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Objectives: Bronchial fistula is a severe complication after thoracic surgery. Although many methods of coverage using various autologous tissues including pedicled pericardial fat pad have been reported to be useful for the prevention of bronchial fistula, the ideal roles of these approaches and the coverage techniques yielding the best results still remain unclear. The clinical use of an autologous free fat graft has been reported in the various surgical fields including otolaryngology, orthopaedics and plastic surgery. Therefore, we have used a free pericardial fat pad (FPFP) as the material for covering the bronchial stump instead of a pedicled pericardial fat pad., Methods: Between January 2009 and December 2013, 1134 patients with lung cancer underwent pneumonectomy or lobectomy without bronchoplasty at our institution. Among them, 46 patients underwent bronchial stump coverage using a FPFP and we investigated the clinical results obtained retrospectively., Results: Bronchial fistula occurred in 5 patients during the study period. Although we performed bronchial stump coverage mainly in patients with several risk factors for bronchial fistula, no bronchial fistula developed in this group. To investigate the viability of the FPFP, we examined the fat tissue around the bronchial stump demonstrated by chest computed tomography retrospectively. Although fat tissue at the bronchial stump gradually decreased in size, it remained evident for 5 months and was identified in almost half of the patients even at 1 year after surgery., Conclusions: No bronchial fistula developed in the FPFP group. Although the FPFP is a free flap, it remains viable for many months after surgery and may contribute to good wound healing of the bronchial stump by offering a wet environment. A pericardial fat pad is easy to make, can be used anywhere in the thoracic cavity and may be useful for bronchial stump reinforcement., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether manual closure of the bronchial stump is safer with lower failure rates than mechanical closure using a stapling device following anatomical lung resection. One hundred and twenty-nine papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question as they included sufficient number of patients to reach conclusions regarding the issues of interest for this review. Complications, complication rates and operation time were included in the assessment. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. When looking at manual vs mechanical staples, it was noted that stapler failure can occur in around 4% of cases. The rate of bronchopleural fistula (BPF) development varied more in patients who underwent manual closure (1.5-12.5%) than in patients who underwent mechanical closure (1-5.7%). Although most of the studies reviewed showed no statistical differences between manual and mechanical closure in terms of BPF development, one study, however, showed that manual closure was significantly associated with lower numbers of postoperative BPF, while another study showed that mechanical closure is significantly associated with lower incidence of BPF. When looking at the role of the learning curve and training opportunities, it seems that the surgeon's inexperience when using mechanical staples can contribute to BPF development. A surgeon's experience can play a major role in the prevention of BPF development in patients having manual closure. Manual closure can provide a cheap and reliable technique when compared with costs incurred from using staplers, it is applicable in all situations and can be taught to surgeons in training with an acceptable risk. However, there is a lack of evidence to suggest that manual closure is better than mechanical stapler closure following anatomical lung resection.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In pneumonectomy patients, is buttressing the bronchial stump associated with a reduced incidence of bronchopleural fistula?'. Fifty-seven papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One prospective randomized controlled trial was identified, which found significantly lower rates of bronchopleural fistula and empyema after pneumonectomy with the use of pedicled intercostal flap buttressing. Intercostal muscle flaps and pericardial flaps have been used in case series of high-risk patients, e.g. those with neoadjuvant therapy or extended resections, with low rates of subsequent bronchopleural fistulae. There is the least-reported evidence for thoracodorsal artery perforator and omental flaps. There is relatively little published evidence beyond the single randomized trial identified, with only a few comparison studies to guide clinicians. We conclude that there is evidence for flap buttressing in reducing the risk of bronchopleural fistulae after pneumonectomy in diabetic patients. Flap coverage in other high-risk situations, such as extrapleural or completion pneumonectomy, has been reported in case series with good results. Of the reported techniques, the evidence is strongest for the pedicled inter-costal flap.

Maintaining blood flow in and supplying various anti-inflammatory or angiogenic cytokines to the bronchial stump are very important factors involved in its healing. Pericardial fat pad tissue samples surgically obtained from 20 patients were assessed, and their angiogenic ability was investigated. The messenger RNA level of all angiogenic cytokines, including vascular endothelial growth factor, fibroblast growth factor-2 (FGF-2), platelet-derived growth factor-A (PDGF-A), angiopoietin-1 (Ang-1), Ang-2 and hepatocyte growth factor (HGF) were detected in the pericardial fat pad tissue. The protein levels of all cytokines except PDGF-A increased with time from day one to day seven after primary culture of the pericardial fat pad tissue. In particular, both HGF and Ang-2 protein levels on day seven were significantly higher than those on day one (P=0.0475 and P=0.0417, respectively). On the other hand, the protein level of FGF-2 decreased in time and was significantly lower on day seven than on day one (P=0.0296). The present study demonstrated the angiogenic ability of the pericardial fat pad. These results suggest that reinforcement of the bronchial stump by the pericardial fat pad is a worthwhile and justified procedure, and may prevent bronchopleural fistula after pulmonary resections.

There is debate about which bronchial closure technique is the best to prevent bronchopleural fistulas (BPFs). We aim to assess the effect of bronchial closure procedures and patients' characteristics on BPF occurrence in pulmonary resections. Bronchial closures in 625 consecutive patients were assessed. Stumps were closed by manual suturing in 204 and by mechanical stapling in 421 cases. In the mechanical stapling group, stapling supported by manual suture was performed in 170 cases. BPFs occurred in 3.8%. Of these, stapling was used in 5.0%, whereas manual suturing was used in 1.5% (P=0.04). BPFs were more prevalent among patients who had undergone pneumonectomy (P<0.01), right pneumonectomy (P<0.01), stapler closure (P<0.01), patients with co-factors (P<0.01), and patients who had undergone preoperative neo-adjuvant (P=0.01) or postoperative adjuvant therapy (P=0.03). There was no difference in the frequency of BPF between patients with and without adjuvant support in the stapling group. The optimum bronchial closure method has to be chosen by considering the patient and bronchus based characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in risky patients. An additive support suture on the bronchial stump does not decrease the risk of BPF.

Bronchopleural fistula after pneumonectomy is a life-threatening complication which is associated with the surgical technique and the experience of the surgeon. We evaluated the incidence of bronchopleural fistula using the posterior membranous flap technique, as originally described by G. Jack in 1965. The surgical technique of bronchial closure proximal to the carina is described and discussed. From 1999 to 2005, 45 consecutive patients underwent pneumonectomy in our hospital using the posterior membranous flap technique for bronchial closure. Twenty-nine patients (64.5%) underwent left pneumonectomy and 16 patients (35.5%) right pneumonectomy. Patients were operated on for non-small cell lung cancer (41 patients - 89%), small cell lung cancer (one patient - 2.2%), mixed and other types of cancer (two patients - 4.4%), and non-neoplastic etiology (one patient - 2.2%). In the follow up of the patients no bronchopleural fistula was identified after pneumonectomy, right or left. Thirty-day mortality was 6.6% (three patients), all because of cardiorespiratory insufficiency. Using the posterior membranous flap technique, we eliminated the two major factors of the occurrence of BPF: (a) the tension in the suture line; and (b) the remaining stump from the resected bronchus. This bronchial closure technique offers a safe method of prevention of bronchopleural fistula.