The optimal approach to postpneumonectomy bronchopleural fistula is prevention. Patients with infections that might result in empyema should be optimally treated medically prior to pneumonectomy, including use of the appropriate antimicrobial therapy. Resection for tuberculosis requires prolonged preoperative antituberculosis therapy (generally at least 3 months) unless done for emergency indications. Excessive bronchial devascularization should be avoided by ligation of bronchial arteries close to the bronchial transection point rather than more proximal. Excessive use of cautery (as opposed to fine suture ligation) to control large bronchial arteries is to be avoided in order to minimize ischemic and necrotic tissue around the bronchus. Inexperienced surgeons often make the stump too long, creating a reservoir which can harbor infected secretions. Transection of the bronchus should be done by sharp division to minimize tissue trauma (avoiding electrocautery). Clamping the proximal bronchus risks injury to the microcirculation of the stump and seems wise to avoid. The mucosal point to be closed should be visually inspected to make sure it is free of cancer (by bronchoscopy if a stapler is used) and frozen section analysis should be performed if there is any suspicion of residual disease. The particular method of bronchial closure is very individual and controversy remains as to what method is best. No randomized trial data exist to allow statistically valid comparisons. Review of reported retrospective series (see Table 43-1) suggests that hand suturing leads to somewhat lower rates of bronchopleural fistula than stapled closure. In fact, the only two large series that report no bronchopleural fistulae are from an unusual tension-reducing hand-sewn method reported by Gordon Jack.1,2 Jack's

Table 43-2 Possible Risk Factors for Postpneumonectomy Bronchopleural Fistula

Pleural Factors Empyema Lung abscess Bronchiectasis Tuberculosis Fungal infection

Technical Factors

Right pneumonectomy Experience of surgeon Bronchial devascularization Mediastinal lymph node dissection Residual disease at bronchial mucosa Excessive stump length Bronchial closure under tension

Postoperative Factors

Mechanical ventilation

Adjuvant Factors

Radiation therapy Chemotherapy

Bronchial artery embolization

Systemic Factors

Diabetes mellitus Chronic steroid therapy Immunosuppression Malnutrition Advanced age method is shown in Figure 43-1 and is most applicable when a cancer encroaches close to the carina, making a stapled closure impossible and an ordinary sutured closure problematic. This technique aims to reduce tension on the suture line and thus reduce the mechanical stress that promotes failure of bronchial closure. Another way to reduce tension on the suture line is to cut the bronchus so that a flap of the membranous wall is left longer to rotate up to the divided cartilage (Figure 43-2). This technique was originally popularized by Lyman Brewer and colleagues11 and is used in our unit. Closure of the evenly divided bronchus with the typical rigid cartilage ring invariably leads to tension and is probably one of the causes for the slightly higher rate of bronchopleural fistula with the stapler. Good results have been reported with permanent monofilament (Prolene) and braided absorbable (Vicryl) sutures. Nonabsorbable braided sutures (silk and polyester) are to be avoided as granulomas have been reported. Tying the sutures should be done very carefully as the membranous wall is easily torn (especially in women and patients on steroids), leading to very troublesome stump leaks. If a stapler is used (not my preference), it must be used just as carefully as if a hand-sutured closure is done. When closing a main bronchial stump, a 4.8 mm staple height should be used to avoid excessive crushing and resultant ischemia of the bronchial stump. One of the disadvantages of using a stapler is that not all stumps can be closed with a stapler, leading the surgeon to close a difficult stump without much experience or confidence in a sutured closure.

Vascularized tissue coverage of the closed main bronchial stump is probably an important component to reduce the incidence of bronchopleural fistulae, especially if risk factors (radiation, right pneumonectomy) exist. In 1942, Rienhoff and colleagues reported the first detailed study of bronchial healing after pneumonectomy (both experimentally in dogs and clinically in humans) and concluded that the bronchus healed by scar formation at the divided end of the bronchus.12 In 82% of the experimental animals, the primary closure with sutures failed, and healing occurred by secondary intention aided by local mediastinal tissue at the cut end of the bronchus. This fact led Rienhoff to the concept of buttressing the closure (which he viewed as temporary only) with local tissue coverage of the stump, both experimentally and in humans. Smith and colleagues reported an experimental study of stapled main bronchial closures and reported primary healing of only 50% of all stapled bronchi.13 Hence, whether the surgeon sutures or staples the bronchus, a fair proportion of bronchi will heal by secondary intention with the aide of local mediastinal tissues. Since there is little disadvantage to placing a flap over the bronchus, it seems to be a

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