Methods of bronchial stump buttressing in post-pneumonectomy bronchopleural fistula prevention: a systematic review

<b>Introduction:</b> The bronchopleural fistula (BPF) remains one of the most severe complications after pneumonectomy. Several surgical methods may enhance bronchial stump healing and reduce the occurrence of BPF. Usually, surgeons use tissue buttressing, such as intercostal muscle flap (IMF), parietal pleura, pericardium fat pad, or mediastinal fat, to reinforce the bronchial stump. This paper reviews the literature describing the impact of different buttressing tissues on the occurrence of early post-pneumonectomy BPF.<b>Material and methods:</b> We included all studies that described the use of bronchial stump buttressing in patients after pneumonectomy. Studies written in languages other than English were excluded. The search was performed using PubMed, Google Scholar, Embase, COCHRANE databases, and the clinical trial registry on December 1, 2023. We used the following search input: "lung cancer" AND "pneumonectomy" AND ("bronchopleural fistula" OR "BPF") AND ("tissue buttressing" OR "intercostal muscle flap" OR "mediastinal fat pad"). We analysed the types of studies, the numbers of patients, and the most important conclusions. We performed descriptive statistics.<b>Results:</b> Twenty-seven articles on the use of bronchial tissue buttressing were identified. Nine papers were rejected due to small sample size (< 20 patients), surgical operation other than pneumonectomy or lobectomy, or papers older than 30 years. Ultimately, 16 articles were included in the analysis. Among them, three papers highlighted the statistically significant influence of bronchial stump buttressing in reducing the risk of BPF formation. Descriptive statistics were reported in nine studies, and two papers included the assessment of the blood perfusion in the buttressing tissue. Only one study was a randomized trial featuring a control group for comparison.<b>Discussion:</b> Buttressing the bronchial stump remains a controversial issue in thoracic surgery. It could be beneficial for high-risk patients. Among different tissues, the ideal one has still not been identified. Future research should incorporate control groups and intraoperative assessments of the blood supply to the tissue employed for bronchial buttressing.