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Objective: To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy., Methods: Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality., Results: During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts., Conclusions: Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Postoperative bronchopleural fistula (BPF) is a rare but severe and sometimes life-threatening complication that needs immediate and proper treatment. Thoracic surgeons should strictly manage the comorbidities such as diabetes mellitus for BPF prevention. Also, coverage of the bronchial stump with pericardial fat tissue will prevent BPF, or at least prevent the turning severe of BPF. However, when BPF occurs, we must promptly determine whether to perform conservative treatment or invasive treatment such as fenestration.

Background: Bronchopleural fistula (BPF) is a serious complication with high mortality and morbidity that can be seen after lung resections. Although several methods have been described to prevent postoperative BPF it is still unclear which method is the best. In this study, we have used tymopericardial fat flap (TPFF) to cover the bronchial stump in patients after pneumonectomy and aim to show its feasibility and efficacy to prevent BPF., Methods: Between January 2013 and June 2021, 187 patients with lung cancer underwent pneumonectomy at our institution. Among them, 53 patients underwent bronchial stump coverage with TPFF. In other 134 patients there wasn't used any coverage method. Patient characteristics, preoperative status, surgical procedures, perioperative course, pathological findings, and long-term prognoses were evaluated retrospectively., Results: Postoperative BPF was observed in 16 (%8.5) patients. It was observed that TPFF was applied in only 1 of the patients who developed BPF. A statistically significant difference was detected between TPFF-coverage with non-coverage groups in terms of postoperative BPF rates (p = 0.044). Other factors associated with the development of postoperative BPF in univariate analysis were right sided pneumonectomy, and re-operation., Conclusion: Bronchial stump coverage with TPFF is a feasible and effective method to prevent postpneumonectomy BPF., (© 2022. The Author(s).)

Bronchopleural fistula (BPF) remains a significant source of morbidity and mortality after right pneumonectomy (RPN). Postoperative mechanical ventilation represents a primary risk factor for BPF. We undertook an experiment to determine the influence of airway diameter on suture line tension during mechanical ventilation after RPN. RPN was performed in 6 fresh human adult cadavers. After initial standard bronchial stump closure (BSC), the airway suture lines were subjected to 5 cm H 2 O incremental increases in airway pressures beginning at 5-40 cm H 2 O. To minimize airway diameter, a carinal resection was then performed with trachea to left main bronchial anastomosis and the airway suture lines subjected to similar incremental airway pressures. Wall tension (N/m) at the suture lines was measured using piezoresistive sensors at each pressure point. As delivered airway pressure increased, there was a concomitant increase in wall tension after BSC and carinal resection. At every point of incremental positive pressure, wall tension was however significantly lower after carinal resection when compared to BSC (P < 0.05). Additionally the differences in airway tension became even more significant with higher delivered airway pressure (P < 0.001). Airway diverticulum after BSC leads to significantly increased tension on the bronchial closure with positive airway pressure as compared to a closure which minimize airway diameter after RPN. This supports the role of Laplacian Law where small increases in airway diameter result in significant increases on closure site tension. Techniques which reduce airway diameter at the airway closure will more reliably reduce the incidence of BPF following RPN., (Published by Elsevier Inc.)

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.)

Background: The development of a bronchopleural fistula (BPF) is the most serious postoperative complication of thoracic surgery. All surgical techniques that have been reported as preventive measures against BPF have disadvantages., Patients and Methods: We herein introduce a new technique (Yatsuhashi method) for covering the bronchial stump after right lower lobectomy using isolated pericardial fat tissue (PFT). Between 2012 and 2015, 878 consecutive patients with lung disease underwent surgery at our Institution. Among these patients, 26 underwent right lower lobectomy. Their clinical records were retrospectively reviewed to identify the presence of residual fat, in patients in whom the traditional pedicle method was applied and in those in whom an isolated PFT method was applied. The data on the characteristics, surgical details, and perioperative outcomes were analyzed., Results: There were no cases of BPF and the 90-day mortality rate was 0%. The mean period of time from the day of surgery until the computed tomographic examination was 207 days. There were no significant differences in the age, gender, clinical stage, pathological stage, the presence of comorbidities or complications, the duration until computed tomography, nor the presence of residual fat between the patients in whom the isolated PFT (n=17) and the standard pedicle (n=9) methods were applied. Furthermore, no postoperative complications due to the use of isolated PFT itself were observed in the patients who were treated using this method. The existence of residual isolated PFT was also confirmed in five out of six cases who underwent surgical treatment with the novel Yatsuhashi method., Conclusion: The simple technique using PFT for covering the bronchial stump after right lower lobectomy was satisfactorily effective and was not associated with any complications., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Purpose: Bronchopleural fistula (BPF) is a serious complication following pneumonectomy in lung cancer patients. The aim of this retrospective study is to investigate the efficacy of bronchial stump reinforcement with a collagen fleece coated with fibrin glue(TachoComb®)., Methods: The bronchial stumps of 43 lung cancer patients who underwent pneumonectomy between January 1998 and January 2003 were covered with pericardial fat pad.From February 2003 to the March 2011, we used TachoComb to cover the bronchial stumps of all lung cancer patients undergoing pneumonectomy (20 cases). Several preoperative, intraoperative, and postoperative variables were recorded retrospectively., Results: Univariate analysis of comorbidities and risk factors did not show any significant differences between the two groups except for neoadjuvant chemotherapy. Postpneumonectomy BPF occurred in three of the 43 (7%) patients who had pericardial fat pad coverage and in none of the patients treated by TachoComb., Conclusion: Reinforcement of the bronchial stump with TachoComb is a simple procedure, comparable to coverage with viable tissue, and should be considered in the prevention of postpneumonectomy BPF.

In order to achieve respectable postoperative outcomes after lung resection it is essential to understand the mechanism of bronchus healing. The bronchus seal should be air-tight and consist of monofilament suture or staples. The bronchus suture should be covered with vital tissue (lung, mediastinum, muscle flap). A complication in the process of bronchus healing should be diagnosed as early as possible in order to stop the destructive effect of the infection as rapidly as possible., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Bronchopleural fistula (BPF) remains an important source of morbidity and mortality after right pneumonectomy. We reviewed our 18-year institutional experience with right pneumonectomy to identify risks factors for BPF., Methods: From 1992 to 2010, a total of 145 patients who underwent right pneumonectomy were identified from an institutional database. Median age was 56 years. Most patients (66.2%) underwent surgery for non-small cell lung cancer. Sixty-seven patients (46.2%) received either chemotherapy or radiotherapy before surgery. Medical records were reviewed for 14 variables potentially predictive for BPF, including two airway closure techniques (standard bronchial closure and carinal closure). Variables predictive of BPF by univariate analysis were entered into a logistic regression model., Results: The overall mortality rate was 13.1% (n=19), with 15.9 and 10.5% mortality in the bronchial closure and carinal closure groups, respectively (P=0.33). The overall BPF rate was 7.6% (n=11), with a 3.9% (3 of 76) rate in the carinal closure group compared to 11.6% (8 of 69) in the bronchial closure group (P=0.08). Seven of eight bronchial closure patients who developed BPF required operative repair. Only one of three patients who developed BPF after carinal closure did not spontaneously heal after open drainage. Multivariate analysis identified preoperative radiation dose (P=0.042) and bronchial closure (P=0.041) as independent risk factors for BPF, while the length of postoperative ventilation before development of BPF approached significance (P=0.057)., Conclusions: In our experience, higher preoperative radiation doses are a risk factor for BPF after right pneumonectomy, while carinal closure exerts a protective effect.

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.

To prevent postpneumonectomy bronchopleural fistula, coverage of the bronchial stump is recommended, especially for patients treated with neoadjuvant and adjuvant chemotherapy or radiochemotherapy. We compared outcomes after proximal pericardial fat pad coverage and coverage with pleura and surrounding tissues, by retrospective analysis of the records of 243 patients. Postpneumonectomy bronchopleural fistula occurred in 7/143 (4.9%) patients who had pericardial fat pad coverage, and in 6/100 (6.0%) treated by pleural covering. Bronchopleural fistula occurred in 11 patients within 21 days, in one after 2 months, and one after 6 months. Univariate analysis of comorbidities and risk factors did not show any significant differences between the groups. Advanced T stage and carcinomatous lymphangiosis at the resection margin were associated with a higher risk of bronchopleural fistula development, independent of the technique. Reinforcement of the bronchial stump by proximal pericardial fat pad coverage appears to be safe and feasible. It is comparable to coverage with pleura and surrounding tissues.

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.

A strategy providing for solution of a number of tactical and technical problems involved in prognosis, prevention and management of postoperative bronchopleural complication after pneumonectomy for lung cancer was suggested. It was followed by a significant decrease in the frequency of bronchopleural fistula, postoperative empyema and lethality from purulent bronchopleural complications.

Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.

The efficacy of local instillation of fusidic acid in the prevention of post-surgical microbial complications during various types of lung resection was studied. Four hundred ninety two consecutive patients who underwent 504 thoracotomies for non-small cell lung carcinoma during April 1998-May 2004 were reviewed. The 290 patients of the first period who underwent 298 thoracotomies received a chemoprophylactic regimen of intravenous cefuroxime while the 202 patients of the second period who underwent 206 thoracotomies were additionally treated with fusidic acid, irrigated with local instillation into the pleural space, for the prevention of postoperative septic complications. Patients were followed postoperatively for development of septic complications (empyema and bronchopleural fistula) as well as of pneumonia and wound infection. Seventeen patients (5.7%) of the first period developed empyema and 13 fistula (4.4%), whereas only 2 patients (1.0%) of the second period developed empyema and fistula (OR = 5.876; 95% CI, 1.343- 25.716; P = 0.008 and OR = 4.193; 95% CI, 1.003-20.130; P = 0.034, respectively). Cases of pneumonia decreased, but not significantly, from 21 (7.0%) during the first period to 9 (4.4%) during the second period (OR = 1.613; 95% CI, 0.724-3.593; P = 0.257) while cases of wound infection decreased significantly from 19 (6.4%) to 2 (1.0%) (OR = 6.567; 95% CI, 1.513-28.510; P = 0.003). During the first period 23 pathogens were found from cases of empyema and 73 pathogens from cases of pneumonia and wound infection, whereas during the second period 3 and 18 pathogens were respectively found (OR = 5.3; 95% CI, 1.570-17.888; P = 0.003, and OR = 2.804; 95% CI, 1.628-4.838; P <0.001, respectively). These results indicate that local instillation of fusidic acid in the pleural space prior to lung resection seems effective in reducing the rate of septic complications as well as of wound infections.

Extended or combined pneumonectomies were performed in 56 cases of advanced complicated non-small cell lung cancer. Bronchial stump was closed by a modification of Overholt's technique using a vascularised tissue flap. Postoperative complication rate was 66%, mortality--23% and bronchial fistula--1.8% (1 case). Our modification of Overholt's technique using a well vascularised flap from the pericardium, muscle or omentum effectively prevented bronchial fistula in cases of multiple risk and is indicated in all cases of surgery for advanced lung cancer.

A venobronchial fistula developed between the azygous vein and the upper aspect of the right main bronchus 12 months after completion of the treatment of a stage IIIB non-small-cell lung cancer in a 54-year-old man. The fistula contained the tip of the catheter placed for chemotherapy perfusion. The reported case presented risk factors previously identified for such a complication. In addition, some clinical particularities were present, suggesting new potent risk factors and some preventive means for safe long-term central venous catheterization.

Objective: To prevent or reduce such postoperative complications of pneumonectomy as bronchopleural fistula and promote the curative effect of the surgery by improving the technique for handling the bronchial stumps., Methods: In 107 patients, bronchial stapler was adopted for closure of the bronchial stump and pneumonectomy was subsequently performed on the side of the staples. A 1-0 polyester suture was used to for suture in the shape of "U" deep in the mechanical suture on the bronchial stump. The postoperative complications were observed., Results: The operations were performed easily and the bronchial stumps were short and sutured firmly. No fluid retention or granuloma occurred in the stumps after the operation, nor were the complications such as intractable cough and infection of thoracic cavity observed. No bronchopleural fistula was found in these patients., Conclusion: This new method is safe and effective for treatment of the bronchial stumps.

Purpose: To investigate whether division of the pulmonary ligament after upper lobectomy obliterates dead space., Methods: Thirty-five patients scheduled to undergo upper lobectomy (23 right, 12 left) were randomly assigned to two groups, according to whether the inferior pulmonary ligament was divided (11 right, 12 left) or preserved (6 right, 6 left). To assess upward movement of the nonoperated lobes, plain chest X-ray films (posterior-anterior) were done at end-inspiration preoperatively and 1 month postoperatively, and the ratio of dead space in the longitudinal axis was measured. To assess the change in the angle of the main bronchus, chest X-ray tomography films were done preoperatively and 1 month postoperatively. The angles formed by the main bronchus and the truncus intermedius on the right side, and by the main bronchus and the lower bronchus on the left side, were measured, and the postoperative changes were calculated., Results: The dead space ratio did not differ significantly between the divided group and the preserved group (3.5% vs 5.5%) or between sides. The change in the angle of the main bronchus did not differ significantly between the two groups on either the right (36.4 degrees vs 36.3 degrees) or the left side (72.5 degrees vs 60.0 degrees)., Conclusion: Division of the pulmonary ligament after upper lobectomy is less effective for the obliteration of dead space than leaving it intact.

Background: Radiation effects make operative dissection difficult, impair subsequent healing, and increase morbidity. This study evaluates tissue reinforcement of the irradiated bronchus as a modality to reduce morbidity after lobectomy for lung cancer., Methods: We retrospectively reviewed all patients who had preoperative radiotherapy before lobectomy for lung cancer between May 1977 and June 2000., Results: There were 56 patients (33 men and 23 women) who ranged in age from 42 to 80 years (median, 59 years). Bronchial stump reinforcement included no coverage in 24 patients (42.8%), mediastinal tissue (parietal pleura, pericardial fat, or azygos vein) in 16 (28.6%), and muscle (serratus anterior) in 16 (28.6%). Median preoperative radiation dose was 4,600 cGy (range, 3,000 to 9,810 cGy) and did not differ between the groups. There were three deaths (13%) in the no coverage group, one (6%) in the mediastinal tissue group, and one (6%) in the muscle group (NS). Pulmonary complication rate was 67% in the no coverage group, 44% in the mediastinal group, and 25% in the muscle group (p = 0.03). Median duration of chest tube drainage was 8 days in the no coverage group, 6 days in the mediastinal group, and 5 days in the muscle group (p = 0.006). Median hospital stay was 13 days in the no coverage group, 9 days in the mediastinal group, and 7 days in the muscle group (p = 0.02). Patients in the muscle group had reduced hospital stay, duration of chest tube drainage, and pulmonary complications compared with the other two groups (p < 0.05). Subjectively, presence and magnitude of postoperative pain, range of motion, and strength of the upper extremity of the muscle flap side were not different between the groups (p = NS). Follow-up was complete and ranged from 4 to 147 months (median, 17 months)., Conclusions: Tissue reinforcement of the irradiated bronchus after lobectomy reduces postoperative morbidity and hospitalization. Transposition muscle flap may be preferred.

A 72-year-old man complaining of cough rejected the operation for squamous cell carcinoma obstructing the right intermediate trunk, therefore he was received 82 Gy (40 Gy and 42 Gy) of radiotherapy. However, the tumor did not decrease, in addition, cough and purulent sputum became severe gradually. We performed right pneumonectomy and omentopexy to prevent bronchial fistula, he had no pulmonary complication. Radiotherapy is a risk factor for postoperative bronchial fistula, omentopexy is useful to prevent it.

Background: The incidence of a bronchopleural fistula (BPF) as a major complication after non-small cell lung carcinoma (NSCLC) surgery has decreased in recent years, due to new surgical refinements and a better understanding of the bronchial healing process. We reviewed our most recent experience with BPFs and tried to determine methods which may effectively reduce its occurrence., Methods: Data on 490 patients with lung resections for NSCLC over a period from 1990 to 1999 were retrospectively reviewed. Details regarding surgery and the subsequent treatment were carefully reviewed. Particular attention was paid to factors possibly affecting the occurrence of BPFs: the technique of the initial bronchial closure, previous radiation and/or chemotherapy, need for postoperative ventilation and presence of residual carcinomatous tissue at the bronchial suture line. Information about age, sex, clinical diagnosis, associated conditions, TNM stage, period between primary operation and rethoracotomy and postoperative outcome was also recorded., Results: The overall BPF incidence was 4.4% (22/490). There were 21 (95.5%) males and 1 (4.5%) female, mean age was 57.8 years. BPFs occurred after pneumonectomy in 12 (54.6%), after lobectomy in 9 (40.9%) patients and after sleeve resections in 1 (4.5%) patient. Mortality rate was 27.2% (6/22). Right-sided pneumonectomy and postoperative mechanical ventilation were identified as risk factors for BPFs (p<0.05). Initial chest re-exploration was performed in 20 (90.9%) patients. After debridement, the bronchial stump was reclosed by hand suture in 10 (45.4%) patients. All 10 (45.4%) patients with a post-lobectomy- and sleeve resection BPF necessitated completion surgery. The BPF was additionally covered with a vascularized flap in 20 (90.9%) patients. In 2 (9%) patients with small BPFs and poor overall condition the initial treatment was endoscopic. In both the fistula persisted and the stump had to be surgically resutured., Conclusions: A BPF remains a major complication in the surgery of NSCLC because of its high mortality and morbidity rate. A BPF is more common after right-sided pneumonectomy and is frequently associated with postoperative mechanical ventilation. The management varies according to the initial type of surgery, the size of the BPF, the overall patient condition and that of the remaining lung. Endoscopic treatment is reserved only for small fistulas associated with poor general condition.

A device of intercostal thoracotomy for preparing an intercostal muscle flap (IMF) is reported. In order to preserve a intercostal muscle (IM) at the level of thoracotomy, a thoracotomy is preformed by incision of lower edge of IM. By this technique, an intercostal thoracotomy can be performed with preservation of an IM. In a case with high risk of bronchopleural fistulas after pulmonary resection, this preserved IM can be easily used for preparing a muscle flap in order to wrap the bronchial stump or the anastomotic site of bronchoplasty. We have used IMF by this technique for 6 cases of lobectomy and 8 cases of bronchoplasty, which have high risk of postoperative bronchopleural fistulas. Of these 14 cases, there have been no postoperative bronchopleural fistulas, including the other complications. By this method of the intercostal thoracotomy with preservation of IM, IMF can be easily prepared without the use of other IMs, even when high risk of bronchopleural fistulas is newly anticipated after pulmonary resection. Therefore, the presented method of the intercostal thoracotomy is recommended for a routine thoracotomy.

Expanded (13) and combined (9) pneumonectomy with laparotomy and plastics of the bronchial stump with the greater omentum on a vascular pedicle were conducted on 22 patients in the period from 1988 (June) to 1990 (April). The omentum was used for the prevention of bronchial fistulas and correction of defects in the pericardium. Laparotomy and omentopexy did not aggravate the patients' condition essentially and did not affect the terms of treatment. A defect in the bronchial stump occurred only in 2 patients in the post-operative period and closed spontaneously in one of them.

Bronchial fistula was found in 5.4% of 542 lung cancer patients treated with pneumonectomy. A relationship between occurrence of fistula and laterality of lesion, extent of surgery, procedure for closing the bronchial stump and gender was established. Bronchial fistula was most common following right-side pneumonectomy which is accounted for by postoperative anatomic conditions. To prevent bronchial fistula formation, mechanical suturing of the bronchial stump supplemented by procedure after Sweet should be performed. The bronchial stump should be shielded with adjacent tissue, as suggested by the authors.

The authors developed a complex of measures for the prevention of purulent bronchopleural complications, among which the "stumpless" method of manual treatment of the bronchus is the principal measure. With this method, the incidence of a bronchial fistula reduced to 0.5% in lobe-bilobectomy and to 1.4% in pulmonectomy. Due to the sharp drop in the incidence of this complication, the total postoperative mortality reduced to 3.3%. The developed methods of manual treatment of the bronchus made it possible to level out the difference in the incidence of a bronchial fistula in surgical and combined treatment (preoperative radiotherapy), 2.1% and 3.9%, respectively. The "stumpless" methods of manual treatment of the bronchus in lung carcinoma improve the conditions for oncological radicalism of the operation and prevent economical losses by reducing the hospital stay of patients.

The authors discuss the results of using the dura mater (DM) in forming the bronchial stump in 56 patients who underwent pneumonectomy for lung carcinoma. The main properties of the DM (strength, absence of antigenic activity, rapid replacement by the recipient's own tissue, resistance to infection) allow it to be considered the material of choice in plastics of the bronchial stump. Comparison with a group of patients who were operated on only with the use of a mechanical suture showed that with the use of the DM the number of bronchial fistulas reduced by half.