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We compared automatic stapling with hand suturing in the rate of bronchopleural fistula. Twenty two hundred forty one patients of 25 hospitals, who were performed lobectomy or pneumonectomy for lung cancer from the year of 1990 to 1992, were investigated about the occurrence of bronchopleural fistula. The rate of bronchopleural fistula following lobectomy were 0.9% (11/1,227 cases) in automatic stapling, and 1.1% (8/753 cases) in hand suturing; there was no difference. However, there was a higher rate of the fistula with the use of automatic stapling devices in pneumonectomy. The rate was 11.2% (11/98 cases) in automatic stapling, and 1.2% (2/166 cases) in hand suturing. Automatic stapling may lead to bronchopleural fistula in pneumonectomy. Moreover, addition of hand suturing to automatic stapling was thought to prevent the fistula.

To determine the efficacy of doxycycline as a pleural sclerosing agent, we examined the outcomes in 31 patients (aged 31 to 87 years) receiving doxycycline (500 to 1,000 mg) through a chest tube for malignant pleural effusions or persistent bronchopleural fistulae. Of the 27 patients with malignant pleural effusions, 21 patients had a complete short-term response (no fluid reaccumulation during the initial hospitalization); 5 of the 6 short-term nonresponders had partial control of effusions, with improvement in respiratory symptoms. Of the 23 patients who survived longer than 1 month, 15 patients did not have reaccumulation of fluid during follow-up. All four patients with persistent bronchopleural fistulae had resolution of their air leaks; one patient had recurrence with a partial pneumothorax. Pleural pain controllable with narcotic therapy was the only important complication. Thus, doxycycline is a suitable substitute for tetracycline as a pleural sclerosing agent.

In the years 1963-1991 inclusive, 88 patients were operated on with a diagnosis of pulmonary hydatid disease. The cysts were intact in 69 and infected in 19 cases. It was possible to use a surgical technique that preserved the pulmonary parenchyma in 67 patients. In this technique, the cavity after removal of the mother membrane is left open and only the air leaks are sutured. Continuous postoperative drainage of the residual cavity and the ipsilateral hemithorax always resulted in complete inflation of the affected lung. Enucleation of the endocyst and extended resection of the sclerotic pulmonary parenchyma were performed in 15, enucleation and obliteration in three, lobectomy in two and Barrett's method was applicable in one patient. A bronchopleural fistula developed in 11 patients postoperatively and in four of these cases a second thoracotomy was necessary. Postoperative empyema developed in four cases. There were two postoperative deaths in the series. Eighty-six patients were symptom-free in the long-term postoperative follow-up. We conclude that in the surgical management of the disease it should not be necessary to obliterate the residual cavity with extensive suturing which always leads to extra fibrosis with loss of viable pulmonary parenchyma.

Objective: Although breakdown of the esophagogastric anastomosis often occurs as a complication of esophagogastrectomy during the early postoperative period, it is not well recognized that anastomotic leaks and fistulas may occur during the late postoperative period (more than 1 month after surgery). The purpose of our study was to determine the radiologic appearance and clinical significance of these late leaks and fistulas., Materials and Methods: A review of radiology records at our hospital from 1985 to 1991 revealed 37 patients who had upper gastrointestinal contrast studies an average of 13.3 months after esophagogastrectomy., Results: Six patients (16%) had anastomotic leaks or fistulas that occurred during the late postoperative period. Four patients were asymptomatic; three had contrast studies that showed thin, blind-ending tracks extending from the anastomosis into the mediastinum, and the fourth had an esophagogastric fistula. One of the blind-ending tracks later progressed to a gastropleural fistula that was treated with antibiotics and drainage. One symptomatic patient had a gastropleural fistula, and the other had a gastrobronchial fistula. Both fistulas were surgically repaired. None of the leaks or fistulas was associated with recurrent tumor., Conclusion: Anastomotic leaks or fistulas may be detected on contrast studies obtained more than 1 month after esophagogastrectomy. Some leaks appear as blind-ending tracks that have no clinical significance, but others may be manifested by life-threatening gastropleural or gastrobronchial fistulas that necessitate surgical intervention.

During a 28-year period, 52 bronchopleural fistulas developed after pulmonary resection of 49 primary and three recurrent lung cancers at the National Cancer Center Hospital, Tokyo. During the same period there were 2359 pulmonary resections for primary lung cancer; the prevalence of bronchopleural fistula was 2.1%. Multivariate analysis on 15 variables in the most recent 1360 resections revealed significant risk factors for bronchopleural fistula: wider resection such as pneumonectomy, residual carcinomatous tissue at the bronchial stump, preoperative irradiation, and diabetes. Univariate analysis further recognized a risk in preoperative bronchial arterial infusion and the postsurgical stage of lung cancer. Six patients were not treated. Apart from chest tube drainage in seven patients, surgical repair was attempted in 39, direct resuture of the stump in 16, wrapping in 25, thoracoplasty in 31, completion pneumonectomy in 6, and other treatments. Despite various treatments, 37 patients (71.2% mortality) died from fistula-related complications (such as regurgitation of infected pleural fluid through the fistula and airway/intrathoracic bleeding). Even for patients whose fistulas were cured and who were discharged, the average hospital stay was 189 days. Further investigation is necessary to answer whether prevention by flap coverage is of any benefit.

Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.

The author has analyzed results of treatment of 28 patients with hepato-thoracic complications of amebic abscesses of the liver. Different variations of operative interventions are proposed including the separate (subdiaphragmatic) draining of the cavity of the liver abscess and pleural cavity and in cases of the appearance of bilio-bronchial fistulas--resection of the lung.

Seventy-seven bronchoscopies have been performed and evaluated in twenty-eight children, aged five months to thirteen years suffering from primary tuberculosis. Endobronchial lesions have been found in 57.1% of the cases. Out of them, broncho-nodular fistula was seen in 32.1% of the cases. It has been found out that the frequency of occurrence of this kids of lesions in the actual epidemiological situation is similar that diagnosed several decades ago.

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.

From 1977 to 1988, 390 cases of lung cancer were resected in our hospital. In 12 patients (3.1%) a postoperative bronchopleural fistula developed. This complication occurred more commonly after right pulmonary resection than left and most common after right pneumonectomy. Moreover, that had occurred following right pneumonectomy was most fatal. After right middle and lower lobectomy, this complication occurred at the same rate as after pneumonectomy and also caused a fatal result. On the other hand, after the resection of single lobe, the rate of the occurrence of a bronchopleural fistula was lower. And, even if it had developed, the fistula sometimes could be healed by a conservative treatment only. In one of our cases the fistula was successfully treated by intra-bronchial gluing through a bronchofiberscope.

An analysis of postoperative complications in 167 infants, operated for suppurative lung diseases, indicated that these complications are mainly the result of the purulent-inflammatory process progression. Recommendations concerning the prophylaxis against these complications with the analysis of the results of their use are given.

Bronchopleural fistula (BPF) is a late complication of collapse therapy for pulmonary tuberculosis which usually develops several decades after the procedure. A characteristic finding in the chest radiogram is a pleural hydroaerial level, which suggests the diagnosis when associated with gravitational chocolate-like sputum. As the treatment of these patients is difficult, we think it is appropriate that they should be controlled in a primary care setting by periodical radiological studies (posteroanterior chest radiograms) which may permit early detection of the condition so as to establish specific therapy.