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Objectives: Covering the bronchial stump with free fat tissue has been used as minimally invasive prophylaxis against bronchial stump fistulas; however, postoperative changes in the bronchial stump have not been well validated. Our goal was to examine changes in the bronchial stump in response to covering with free fat tissue in a rat model., Methods: A left pneumonectomy was performed on 16 Wistar/ST rats, 12 of which had a bronchial stump covered with free subcutaneous fat tissue. Four rats that underwent a left pneumonectomy alone were sacrificed on postoperative day 7, and the 12 rats whose bronchial stumps were additionally covered with fat tissue were sacrificed on postoperative days 7, 14 and 56. Macroscopic and histological changes and pressure resistance of the bronchial stumps due to coverage with free fat tissue were examined., Results: None of the rats showed macroscopic infection or necrosis in the thoracic cavity at the time of the rethoracotomy. The normal bronchial stumps remained mostly exposed, whereas the bronchial stumps covered with fat tissue were well-coated with tissue mass. Histologically, fibrous connective tissue containing microvessels gradually formed around the bronchial stump covered with fat tissue, and some of the tissue masses still had normal fat structures 56 days postoperatively. Covering with fat tissue significantly increased the pressure resistance of the bronchial stump 7 days postoperatively and further increased with time., Conclusions: Covering the bronchial stump with free fat tissue formed fibrous connective tissue around the bronchial stump and reinforced its closure., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The occurrence of bronchopleural fistula (BPF) after pneumonectomy is associated with high morbidity and mortality. The incidence of BPF in historical patients not subjected to bronchial stump coverage (BSC) was between 6 and 12% after pneumonectomy for lung cancer surgery or benign disease. BSC is considered an important prophylactic measure against BPF and is widely used, but its efficacy remains unknown. Our aim was to systematically review the literature, in order to quantify BPF risk in patients receiving or not receiving BSC with any tissue after pneumonectomy. We performed a systematic review in PubMed, for papers published between 1999 and 2012, analysing series of patients treated with pneumonectomy and including both patients receiving coverage and patients not receiving coverage. Both randomized and non-randomized series were eligible. Proportion of failures (i.e. BPF) was analyzed separately in the two groups (patients receiving BSC and patients not receiving BSC). For each study and for the overall series, 95% confidence interval (CI) (without continuity correction) of the observed proportion was calculated. Overall, 21 series were eligible, with 3879 patients (1774 receiving BSC and 2105 not receiving coverage). The decision to perform or not the BSC was randomized only in one small trial, limited to diabetic patients, showing a significant reduction of BPF in favour of coverage. In the 20 remaining studies, baseline risk of BPF in the group of patients receiving BSC and in the group of patients who did not receive coverage was different. In patients receiving coverage, the proportion of BPF was 6.3% (95% CI: 5.3-7.5%). In patients not receiving coverage, the proportion of BPF was 4.0% (95% CI: 3.2-4.9%). In recently published series, the vast majority of patients considered at high risk for BPF received BSC. This common practice hinders an unbiased estimate of the efficacy of BSC in reducing BPF risk. Results of this meta-analysis show that, despite a clear negative selection, the incidence of BPF in patients considered at high risk and receiving coverage was only slightly higher compared with patients considered at low risk and not covered. A randomized trial would help answer the question., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The pedicled intercostal muscle flap (IMF) is a high quality vascularized tissue commonly used to buttress the bronchial stump after pneumonectomy or bronchial anastomosis after sleeve lobectomy in order to prevent bronchopleural fistula formation. The evaluation of the viability of the muscle flap is difficult. The aim of this study was the assessment of the application of indicyanine green fluorescence for the evaluation of IMF perfusion., Methods: The study included 27 patients (10 males and 17 females), mean age 62.6 years (47-77 years). Indocyanine green fluorescence (ICG) was used for objective assessment of the IMF quality by a near-infrared camera system (Photodynamic Eye(®), Hamamatsu Photonics, Japan). The following factors that may have an impact on the quality of the IMF were assessed: age, gender, body mass index, comorbidities, IMF length and thickness and timing of the harvesting during the procedure., Results: The following surgical pulmonary resections with IMF harvesting were performed: 12 pneumonectomies, 2 sleeve lobectomies and 13 lobectomies. Intercostal muscle flap (IMF) was harvested before rib spreader insertion in 23 patients (85%) and at the end of the surgery in 4 patients (15%). The mean length and thickness of the harvested intercostal muscle were 19.9 ± 2.9 cm (range 13-24 cm) and 2.4 cm ± 0.7 cm (range 1.0-3.5 cm), respectively. Indocyanine green angiography showed ischaemia in the distal part of the muscle in all cases, despite the lack of obvious macroscopic signs. Median length of the ischaemic part was 4 cm (range 0.5-20 cm). The IMF length and thickness had a significant impact on the length of the ischaemic segment. In 24 patients, the ischaemic part of the muscle flap was severed. In 3 patients with the longest ischaemic segment (11, 13 and 20 cm), an alternative tissue was used to cover the bronchial stump. No major complications occurred., Conclusions: Our preliminary results confirmed the simplicity and high efficacy of ICG in the assessment of intercostal muscle blood perfusion. ICG was superior to macroscopic evaluation and influenced surgical proceeding.

Objectives: One of the fundamental steps in an anatomical pulmonary resection is the main and lobar bronchus suture. Nowadays, two different types of staplers are on the market: the linear TA stapler for open surgery (Tyco Healthcare Group LP, Norwalk, CT, USA), which is based on a 'guillotine' mechanism, sewing, but not cutting the bronchus, and the endoscopic linear stapler which both cuts and sews. This study aimed to fill the void in the use of an instrument used to staple and cut at the same time in 'open' thoracic surgery, eliminating the need for a scalpel: the curved cutter stapler (Contour Curved Cutter Stapler; Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA)., Methods: Between May 2009 and March 2011, the Contour Curved Stapler (Ethicon) was used for the bronchus in 139 cases of non-small cell lung carcinoma (NSCLC)-29 females and 110 males ranging between 48 and 85 years (average 71.1)-and comprising 115 lobectomies (8 bilobectomies) and 24 pneumonectomies (8 on the right lung, 16 on the left lung)., Results: All patients underwent a bronchoscopic check-up 30 days after they were discharged: in all cases, the bronchial stump was clearly within normal limits. No cases of bronchopleural fistulas were observed in the 139 patients., Conclusions: On the basis of this study, the curved cutter stapler showed to be a satisfactory device for securing the bronchus during an anatomic resection (whether lobar or main), in 'open' thoracic surgery. However, even though there were no cases of fistula, we consider that our data is still too limited to be statistically significant.

Objective: Bronchopleural fistula is a serious complication of pulmonary resection. For anatomical reasons, lower lobectomy is thought to carry a higher risk for bronchopleural fistula. We investigated the efficacy of bronchial stump reinforcement with a pedicled intercostal muscle flap after lower lobectomy and compared the responses in patients treated with the flap, without the flap, and with other types of flap. We also investigated whether harvesting the intercostal muscle flap leads to an increase in blood loss during surgery and whether the type of flap influences chest-tube volume and pain after surgery., Methods: One hundred and sixty-eight patients had lower or middle-lower lobectomy between January 1990 and December 2004. The bronchial stumps were treated in one of the three ways: covered with an intercostal muscle flap (116 patients, group A), not covered with a muscle flap (32 patients, group B), or covered with free fat or pleura (20 patients, group C). In a separate study, we compared the blood loss during surgery, and chest-tube volume and pain after surgery between patients treated with the intercostal muscle flap (23 patients) and non-intercostal muscle flap (32 patients)., Results: No patients in group A exhibited bronchopleural fistula, and two patients in group B and one patient in group C exhibited bronchopleural fistula. These differences were not significant. Blood loss, chest-tube volume, and pain score after surgery did not differ significantly between treatment groups., Conclusions: Bronchial stump reinforcement with the intercostal muscle flap after pulmonary resection is safe and effective when performed during lower and lower-middle lobectomy and does not increase the risk of complications.

Objective: In a previous experimental study on 60 freshly slaughtered pig trachea, a statistically significant better resistance to pressure was found after mechanical stapling compared to hand suture. The objective of this study was to determine the resistance to pressure of a bronchial stump depending upon the closure technique (manual vs. mechanical) used in sheep 14 days after pneumonectomy., Methods: Pneumonectomy was performed on 30 sheep, which were alternatively closed either by a double-layer running suture at 90 degrees to the cartilaginous rings or with an automatic stapling device. Exactly 14 days after pneumonectomy, the animals were sacrificed and the trachea with the bronchial stump was retrieved. Sutures were placed under pressure until air leakage was observed. The air-leakage pressure was recorded digitally., Results: In both groups, there was no evidence of a bronchopleural fistula. As in the previous experimental study, mean values of air-leakage pressure revealed a large standard deviation in both groups (min. 0.16-max. 1.15 bar). Unlike the results in the first experiment there was no statistically significant difference between the two groups., Conclusions: After 14 days, when a bronchial stump is considered to be healed, the resistance to pressure of a mechanical suture is equal to that of the manual suture.

Objective: The invention of the mechanical suture of the bronchial stump resulted in the significant decrease of the incidence of bronchial fistulas. Bronchial fistula constitutes the most dangerous complication of the pulmonary resection. In connection with some negative opinions in world literature regarding the safety of applying some types of mechanical suture, the multi-factor analysis of efficacy of bronchial stump closure following the total pneumonectomy by two different types of stapling devices was performed., Methods: The experimental study was performed on 22 sheep. Each sheep underwent left pneumonectomy. In group I the bronchus was closed by the hinged-jaw stapling device (TA-Premium, Auto-Suture). In group II the bronchus was closed by the stapling device of parallel pattern (RLV 30 Ethicon). The macroscopic parameters (i.e. linear structure of staples, degree of staples closure, the symmetry of staples closure in the medial and lateral part of bronchial stump) as well as microscopic parameters (i.e. degree of inflammatory reaction, degree disorder in collagen fibers system, degree of disorders in cartilaginous system, degree of vascular proliferation and nervous regeneration) were evaluated., Results: In three cases of group I the serious abnormalities in staples closure in the medial part of the bronchial stump were revealed. Abnormalities were found also in microscopic evaluation of the specimens. In the whole group the inflammatory reaction predominated in the medial part of bronchial stump near the hinge of the cartridge (P value <0.05). The disorder in the collagen fibers system as well as in the stratified structure of muscular fibers and cartilaginous system was proved. On the other hand, in group II all staples were properly closed in adequate linear structure, without any symmetry in both medial and lateral end of the bronchial stump. The microscopic findings were only the subtle inflammatory process and a slight disarrangement in muscular, collagen and cartilaginous systems., Conclusion: The listed abnormalities of mechanical, hinged-jaw suture of bronchial stump seem to be due to the inaccurate placement of staples, their incomplete closure, and excessive damage to the sutured tissues. We conclude that the application of the hinged-jaw mechanical suture of the bronchial stump might result in higher incidence of bronchial fistula after pneumonectomy.