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Impact of different coverage techniques on incidence of postpneumonectomy stump fistula
W Klepetko1, S Taghavi, A Pereszlenyi
1Department of Cardiothoracic Surgery, University of Vienna, Austria. walter.klepetko@akh-wien.ac.at
Insights
Bronchial stump coverage after pneumonectomy significantly reduces the risk of postpneumonectomy bronchial stump fistula (PBSF). The pericardial flap technique appears most effective, completely avoiding PBSF in high-risk patients.
Area of Science:
- Thoracic Surgery
- Surgical Complications
- Pulmonary Medicine
Background:
- Postpneumonectomy bronchial stump fistula (PBSF) is a severe complication with variable incidence (0-12%).
- Effective strategies for preventing PBSF are crucial following pneumonectomy.
Purpose of the Study:
- To evaluate the efficacy of various bronchial stump coverage techniques in preventing PBSF.
- To identify the optimal method for bronchial stump management post-pneumonectomy.
Main Methods:
- Retrospective analysis of 129 pneumonectomy patients (1987-1997).
- Bronchial stump closure using stapling devices.
- Comparison of different stump coverage methods: pericardial flap, posterior pericardium, azygos vein, mediastinal tissue, pleura, intercostal muscle flap, and no coverage.
- Pericardial flap used for high-risk patients (neoadjuvant therapy or extended resections).
Main Results:
- Overall PBSF incidence was low at 0.8% (1 patient).
- The pericardial flap group showed no instances of PBSF.
- One complication (cardiac tamponade) occurred, unrelated to PBSF.
Conclusions:
- Bronchial stump coverage is vital in minimizing PBSF incidence.
- The pedicled pericardial flap technique demonstrates superior results, effectively preventing PBSF, especially in high-risk cases.
Objective:
Postpneumonectomy bronchial stump fistula (PBSF) is a serious complication with a reported incidence between 0 and 12%. The aim of this retrospective study was to investigate the effectiveness of different coverage techniques of the bronchial stump applied in a consecutive series of pneumonectomies in avoiding this particular problem.
Methods:
Between 1/87 and 10/97, 129 patients (90 male, 39 female, mean age 57.8 years, range: 15-78 years) underwent pneumonectomy by one surgeon (W.K.). In 14 patients, additional resection procedures were performed (aorta n = 6, vena cava n = 5, thoracic wall n = 3). In all patients with malignancies (n = 123), mediastinal lymphadenectomy was routinely added to the procedure. Bronchial stump closure was performed by means of stapling devices in all patients. Coverage of the bronchial stump was performed with a generous pedicled pericardial flap and concomitant reconstruction of the pericardium with Vicryl mesh (n = 50), with a portion of the posterior pericardium (n = 16), with the azygos vein (n = 12), with surrounding mediastinal tissue (n = 25), with pleura (n = 16), or with intercostal muscle flap (n = 3); no coverage at all was performed in seven patients. In all patients with high risk for development of PBSF, i.e. patients who received any form of neoadjuvant therapy or had extended resections, the pericardial flap technique was used.
Results:
Perioperative mortality was 5.4% (n = 7) and five patients (3.9%) experienced significant perioperative complications, with one of them directly related to the method of bronchial stump coverage (cardiac tamponade due to the use of a too small Vicryl mesh for reconstruction of the pericardium). Follow-up was 96.1% complete (five patients were lost to follow-up). Fourty-seven patients (36.4%) died late after operation (mean 19+/-13 months, median 17 months), mainly due to recurrence of their underlying malignant disease. PBSF occurred in one patient only (0.8%), 2 weeks after operation (coverage with pleura). No PBSF was seen in the long term follow-up period.
Conclusion:
Coverage of the bronchial stump contributes to a low incidence of PBSF. In view of the fact, that this serious complication was completely avoided in the pericardial flap group (used in patients with expected higher risk for PBSF), this particular technique seems to offer the best results.