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eComment: Manual closure of bronchial stump during pneumonectomy: an obsolete method for only selective cases

Department of Cardiothoracic Surgery, Patras University School of Medicine, 26500 Rio Patras, Greece

The posterior membranous flap technique for bronchial closure after pneumonectomy

In your study, by using non-mechanical closure of the bronchus (‘the posterior membranous flap technique’) you reported no incidence of bronchopleural fistula development [1].

According to the literature [2] risk factors for bronchopleural fistula development are considered diabetes mellitus (only 8% in your cohort), neoadjuvant therapy (relatively high in your patients – up to 20%), right pneumonectomy (only 35% in your study), complementary pneumonectomy, residual disease on the bronchial margins after resection, preoperative infection, prolonged ventilation time, postpneumonectomy empyema formation and various technical factors. Such factors are local trauma, extensive devascularization of bronchial stump and long residual bronchial stump. Our opinion based on a cohort study of 221 patients who underwent pneumonectomy for non-small cell lung carcinoma, but according to other authors as well [3,4], suggests that manual bronchial closure is associated with an increased risk for fistula development in contrast to a mechanical type of closure used by most of the surgeons. The main disadvantages of the manual type of closure are the following: possible infection of hemithorax and eventual empyema formation, prolonged intraoperative time associated with a time-consuming method, asymmetrical closure of the stump, increased need for bronchial mobilization and devascularization, and increased tissue-trauma to the surrounding tissues due to the inevitable traction of the stump (especially on the left side). Additionally, there may be granulation tissue formation at the suture line, as well as some air leaks at the site of suture insertion at the bronchial stump.

In our opinion, manual bronchial stump closure should be preserved in only selected cases, where mechanical closure is considered practically impossible or in patients with increased risks to develop complications. In such cases, flap utilization for bronchial stump reinforcement as correctly suggested [1], is essential for prevention of bronchopleura fistula development. Moreover, stump reinforcement should be routinely performed in operated patients with one or more of the characterized as ‘predictive’ risk factors. According to our opinion these factors may be divided into preoperative and intraoperative. Diabetes mellitus, neoadjuvant therapy, steroid therapy, low respiratory reserves, and history of immunosupression should be considered in the preoperative factors. As intraoperative should be considered right pneumonectomy, long bronchial stump, extensive mobilization and bronchial devascularization, extended lymph node dissection around the bronchial stump, proximal tumors with possible infiltration of the bronchial margin, possible postoperative administration of chemo- or radiotherapy, and possible prolonged ventilatory support.

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1. Kakadellis J, Karfis E. The posterior membranous flap technique for bronchial closure after pneumonectomy. Interact CardioVasc Thorac Surg 2008;7:638–642.[Abstract/Free Full Text]
2. Ponn R. Pulmonary resection, Shields T, LoCicero J, Ponn R, Rusch V, editors. General thoracic surgery, 6th Ed, Lippincott Williams and Wilkins; 2005:569.
3. Cerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001;13:3–7.[Medline]
4. Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures. Eur J Cardiothorac Surg 2000;17:106–110.[Abstract/Free Full Text]

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