomy bronchopleural fistula: analysis of risk factors and the role of bronchial stump coverage

  • Marco Mammana
  • Giuseppe MarulliEmail author
  • Andrea Zuin
  • Egle Perissinotto
  • Giovanni Maria Comacchio
  • Elisa De Franceschi
  • Federico Rea
Original Article
  • 30 Downloads

Abstract

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.

Keywords

Bronchopleural fistula Pneumonectomy Complications Flap coverage Risk factors 

Notes

Compliance with ethical standards

Conflict of interest

We have no conflicts of interest to declare.

References

  1. 1.
    Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg. 1992;104:1456–63.Google Scholar
  2. 2.
    Jichen Q, Guangyu C, Gening J, Jian D, Wen G, Chang C. Risk factor comparison and clinical analysis of early and late bronchopleural fistula after non-small cell lung cancer surgery. Ann Thorac Surg. 2009;88:1589–93.CrossRefGoogle Scholar
  3. 3.
    Klepetko W, Taghavi S, Pereszlenyi A, Birsan T, Groetzner J, Kupilik N, et al. Impact of different coverage techniques on incidence of postpneumonectomy stump fistula. Eur J Cardiothorac Surg. 1999;15:758–63.CrossRefGoogle Scholar
  4. 4.
    Haraguchi S, Koizumi K, Hioki M, Hirata T, Hirai K, Mikami I, et al. Analysis of risk factors for postpneumonectomy bronchopleural fistulas in patients with lung cancer. J Nippon Med Sch. 2006;73:314–9.CrossRefGoogle Scholar
  5. 5.
    Zakkar M, Kanagasabay R, Hunt I. No evidence that manual closure of the bronchial stump has a lower failure rate than mechanical stapler closure following anatomical lung resection. Interact Cardiovasc Thorac Surg. 2014;18:488–93.CrossRefGoogle Scholar
  6. 6.
    Di Maio M, Perrone F, Deschamps C, Rocco G. A meta-analysis of the impact of bronchial stump coverage on the risk of bronchopleural fistula after pneumonectomy. Eur J Cardiothorac Surg. 2015;48:196–200.CrossRefGoogle Scholar
  7. 7.
    Sweet RH. Closure of the bronchial stump following lobectomy or pneumonectomy. Surgery. 1945;18:82–4.Google Scholar
  8. 8.
    Overholt RJ. General considerations pertaining to all resections. In: Overholt RJ, Langer L, editors. The technique of pulmonary resection. Springfield, IL: Charles C. Thomas; 1949. p. 24–68.Google Scholar
  9. 9.
    Hamad AM, Marulli G, Sartori F, Rea F. Pericardial flap for bronchial stump coverage after extrapleural pneumonectomy; is it feasible? Eur J Cardiothorac Surg. 2008;34:1255–6.CrossRefGoogle Scholar
  10. 10.
    Algar FJ, Alvarez A, Aranda JL, Salvatierra A, Baamonde C, López-Pujol FJ. Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis. Ann Thorac Surg. 2001;72:1662–7.CrossRefGoogle Scholar
  11. 11.
    Hu XF, Duan L, Jiang GN, Wang H, Liu HC, Chen C. A clinical risk model for the evaluation of bronchopleural fistula in non-small cell lung cancer after pneumonectomy. Ann Thorac Surg. 2013;96:419–24.CrossRefGoogle Scholar
  12. 12.
    Wright CD, Wain JC, Mathisen DJ, Grillo HC. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management. J Thorac Cardiovasc Surg. 1996;112:1367–71.CrossRefGoogle Scholar
  13. 13.
    Darling GE, Abduraman A, Yi QL, Johnston M, Waddell TK, Pierre A, et al. Risk of a right pneumonectomy: role of bronchopleural fistula. Ann Thorac Surg. 2005;79:433–7.CrossRefGoogle Scholar
  14. 14.
    Panagopoulos ND, Apostolakis E, Koletsis E, Prokakis C, Hountis P, Sakellaropoulos G, et al. Low incidence of bronchopleural fistula after pneumonectomy for lung cancer. Interact CardioVasc Thorac Surg. 2009;9:571–5.CrossRefGoogle Scholar
  15. 15.
    Mansour Z, Kochetkova EA, Santelmo N, Meyer P, Wihlm JM, Quoix E, et al. Risk factors for early mortality and morbidity after pneumonectomy: a reappraisal. Ann Thorac Surg. 2009;88:1737–43.CrossRefGoogle Scholar
  16. 16.
    Hubaut JJ, Baron O, Al Habash O, Despins P, Duveau D, Michaud JL. Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer. Eur J Cardiothorac Surg. 1999;16:418–23.CrossRefGoogle Scholar
  17. 17.
    Birdas TJ, Morad MH, Okereke IC, Rieger KM, Kruter LE, Mathur PN, et al. Risk factors for bronchopleural fistula after right pneumonectomy: does eliminating the stump diverticulum provide protection? Ann Surg Oncol. 2012;19:1336–422.CrossRefGoogle Scholar
  18. 18.
    Li S, Fan J, Zhou J, Ren Y, Shen C, Che G. Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis. Interact Cardiovasc Thorac Surg. 2016;22:327–35.CrossRefGoogle Scholar
  19. 19.
    de Perrot M, Licker M, Robert J, Spiliopoulos A. Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy. Scand Cardiovasc J. 1999;33:171–4.CrossRefGoogle Scholar
  20. 20.
    Hollaus PH, Setinek U, Lax F, Pridun NS. Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter. Thorac Cardiovasc Surg. 2003;51:162–6.CrossRefGoogle Scholar
  21. 21.
    Halezeroglu S, Keles M, Uysal A, Celik M, Senol C, Haciibrahimoglu G, et al. Factors affecting postoperative morbidity and mortality in destroyed lung. Ann Thorac Surg. 1997;64:1635–8.CrossRefGoogle Scholar
  22. 22.
    Chataigner O, Fadel E, Yildizeli B, Achir A, Mussot S, Fabre D, et al. Factors affecting early and long-term outcomes after completion pneumonectomy. Eur J Cardiothorac Surg. 2008;33:837–43.CrossRefGoogle Scholar
  23. 23.
    Puri V, Tran A, Bell JM, Crabtree TD, Kreisel D, Krupnick AS, et al. Completion pneumonectomy: outcomes for benign and malignant indications. Ann Thorac Surg. 2013;95:1885–900 discussion 1890–1.CrossRefGoogle Scholar
  24. 24.
    Tabutin M, Couraud S, Guibert B, Mulsant P, Souquet PJ, Tronc F. Completion pneumonectomy in patients with cancer: postoperative survival and mortality factors. J Thorac Oncol. 2012;7:1556–622.CrossRefGoogle Scholar
  25. 25.
    Liberman M, Cassivi SD. Bronchial stump dehiscence: update on prevention and management. Semin Thorac Cardiovasc Surg. 2007;19:366–73.CrossRefGoogle Scholar
  26. 26.
    Deschamps C, Bernard A, Nichols FC 3rd, Allen MS, Miller DL, Trastek VF, et al. Empyema and bronchopleural fistula after pneumonectomy: Factors affecting incidence. Ann Thorac Surg. 2001;72:243–8.CrossRefGoogle Scholar
  27. 27.
    Al-Kattan K, Cattalani L, Goldstraw P. Bronchopleural fistula after pneumonectomy with a hand suture technique. Ann Thorac Surg. 1994;58:1433–6.CrossRefGoogle Scholar
  28. 28.
    Rienhoff WF, Gannon J, Sherman I. Closure of the bronchus following total pneumonectomy. Ann Surg. 1942;116:481–531.CrossRefGoogle Scholar
  29. 29.
    Smith DE, Karish AF, Chapman JP, Takaro T. Healing of the bronchial stump after pulmonary resection. J Thorac Cardiovasc Surg. 1963;46:548–55.Google Scholar
  30. 30.
    Brewer LA, King EL, Lilly LJ, Bai AF. Bronchial closure in pulmonary resection: a clinical and experimental study using a pericardial fat graft reinforcement. J Thorac Cardiovasc Surg. 1953;26:507–32.Google Scholar
  31. 31.
    Taghavi S, Marta GM, Lang G, Seebacher G, Winkler G, Schmid K, et al. Bronchial stump coverage with a pedicled pericardial flap: an effective method for prevention of postpneumonectomy bronchopleural fistula. Ann Thorac Surg. 2005;79:284–8.CrossRefGoogle Scholar
  32. 32.
    Vester SR, Faber LP, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg. 1991;52:1253–7 discussion 1257–8.CrossRefGoogle Scholar
  33. 33.
    Sfyridis PG, Kapetanakis EI, Baltayiannis NE, Bolanos NV, Anagnostopoulos DS, Markogiannakis A, et al. Bronchial stump buttressing with an intercostal muscle flap in diabetic patients. Ann Thorac Surg. 2007;84:967–71.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Marco Mammana
    • 1
  • Giuseppe Marulli
    • 2
    Email author
  • Andrea Zuin
    • 1
  • Egle Perissinotto
    • 3
  • Giovanni Maria Comacchio
    • 1
  • Elisa De Franceschi
    • 1
  • Federico Rea
    • 1
  1. 1.Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of PaduaPaduaItaly
  2. 2.Thoracic Surgery Unit, Department of Emergency and Organ TransplantationUniversity Hospital of BariBariItaly
  3. 3.Biostatistic Unit, Department of Cardiac, Thoracic and Vascular SciencesUniversity of PaduaPaduaItaly

Personalised recommendations