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Background: Broncho-pleural fistula (BPF) can occur after pulmonary resections as a complication with high morbidity and mortality rates., Aim: In the present study, we analyzed the relation between the possible risk factors and the two major bronchial closure techniques for BPF after lung resections, and the management methods of BPF., Materials and Methods: A total of 26 cases detected and managed with BPF diagnosis in our clinic between September 2005 and September 2017 were evaluated retrospectively. The cases were divided into two groups: Group 1 (n=14); bronchial closure performed manually and Group 2 (n=12) bronchial closure with stapler. We analyzed cases for age, gender, body mass index, pulmonary function tests, time to fistula, total protein/albumin level, length of hospital stay, bronchial stump distance, presence of bronchial stump coverage, and the mean survivals., Results: Twenty-three of the cases were males (88.5%) with a mean age of 60.03±8.7 years (range 38-73). While BPF was detected in twenty-three (88.5%) of the cases after pneumonectomy, three (11.5%) of them were after lobectomy. There was no statistically significant correlation between the two groups in gender, age, BMI, preoperative FEV1, time to fistula, total protein/albumin level, length of hospital stay, bronchial stump distance, and presence of bronchial stump coverage (chi-square test, p>0.05). As a result of the applied Kaplan-Meier analysis, we found no statistically significant difference in the mean survival rates between the two groups (p>0.05)., Conclusions: Broncho-pleural fistulas still remains a major challenge. Although there is no statistical relationship between bronchial closure techniques and possible risk factors in our study, patients should be assessed in terms of possible risk factors. The management strategy for BPF varies according to individual patients’ clinical condition, the size of the fistula, and development time., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Bronchopleural fistula (BPF) is a potentially fatal complication of pneumonectomy. We analyze its occurrence rate, risk factors, and the methods used for its prevention., Methods: We reviewed the medical records of patients who underwent pneumonectomy at our Institution between January, 1990 and March, 2016. The risk factors for postoperative BPF were analyzed by univariate analysis and multiple logistic regression., Results: Over the study period, 511 patients underwent pneumonectomy for non-small cell lung cancer (NSCLC) and had the bronchus closed by manual suturing. BPF developed in 23 patients (4.5%). Multiple logistic regression identified no coverage of the bronchial stump, right-sided pneumonectomy, residual tumor in the bronchial stump, postoperative ventilatory support, and completion pneumonectomy, as independent risk factors for BPF. The cumulative rate of BPF decreased significantly over time from 18% between 1990 and 1995 to 1% between 2011 and 2016 (p < 0.001). Concurrently, the data of several patients showed a significant positive trend over time, including bronchial stump coverage (BSC)., Discussion: Several known risk factors for BPF were confirmed. The more frequent usage of tissue flaps for coverage of the bronchial stump may have contributed to the reduction in the rate of postoperative BPF over time.

Bronchopleural fistula is an uncommon complication occurring especially following lung resection (pneumonectomy) and associated with high morbidity and mortality rates. The treatment is surgical but some studies reported bronchoscopic treatment. Localization and size of the fistula may indicate different endoscopic procedures. This overview described the different endoscopic procedures and their benefits., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Purpose: Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings., Methods: A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis., Results: The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47)., Conclusions: The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Background: The bronchopleural fistula (BPF) is a rare but potentially fatal complication of major thoracic surgery. The purpose of this work is to investigate the risk factors associated with the development of fistulas after lobectomy and pneumonectomy., Methods: We retrospectively reviewed the records of 835 patients who underwent major anatomic lung resection at our centre from January 2003 to December 2013. Of these, 49 underwent pneumonectomy (P group) and 786 lobectomy (L group)., Results: A total of 18 patients (2.6%) developed a BPF in the postoperative period, of which there were 11 in the L group (1.3%) and seven in the P group (14.28%). The 30-day mortality was 0.05% (one patient after right pneumonectomy). In the L group, three patients developed a fistula after a left lobectomy and eight after a right one, of which four developed after bilobectomy. Univariate analysis showed that induction therapy, lower lobectomy, manual suture of the bronchus, 'not covered' bronchial stump, empyema, postoperative anaemia and pulmonary infections and mechanical ventilation >24 h are associated with the development of fistulas after lobectomy. Multivariate analysis confirmed that induction therapy, manual closure of the bronchus, postoperative pulmonary infections and anaemia are the main risk factors involved in our series. In the P group, four patients developed a fistula after a right pneumonectomy and three after a left one. Postoperative empyema and pulmonary infections, mechanical ventilation >24 h and female gender emerged as the main risk factors on univariate analysis, while on multivariate analysis, only the female gender presented a trend towards significance., Conclusions: Postoperative pulmonary infections, empyema and mechanical ventilation >24 h are strongly associated with the development of BPFs after both pneumonectomy and lobectomy in our series., (© 2017 Royal Australasian College of Surgeons.)

Background: Globalization and emigration impact on the spectrum of diseases challenging health care systems. Medical practitioners have to particularly prepare for infectious diseases., Methods: The database of a health care center specialized on tropical medicine was screened for patients with history of migration and one of the following diagnoses: Cystic echinococcosis, tuberculosis, schistosomiasis, visceral leishmaniosis, and neurocysticercosis. Representative casuistics were prepared from select case histories. Radiological pertinent knowledge was compiled based on literature search., Results: A small selection of frequently imported infectious diseases covers a considerable fraction of health care problems associated with migration. For cystic echinococcosis, schistosomiasis, and neurocysticercosis imaging is the most relevant diagnostic procedure defining also disease stages. Tuberculosis and visceral leishmaniosis are important differentials for malignant diseases., Conclusion: Imaging plays a meaningful role in diagnosis, treatment stratification, and follow-up of imported infectious diseases. Radiological skills concerning these diseases are important for providing health care for patients in context of migration., Key Points: · Imaging plays a meaningful role in multidisciplinary care for imported infectious diseases.. · A small selection covers a considerable fraction of infectious diseases expected in context of migration.., Citation Format: · Stojkovic M, Müller J, Junghanss T et al. Radiological Diagnoses in the Context of Emigration: Infectious diseases. Fortschr Röntgenstr 2018; 190: 121 - 133., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of this article was to clarify recent risk factors for the early bronchopleural fistula after anatomical lung resection., Methods: Reports on early bronchopleural fistula after anatomical lung resection in adults, including information on risk factors, published between 2006 and 2016 were reviewed and our institutional data were evaluated. The early period was defined as within 30 days from surgery or as described early in the manuscript., Results: A total of seven retrospective observational articles were selected. Four articles investigated lobectomy and pneumonectomy, while the other three articles investigated only pneumonectomy. The surgical procedure, preoperative therapy, complications after surgery, right side, patient age, past history, and tumor residuals were mentioned as risk factors of bronchopleural fistula. Our data concluded that neoadjuvant therapy and a right lower lobe location were risk factors after a lobectomy, while a right side and complete pneumonectomy were risk factors after a pneumonectomy., Conclusions: Although recent studies have reached nearly the same conclusions as older reports, continuous research of potential risk factor is needed as therapeutic procedures continue to evolve.

Objectives: Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their interposition between the airways and the gastro-intestinal tract, patched into gastro-intestinal or airway defects if primary closure seemed risky., Methods: A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting., Results: Airway defects were closed by muscle flap patch ( n  = 12), lobectomy ( n  = 4), airway resection/anastomosis ( n  = 2), pneumonectomy ( n  = 1), segmentectomy ( n  = 2) or primary suture ( n  = 1). Gastro-intestinal defects were repaired by oesophageal diversion ( n  = 9), muscle flap patch ( n  = 8) or primary suture ( n  = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants., Conclusions: Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Bronchopleural fistula is a rare but potentially fatal complication of pulmonary resections and proper management is essential for its resolution. In this study, we analyzed the incidence of fistula after pulmonary resection and reported data about endoscopic and conservative treatments of this complication., Methods: From January 2003 to December 2013, 835 patients underwent anatomic lung resections: 786 (94.1 %) had a lobectomy and 49 (5.9 %) a pneumonectomy. Bronchopleural fistula was suspected by clinical signs and confirmed by endoscopic visualization., Results: Eighteen patients (2.2 %) developed a bronchopleural fistula, 11 in lobectomy group (1.4 %) and 7 in pneumonectomy group (14.3 %). The fistula size ranged between <1 mm and 6 mm and mean time of fistula onset was 33.9 ± 54.9 days after surgery. Of 18 patients who developed fistula, one died due to acute respiratory failure and another one was reoperated and then died to causes unrelated to the treatment. All the remaining 16 patients were treated with a conservative therapy that consisted in keeping or replacing a drainage chest tube. Nine of them underwent also endoscopic closure of the fistula using biological or synthetic glues. The mean period of time elapsed for the resolution of this complication was shorter with combined (conservative + endoscopic) than with conservative treatment alone (15.4 ± 13.2 vs. 25.8 ± 13.2 days, respectively), but without significant difference between the two methods (p: 0.299)., Conclusion: Endoscopic therapy, associated with a conservative treatment, is a safe and useful option in the management of the postoperative bronchopleural fistula.

Purpose: The incidence and etiology of empyema with fistula (EWF) in children is unknown. We analyzed a national database to define the epidemiology and diagnoses associated with this condition., Methods: Discharge data from the Kids' Inpatient Database were reviewed for EWF (ICD-9 diagnosis code 510.0) in children ≤18 years from 2000 to 2012. Patient characteristics, institutional data, and accompanying conditions were evaluated. Weighted national estimates were calculated and incidence compared across years (2000, 2003, 2006, 2009) using the Rao-Scott Chi Square., Results: From 2000 to 2012, 908 children were hospitalized with EWF. Age distribution was bimodal. Common primary diagnoses related to the hospitalization were pneumonia/pulmonary abscess (31.2 %) and EWF (19.3 %). Manipulation of the pleural space (e.g. decortication, drainage) comprised 45.0 % of procedures. Incidence rates of EWF increased (Rao Scott Adjusted Chi Square: 16.13, p < 0.01) over the study period. Although not statistically significant, median length of stay and age of diagnosis decreased and increased, respectively., Conclusion: This first, national pediatric EWF study reveals rising incidence during the years 2000-2009. Despite limitations in ICD-9 coding, concomitant primary diagnoses and procedures suggest bronchopleural fistulae likely represent the vast majority of cases in this cohort. Multi-institutional studies are needed to confirm etiology and characterize outcome of EWF.

Background: Bronchopleural fistula (BPF) remains a rare but fatal complication of thoracic surgery. The aim of this study was to develop and validate a predictive model of BPF after pulmonary resection and to identify patients at high risk for BPF., Methods: From January 2005 to December 2012, 34,000 patients underwent major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) and were entered into the French National database Epithor. The primary outcome was the occurrence of postoperative BPF at 30 days. The logistic regression model was built using a backward stepwise variable selection., Results: Bronchopleural fistula occurred in 318 patients (0.94%); its prevalence was 0.5% for lobectomy (n = 139), 2.2% for bilobectomy (n = 39), and 3% for pneumonectomy (n = 140). The mortality rate was 25.9% for lobectomy (n = 36), 16.7% for bilobectomy (n = 6), and 20% for pneumonectomy (n = 28). In the final model, nine variables were selected: sex, body mass index, dyspnea score, number of comorbidities per patient, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and the side of the resection. In the development data set, the C-index was 0.8 (95% confidence interval: 0.78 to 0.82). This model was well calibrated because the Hosmer-Lemeshow test was not significant (χ(2) = 10.5, p = 0.23). We then calculated the logistic regression coefficient to build the predictive score for BPF., Conclusions: This strong model could be easily used by surgeons to identify patient at high risk for BPF. This score needs to be confirmed prospectively in an independent cohort., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background. Hydatid cyst (HC) disease is endemic in many developing countries, like Yemen, Egypt, and Saudi Arabia, especially in the rural regions. The disease has a variable clinical courses and even might be asymptomatic for many years. Objectives. In giant and large pulmonary hydatid cysts, pulmonary resection is the usual method of surgical treatment. In this study, we aimed to evaluate the lung conservative surgery in treatment of cases with giant and large hydatid lung cysts, as an effective method of management. Patients and Methods. Between January 2009 and August 2014, a total of 148 patients with pulmonary hydatid cysts were operated and their data was reviewed retrospectively and analyzed. Out of these cases, 52 (35.14%) cysts with more than 10 cm in diameter and 36 (24.32%) cysts with 5-9 cm were regarded as giant and large hydatid lung cysts, respectively. The small cysts less than 5 cm were presented in 8 (5.4%) cases only; other cases had ruptured cysts. Preservation of the lung tissues during surgery by cystotomy and Capitonnage was our conservative surgical methods of choice. Results. Eight patients developed bronchopleural fistula (BPF); of them, 4 BPFs have healed with chest tube and physiotherapy, but in the other 4 patients reoperation was done for the closure of persistent BPF. No mortality was observed in the present study. Conclusion. We conclude that conservative surgical procedure can achieve complete removal of the pulmonary hydatid cyst. Enucleation of the intact huge cysts is safe. Careful and secured closure of the bronchial communication should be done by purse string or figure-of-8 sutures, with or without Teflon pledgets. These simple procedures are safe, reliable, and successful.

Background: Gastrobronchial fistula (GBF) is a complication of esophageal, splenic, or antireflux surgeries and was recently described as a complication of bariatric surgery. Our aim was to study all cases of GBF after laparoscopic sleeve gastrectomy (LSG) managed in five French university bariatric centers in order to establish the incidence and to evaluate the different treatments of this complication., Methods: We retrospectively studied 13 patients which developed GBF after LSG performed between March 2007 and August 2012. Patients were separated into two groups: patients who had early gastric fistula which has evolved into a GBF (group 1) and patients who had a late gastric fistula, either directly GBF or a late gastric fistula evolved in GBF (group 2)., Results: Group 1 consisted of five patients and group 2 of eight patients. All patients were undernourished at diagnosis. Management of GBF was a combined thoraco-abdominal surgery with gastrojejunal anastomosis (n = 5) or total gastrectomy (n = 1), multiple endoscopic treatment and thoracic surgery (n = 3), an endobronchial valve (n = 1), total gastrectomy and thoracic drainage (n = 1), and transorificial intubation with thoracic surgery or drainage (n = 2). There was no mortality. All GBF healed., Conclusions: GBF after LSG is a serious complication which is not anecdotal. Most of the early gastric fistulas occuring after LSG become chronic and can evolve into a GBF. Surgical approach is an effective treatment. Endobronchial valve is a novel alternative.

Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR)., Methods: Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres)., Results: Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively)., Conclusions: ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To retrospectively analyze the efficacy and short- to mid-term survival rate of cryoablation for malignant lung tumors., Methods: Percutaneous CT-guided cryoablation for 45 malignant lung tumors in 26 patients during 41 sessions from 2009 to 2013 were performed. Follow up CT-scan were used to determine local tumor progression. Survival rate, local tumor control rate and associated risk factors were analyzed., Results: The immediate during and short-term complications with CTCAE grade 2 or upper include pneumothorax (15%), pleural effusion (20%), pulmonary hemorrhage (24%), pneumonitis (15%), hemothorax (15%), hemoptysis (10%), pain (20%), bronchopleural fistula (n=1), and empyema (n=2). Life-threatening bleeding or hemodynamic instability was not observed. There was no procedural-related mortality. Overall survival rate of 1, 2, 3 years are 96%, 88%, 88%. For curative intent, local tumor control (LTC) rate of 1, 2, 3 years are 75%, 72%, 72%., Conclusion: Cryoablation for malignant lung tumors is effective and feasible in local control of tumor growth, with good short- to mid-term survival rate, as an alternative option for inoperable patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Fistula of bronchial stump developed in 246 (9.4%) cases of 2614 patients who were underwent pneumonectomy for lung cancer in 1964-2013. Mortality rate in case of bronchial fistulae was 17.9%. It was analyzed causes of this complication, an important role of infection for its development was emphasized. So prevention of wound infection is main prophylactic action. Postoperative pneumonia and bleeding are considerable risk factors. Clinico-anatomical type of tumor, stage and technique of bronchial stump treating don't affect incidence of fistulae. Bronchial stump covering is important intraoperative preventive measure. Treatment of this complication includes early drainage and pleural cavity sanitation and isolation of fistula from pleural cavity. Endoscopic procedures (impact with silver nitrate, trichloroacetic acid, laser) are preferred to solve the last problem. It allowed to achieve fistulae healing in 58.1% of cases.

Background: There are no reliable risk factors to predict bronchopleural fistula (BPF) formation in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC). This study aims to create a validated clinical model based on the risk factors for BPF after pneumonectomy. The model to estimate the risk of BPF may help select patients for intervention therapy to reduce the rate of BPF after pneumonectomy., Methods: This retrospective analysis included 684 patients with NSCLC who underwent pneumonectomy at our institution from 1995 to 2012. The rates of BPF were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for the BPF and based on which a clinical model for the prediction of the incidence of BPF was formed., Results: The incidence of BPF was 4.4% (30 of 684 patients). Three factors were independently associated with BPF after pneumonectomy for NSCLC: neoadjuvant therapy (hazard ratio, 2.479), diabetes mellitus (hazard ratio, 1.061), and age 70 years or older (hazard ratio, 1.175). A scoring system for BPF was developed by assigning 2 points for a major risk factor (neoadjuvant therapy) and 1 point for each minor risk factor (diabetes mellitus and age ≥ 70 years). The 684 patients were divided into a low-risk group (score, 0 to 1), moderate-risk group (score, 2), and high-risk group (score, ≥ 3), with respective incidences of early BPF after pneumonectomy of 2.4%, 18.2%, and 58.3%, Conclusions: This model, based on readily available clinical characteristics, can estimate the risk of BPF after pneumonectomy in the NSCLC patients, independent of early BPF and late BPF classifications. This model could be used to select patients for intervention therapy (parenteral alimentation, control of blood glucose level, oxygen therapy, and strengthening the antibiotic treatment) if validated in independent data sets., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Background: The potential effect of intraoperative factors on respiratory complications after pneumonectomy is still unclear., Methods: We conducted a retrospective cohort study; charts of 129 patients who underwent elective pneumonectomy at the University of Virginia were reviewed. Logistic regression was used to estimate the effect of anesthetic factors on the odds of at least one respiratory complication. Linear regression models were fit to assess the impact of these outcomes on length of stay (LOS)., Results: The incidence of respiratory complications in this cohort was 21%. In univariate analysis total nonblood fluids (p = 0.001), and the blood products packed red blood cells (p < 0.001), plasma (p < 0.001), and platelets (p = 0.044) were significantly associated with respiratory complications. In a multivariable logistic regression analysis, single unit transfusion of any blood product (packed red blood cells, plasma, or platelets) was identified as a major risk factor for respiratory complications after controlling for covariates (odds ratio = 1.47, 95% confidence interval 1.06 to 2.05). Respiratory failure and complications were closely related to LOS, increasing the LOS by a factor of 4.7 (95% confidence interval 3.51 to 6.18) and 3.5 (95% confidence interval 2.69 to 4.41), respectively., Conclusions: Blood product transfusion affects respiratory function and is an independent risk factor for respiratory complications after pneumonectomy., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment., Methods: After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics., Results: Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%., Conclusions: To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The frequency of complicated pneumococcal disease, including necrotizing pneumonia, has increased over the last decade. During 2008-2009, we noted an increase in the number of children whose empyema was complicated by the development of a bronchopleural fistula and air leak. We studied these children to see if there was an associated cause., Methods: This was a retrospective case note and database review of children admitted to our tertiary unit with a parapneumonic effusion or empyema from 2002 to 2007, compared with 2008 to 2009. For the latter period, we also compared the outcomes of those with a bronchopleural fistula to those without., Results: During the 8-year period, 310 children were admitted. In the first 6 years, the frequency of air leaks was 1% (2/258) rising to 33% (16/49) in the last 2 years (P<0.0001). Three children were excluded as their fistulas were possibly iatrogenic. This was associated with a significant increase in median hospital stay (7 vs. 10 days, P<0.0001) and surgical intervention rate (2% vs. 14%, P=0.001). In the latter 2 years, S. pneumoniae serotype 3 was identified in 10/16 (91%) of those with a bronchopleural fistula compared to 1/33 (3%) of those without., Conclusions: The frequency of bronchopleural fistulas increased markedly in the 2 years 2008-2009. Although these cases were associated with pneumococcal serotype 3 infection, which was not covered by the heptavalent pneumococcal vaccine Prevenar® in use at that time, we do not know whether the increased incidence of fistulas was due to a change in serotype 3 prevalence., (Copyright © 2011 Wiley-Liss, Inc.)

Objective: To report the case and surgical therapy of a patient with bilioptysis after vaginal delivery, caused by bronchobiliary fistula. Histologic analysis revealed endometrial glands embedded in the decidual stroma neighboring the liver and the lung., Design: Case report., Setting: University hospital., Patient(s): A 39-year-old patient, 7 days after vaginal delivery, without endometrial history., Intervention(s): Synchronous liver and lung resection of a bronchobiliary fistula by laparotomy and a transdiaphragmatic approach., Main Outcome Measure(s): For complicated brochobiliary fistula caused by endometriosis, radical surgical treatment is mandatory., Result(s): Histopathologic analyses confirmed the presence of clusters of endometrial glands embedded in the decidual stroma that were neighboring the liver, and perifistulous lung tissue was shown to contain biliary pigment absorbed by macrophages and their derivatives., Conclusion(s): Hepatic and perihepatic endometriosis can cause a bronchobiliary fistula. Exacerbation of the symptoms can be triggered by high estrogen levels, physiologically dominating the last trimester. For such a rare case, surgery is mandatory., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Background: We retrospectively analyzed risk factors for late bronchopleural fistula after non-small cell lung cancer (NSCLC) surgery and compared with those for early bronchopleural fistula., Methods: In all, 6,239 patients with NSCLC who underwent surgery were studied, and clinical risk factors were examined by univariate and multivariate analysis. This study included 23 patients (0.38%) with late bronchopleural fistula and 43 patients (0.65%) with early bronchopleural fistula among all 6,239 patients. Follow-up data were recorded until December 2005 or until death. Statistical significance was calculated using the log rank test., Results: By univariate analysis, patients with radiotherapy after operation, pneumonia after operation, pneumonectomy, and advanced age were related to higher risk of bronchopleural fistula. In the multiple logistic regression models, both pneumonia and operative procedure were among the independent risk factors of early and late bronchopleural fistula. Early bronchopleural fistula was observed primarily in the aged. Late bronchopleural fistula was associated with postoperative radiotherapy. The average intervals of bronchopleural fistula between pneumonectomy and lobectomy were significantly different. Compared with the mortality rate of late bronchopleural fistula (0%), the mortality rate of early bronchopleural fistula (11.6%) was significantly higher., Conclusions: There are both similarities and differences between the risk factors for early and late bronchopleural fistula. We should analyze the different reasons for the occurrence of bronchopleural fistula, and adopt different preventive measures. Different follow-up should be provided for the different operations.

The lengthening of life expectancy has led to more surgical procedures in elderly patients. The aim of this work was to determine whether age >70 years is a risk factor for pneumonectomy. All cases of pneumonectomy from January 1999 to December 2006 were retrospectively reviewed. The 40 patients aged >70 years were compared with a group of 70 patients aged 40-68 years matched for sex, physical status, respiratory function, side of pneumonectomy, and pathologic stage. Postoperatively, significantly more older patients had atrial fibrillation (24% vs. 5.6%). There was a low incidence of respiratory complications in both groups, and reduced respiratory function did not increase respiratory morbidity. Thirty-day mortality was not significantly different (2.5% in older vs. 1.4% in younger patients), but long-term mortality rates evaluated at December 31, 2007 were 50% for those aged <70 years (35 patients) and 72.5% for the older group. Although age is a risk factor for morbidity and mortality in pneumonectomy, the risk is acceptable.

Background: Higher operative risks after pneumonectomy for non-small cell lung cancer (NSCLC) have been reported after neoadjuvant chemotherapy or radiotherapy, or both. Patients who underwent pneumonectomy for NSCLC were evaluated for effect of neoadjuvant treatment on mortality and morbidity, especially bronchopleural fistula., Methods: Between 1996 and 2003, 130 consecutive patients underwent pneumonectomy: 35 received preoperative radiotherapy and chemotherapy (the neoadjuvant group), and 95 patients did not (the first-surgery group). Operative mortality and postoperative complications were compared between the groups., Results: Minor postoperative complications were comparable in both groups (p > 0.10). Five patients in the neoadjuvant group and 10 in the first-surgery group had serious complications (p = 0.55). Eight had bronchopleural fistulas (7 right and 1 left, p < 0.01); 3 were in the neoadjuvant group (p = 0.49). Three fistulas required reoperation. One patient in the first-surgery group died within 30 days postoperatively. Duration of symptoms (hazard ratio, 6.6; p = 0.01) and right-sided pneumonectomy (hazard ratio, 2.4; p = 0.05) were associated with an increased risk of bronchopleural fistula. Induction treatment, postoperative radiotherapy, or coverage of the bronchial stump did not increase the risk of bronchopleural fistulation. Survival at 1 and 5 years was comparable for the neoadjuvant and first-surgery groups: 74% and 46% vs 72% and 34%, respectively (p > 0.2)., Conclusions: Pneumonectomy is a safe procedure with low operative mortality. Postoperative morbidity is significant, especially bronchopleural fistulas after right-sided pneumonectomy (11%). However, neither operative mortality nor morbidity appears to be directly associated with preoperative radiotherapy or chemotherapy.

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.

Introduction: The prognosis and proper management of patients with microscopic residual tumor at the bronchial resection margins (bronchial R1) remain unclear., Methods: We performed a retrospective analysis of 74 patients who underwent pulmonary resection for lung cancer between 1976 and 2003 and had bronchial R1. The prognosis, pattern of the recurrence, and occurrence of the bronchopleural fistula (BPF) were analyzed according to the types of bronchial R1 morphology: direct extension (DIR, n = 11), peribronchial extension (PER, n = 54), and carcinoma in situ (CIS, n = 9)., Results: Five-year survival rates of patients with DIR, PER, and CIS were 0, 10, and 63%, respectively. The patients with CIS showed significantly better prognosis than those with DIR and PER (p = 0.0006, p = 0.0009, respectively). No prognostic difference was observed between patients with DIR and PER (p = 0.1753). Recurrent disease developed in 43 patients (58%). Only one of nine patients with CIS (11%) had recurrence, whereas 6 of 11 patients with DIR (55%) and 36 of 54 patients with PER (67%) had disease relapse. The recurrence rate in the CIS group was significantly lower than those of the other two groups (CIS versus DIR, p = 0.036; CIS versus PER, p = 0.006, respectively). BPF formation was not detected in patients with CIS; however, BPF developed in 3 of 11 patients with DIR (27%) and 3 of 54 patients with PER (5.6%)., Conclusions: Residual tumor morphology influenced the prognosis of patients with postresection bronchial R1 disease.

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

Objective: To explore the methods of the treatment and the principles of the prevention of bronchus-pleural fistula (BPF) after pneumonectomy., Methods: The clinical data of 15 cases of BPF after pneumonectomy in 815 lung cancer cases treated from July 1999 to June 2006 were analyzed retrospectively., Results: The occurrence rate of BPF after right pneumonectomy was 3.9% (12/310), higher than 0.6% (3/505) of left pneumonectomy (P < 0.01). The occurrence rate of BPF in cases with positive cancer residues in stump of bronchus was 22.7% (5/22), higher than 1.3% (10/793) of the cases with negative stump of bronchus (P < 0.01). The occurrence rate of BPF in the cases received preoperative radio- or chemotherapy was 5.0% (6/119), higher than 1.3% (9/696) of the cases received operation only (P < 0.05). There were no BPF occurred in the 76 cases whose bronchial stump were covered with autogenous tissues. All of the cases diagnosed as BPF were undertaken either closed or open chest drainage. Two cases were cured by thoracentesis aspiration and infusion antibiotics repeatedly. Two cases were cured by blocking the fistula with fibrin glue after sufficient anti-inflammatory treatment and hypertonic saline flushing. Six cases were discharged with a stable condition after closed drainage only. One case was discharged with open drainage for long time and 1 case was cured by hypertonic saline flushing after failure to cover the BPF using muscle flaps. Three cases died of multi-organs functional failure., Conclusions: BPF are related to the bronchial stump management and positive or negative residue of tumor at the bronchial stump. Autogenous tissues covering of the bronchial stump is a effective method for decrease the rate of BPF and especially for those patients received preoperative radio- or chemotherapy and right pneumonectomy. It should be performed for early mild cases with repeated thoracentesis aspirations or blocking the fistula with fibrin glue together with antibiotics. Chest closed drainage immediately and flushing with hypertonic saline repeatedly are effective methods for BPF.

Background: Sleeve pneumonectomy is challenging both from the technical and oncological standpoint. The benefit of induction treatment is still under investigation., Material and Methods: The study included 42 patients with sleeve pneumonectomy for non-small cell lung cancer in an eight-year period. Right sleeve pneumonectomy was performed in 39 patients. Squamous cell and adenocarcinoma were found in 33 (78.5%) and 5 (11.9%) patients, respectively. Overall stage was IIIa for 25 (59.5%) and IIIb for 17 (40.5%) patients, respectively., Results: Perioperative mortality and morbidity were 16.6% and 35.7%. Leading cause of death was bronchopleural fistula. Five-year survival was 35%. The survival difference between patients with NO+N1 versus N2 lesions was statistically significant (p = 0.01). There were no two-year survivors among patients with N2 lesions. Survival difference between T3 and T4 patients was also significant (p = 0.04). In a multivariate analysis, only T and N components were found significant in terms of prognosis., Conclusion: Sleeve pneumonectomy should be avoided in patients with N2 lesions confirmed preoperatively. A safe operation can be performed if the surgeon restricts airway resection to a maximum length of 4 cm.

Background: Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema., Methods: Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression., Results: One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis., Conclusions: Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

The results of treatment are analyzed in 78 patients with brochopleural fistilas after lung surgery. A method for imaging the draining bronchus under endoscopic guidance, by using the foamed dye administered into the residual cavity, has been developed. A valvular bronchial blocker for abolishing the function of bronchopleural fistular inserted into the lobular and segmental bronchus at bronchoscopy was designed and clinically tested. This procedure allows resurgery to be avoided in 91.7% of cases.

Background: Bronchopleural fistula is a potentially fatal complication of pulmonary resections, especially pneumonectomy., Methods: Univariate and multivariate analyses of the development of bronchopleural fistula were performed in 12 patients with bronchopleural fistula and 102 patients without bronchopleural fistula who had undergone pneumonectomy from January 1983 through December 2005., Results: Bronchopleural fistula developed after pneumonectomy in 12 patients (8.5%). Seven (58.7%) of the 12 patients died of bronchopleural fistula. Univariate analysis showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease significantly contributed to the development of postpneumonectomy bronchopleural fistula (p=0.0002, p=0.0043, and p=0.0387, respectively). Multivariate analysis also showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease were significant risk factors for postpneumonectomy bronchopleural fistula., Conclusions: Bronchopleural fistula is strongly associated with preoperative infection, right pneumonectomy, and pathological N2, 3 disease. Bronchial stump coverage with pedicled tissue flaps and preservation of the bronchial arteries during mediastinal lymph node dissection are recommended to maintain the blood supply to the bronchial stump in patients at risk.

Background: Patients undergoing pulmonary resection are thought to be at high risk for the development of postoperative pulmonary complications (PPCs), and these complications may lead to serious morbidity. The purpose of this study was to identify the factors associated with postoperative pulmonary complications in patients undergoing lung cancer resection and to determine the effect of PPCs on survival., Methods: The study involved a retrospective review of 635 patients who had undergone curative resection for lung cancer. The patient group included 504 males (79.4%), and the overall mean age was 61.3 years. Patients were classified as those who had experienced PPCs (PPCs group, n = 105, 16.5%) or those who had not (no-PPCs group, n = 530, 83.5%)., Results: The surgical procedures performed were 101 pneumonectomies (15.9%), 505 lobectomies (79.5%), and 29 lesser resections (4.6%). Cancer types comprised 330 squamous cell carcinomas (52.0%), 255 adenocarcinomas (40.2%) and 50 others (7.8%). Univariate analysis showed that the following factors were predictors for PPCs: male sex, erythrocyte sedimentation rate, preoperative serum fibrinogen level, pulmonary function, chronic obstructive pulmonary disease, smoking, double primary cancer, and surgical duration. Multivariate logistic regression showed that preoperative serum fibrinogen level (p < 0.001), surgical duration (p < 0.0001) and being male (p = 0.02) were significant predictors of PPCs. Overall survival 3 years after surgery was 68.2% in no-PPCs group and 38.8% in PPCs group (p < 0.0001). Regardless of tumor staging, overall survival differed significantly between PPCs and no-PPCs groups, whereas disease-free survival did not., Conclusions: Higher preoperative serum fibrinogen levels, longer surgical duration, and being male were the predictive factors for PPCs in surgical candidates. The development of PPCs was linked to a shortened overall survival.

Objective: The aim of this study was to define symptoms and signs for early diagnosis of occult bronchopleural fistula (OBPF) after routine pneumonectomy., Patients and Method: From 1999 to 2003, 301 pneumonectomies for malignancy were performed. The records of these patients were retrospectively analyzed for several clinicopathologic factors. All patients (group A) that presented postoperatively with one or more suspicious symptoms and signs were recorded. These cases were grouped according to bronchopleural fistula documentation (group A1) or not (group A2). Both groups were subjected to multivariate analysis., Results: In 10 cases (3.3%) bronchopleural communication was confirmed (group A1). The most frequent signs included the lack of contracture or even enlargement of postpneumonectomy space (52.7%), subcutaneous emphysema (33.3%), fever (27.7%), respiratory insufficiency (27.7%), and cough (22.2%). Multivariate analysis disclosed failure of the postpneumonectomy space to contract as an independent prodromal sign for bronchopleural communication (P=0.03, odds ratio 58.3, 95% CI: 1.45-2335.9)., Conclusion: Chest radiology proved to be the diagnostic modality of choice for early detection of bronchopleural fistula.

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

Esophago-respiratory fistulas developing in malignant disease have serious consequences by continuous airway contamination. Between 1984 and 1999 in the 1st Department of Surgery of Semmelweis University 1439 patients were treated with esophageal cancer. During regular examinations esophago-respiratory fistulas were detected in 163 patients (11.3% incidence). By analyzing data about these patients, we examined the causes, the characteristics of the disease and the possibilities and the efficiency of treatment. The mean age of these 163 patients was 55 (21-83) years, the ratio between men and women 3.7:1. By analyzing data of these patients according to their age, history, degree of dysphagia, weight loss, tumor size and survival rate, it can be noticed that there are two specific peaks, which differs from the average patients with esophageal tumors. Presumably, patients with esophago-respiratory fistulas can be divided into two groups. One consists of relatively younger patients with biologically more aggressive carcinomas, while the other group is of older patients where the fistula formation is the end stage of the slower progressing tumor. Twenty eight patients received irradiation before the fistula developed, most likely the longer survival rate contributed to the rise of the number of the fistulas. Ninety-five patients underwent endoscopic endoprosthesis implantation, 24 had the position of a stent corrected, 44 patients received palliative therapy, gastrostomy was performed in 15 patients. The median survival period was 5.0 months (0-46 months). Patients with endoprosthesis, gastrostomy and palliative treatment only had mean survival periods of 6.2 (1-46), 1.7 (0-5) and 1.6 (0-5) months. By sealing off the fistula, a successful endoscopic stent can end the serious airway contamination and the dysphagia, improving the quality of life and length of survival. Endoscopic endoprosthesis implantation is a feasible method in the treatment of patients with esophago-respiratory fistula.

Objective: Patients with persistent pulmonary infections from mycobacterial disease present a difficult clinical challenge. These individuals typically have poor pulmonary function, malnutrition, and other comorbidities, and few guidelines exist regarding optimal therapy. We report our experience with completion pneumonectomy as part of a multidisciplinary treatment program for patients with recurrent, persistent mycobacterial disease., Methods: During a 9-year period, 26 consecutive patients underwent completion pneumonectomy for mycobacterial disease. All patients underwent intensive, guided preoperative antibiotic therapy and aggressive nutritional supplementation. Complete surgical resection of the remaining destroyed or infected lung tissue was performed, often through an extrapleural dissection with intrapericardial ligation of vessels. Vascularized tissue flaps were used whenever possible to buttress the bronchial stump closure. Postoperative management consisted of a multidisciplinary approach, with ongoing antibiotic and nutritional therapy., Results: The primary organisms were Mycobacterium avium complex (n = 15), Mycobacterium tuberculosis (n = 5), Mycobacterium abscessus (n = 3), Mycobacterium xenopi (n = 2), and Mycobacterium chelonae (n = 1). Operative mortality was 23% (6/26): respiratory failure or adult respiratory distress syndrome in 2 cases, sepsis in 2, bronchopleural fistula in 1, and pulmonary embolism in 1. Significant morbidity occurred in 46% (12/26). Among the 17 long-term survivors, sputum conversion or discontinuation of medications was achieved in 14 (82%). Mean length of follow-up was 45 months (range 4-105 months)., Conclusion: Completion pneumonectomy remains an important component of therapy in patients with mycobacterial disease who have had failure of previous therapy. Although associated with significant risks, successful outcomes can be achieved with an organized, multidisciplinary approach and careful postoperative follow-up.

Background: Pneumonectomy is considered in the treatment of nontuberculous mycobacterial infections when an entire lung is affected. However, this procedure carries high morbidity. We report on our experience in using pneumonectomy for treating patients with nontuberculous mycobacterial infections., Methods: Between 1983 and 2002, 53 patients infected with nontuberculous mycobacteria underwent 55 pulmonary resections. Of these patients, 11 (3 men, 8 women) underwent pneumonectomy (5 right, 6 left). Median age was 57 years (range, 43 to 69 years). Mycobacterium avium complex disease occurred in 10 patients and Mycobacterium abscessus disease in 1. Indications for pneumonectomy included multiple cavities in one lung and destruction of an entire lung. The bronchial stump was covered with a latissimus dorsi muscle flap in 7 patients and with an intercostal pedicle flap in 2., Results: Operating time ranged from 142 to 477 minutes (median, 360 minutes). The median intraoperative blood loss was 555 mL (range, 130 to 1,245 mL). There was no operative mortality. Bronchopleural fistula occurred in 3 patients. All fistulas were observed after right pneumonectomy, and were treated by reclosure of the bronchus. Empyema occurred in 1 patient, who was treated with irrigation. All patients achieved sputum-negative status after surgery. Two late deaths occurred. One patient died of respiratory failure 11 months after surgery. A second patient, the only patient who had recurrent disease, died of respiratory failure 4 years postoperatively., Conclusions: Despite bronchial stump protection, right pneumonectomy carries a risk for bronchopleural fistula. Nonetheless, pneumonectomy can result in high cure rates in patients with nontuberculous mycobacterial infections.

Objective: Side- and sex-related differences were analysed to explain the occurrence of bronchopleural fistula (BPF) after pneumonectomy on the right-hand side in men., Patients and Methods: Surgical pathology reports on 209 patients (15 with BPF) were retrospectively reviewed regarding sex, age, side, TNM stage, outer diameter of the resection margin (mm) and intrabronchial distance between tumour and resection margin (mm). Patients without macroscopic bronchial invasion were categorised as peripheral tumours. The t-test, U-test (Mann-Whitney) and cross-tabulation using the chi 2-test were performed for univariate statistical analysis. A logistic stepwise backwards regression model was used for multivariate analysis., Results: Women were significantly younger than men, had a smaller resection margin and fewer central tumours. Stage 4 was overrepresented in women, stage 2 in men. On the right-hand side, the distance was significantly shorter, the resection margin longer and the patients younger. Fistula patients showed a longer resection margin and a shorter distance, men were dominant. Multivariate analysis only identified length of the resection margin as an independent risk factor for BPF (p = 0.024, OR 1.177 CI: 1.033 - 1.356). Gender and side significantly influenced the diameter of the resection margin (p = 0.00)., Conclusion: The diameter of the bronchial stump is a major risk factor in the occurrence of post-pneumonectomy BPF, and explains the predominance of the male sex, the right-hand side and pneumonectomy. Where it exceeds 25 mm, prophylactic stump coverage with viable tissue should be performed.

The aim of this study is to assess the frequency and clinical importance of mediastinal tubercular lymphadenitis and adenobronchial fistulas (TABF) and to evaluate the role of fiberbronchoscopy and surgical bronchoscopy associated with antimicrobical chemotherapy. 136 cases of primary pulmonary TBC, admitted to the Unit of Infectious Diseases, Bambino Gesu Children Hospital in Rome, between 1980 and 2001, were enrolled in the study. We considered 56 patients with clinical and radiological evidence of mediastinal tubercular lymphadenitis and 28 patients with adenobronchial fistulas (TABF). The incidence of TABF was 20,58% of primary pulmonary TBC. All patients were treated by medical therapy combined with local endobronchial surgery. TABF emerges as a complication of pediatric primary pulmonary TBC. We suggest a clinical and radiological survey to decide the utility of a diagnostic and therapeutic surgical bronchoscopy

Between 1984 and 2000 in the Thoracic Surgery Centre pneumonectomies were performed in 947 patients. Postpneumonectomy empyema (PE) occurred in 67 (7%) patients. The aim of this paper were: analysis the reasons of postpneumonectomy empyema appearance, defined bacterial flora, clinical course and optimal management. The causes of PE were: pleural cavity haematoma (20 patients-29.8%), wound suppuration (18 patients-26.8%), bronchial fistula (31 patients-46.2%). These complications appeared singly or together in 49 (73.1%) patients. In 2 (3.0%) patients a long treatment in the Intensive Care Unit because of postoperative shock was the cause of infection. In 3 (4.5%) cases the cause of empyema was associated with infection during the operation. In 13(19.4%) cases the cause of empyema was not established. In 55 patients infections of pleural cavities were diagnosed in the first 8 weeks after operations. In 12 patients empyemas were established later. 12 (17.9%) patients died during the analyzed 1 year period after operation. In 18 (26.9%) patients infections were caused by only one bacterial strain and in 49 (73.1%) by two or three bacterial strains. The different methods of treatment (thoracentesis, drainage, operation) depending on general condition of patient were done.

Background: Bronchopleural fistula (BPF) is an infrequent but life-threatening complication after lung resection. The incidence of BPF reported in the literature varies between 0 and 15%., Aim: To evaluate the incidence of BPF after pneumonectomy for primary lung cancer in a single practice using a single technique., Methods: Hospital records of patients who underwent pneumonectomy from 1 January 1988 to 1 October 1998 were reviewed retrospectively. The bronchial stump was closed using a uniform hand suture technique. There was a total of 157 patients, including 118 males and 39 females with a mean age of 64 years (range 37-78). Sixty-two patients (39.5%) had a right pneumonectomy., Results: Three patients developed BPF (1.9%). All occurred within seven days of the operation. Two of the three patients died. Ventilation for more than 24 hours was found to be the only significant risk factor for the development of BPF (p < 0.001)., Conclusions: Hand suture closure of bronchial stump after pneumonectomy is a safe, reproducible and inexpensive technique, and a low incidence of BPF can be achieved.

Background: The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication., Methods: We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses., Results: Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation., Conclusions: Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.

Objective: The method used to achieve bronchial closure, especially the relative merits of sutured versus stapled closure, remains an important topic among thoracic surgeons who seek the best way to prevent postoperative bronchopleural fistula (BPF) formation., Methods: Bronchial closure in 533 consecutive stumps in pulmonary resection from 1995 to 1997 at the National Cancer Center Hospital, Tokyo, was reviewed in terms of the incidence of troubles related to mechanical stapling (stapling failure) and to BPF formation. Fifty stumps (9%) were closed by manual suturing and 483 (91%) by mechanical stapling. For stapling, endostaplers were used for 313 stumps (65%), and other types of conventional staplers for 170 stumps (35%)., Results: There were 18 stapling failures (a 3.7% overall incidence, 4.8% for endostaplers, 1.8% for other types of staplers). However, of these 18 patients only one developed BPF after surgery. Seven BPFs developed postoperatively among the 533 closures (overall incidence, 1.3%): two after manual suturing (4%) and five after stapling (1%), and this difference was not statistically significant. Of seven patients with BPF, four died of BPF-related complications., Conclusions: Although bronchial closure by stapling was accompanied by failure, its incidence was acceptable and was not directly associated with the development of BPF postoperatively, as long as properly repaired. Newly developed endostaplers had similar incidence of stapling failure and BPF formation compared with other types of conventional staplers. These results suggest endostaplers can be used safely for various types of bronchial closure. The advantage of such devices could be the least chance of pollution of the operative field, simultaneous performance of stapling and division by one motion, and subsequently great saving of time.

Bronchopleural fistula after pneumonectomy is a dreaded complication, because of its high morbidity and mortality. We describe a successful technique using closed-chest irrigation of the pleural cavity continued with transposition of a latissimus dorsi island flap.

The mechanical suture was introduced into thoracic surgical procedures by Amonosow and Androsow, Soviet surgeons, in the late 50s. The aim of the paper is to compare the incidence of bronchopleural fistulae that develop after the mechanical suture has been applied in bronchus surgery with the corresponding figures for traditional manual sutures. In the period of January 1997-March 1999 a series of 524 anatomical lung parenchyma resections was performed at the Department of Thoracic Surgery, Medical Academy of Gdańsk. In 460 cases (87.8%) the indication for the procedure came from primary lung carcinoma, and in 64 cases (12.2%) from tuberculosis, hamartoma, arteriovenous fistula, inflammatory lesions, asperpilloma, and metastases to the lungs. Depending on the way the bronchus was surgically closed the patients were subgrouped as follows: group I comprised 209 subjects (40.6%) whose bronchus was closed with a mechanical TA Premium Auto Suture, and group II that embraced 306 subjects (59.4%) whose bronchus was closed with a manual PDS 3/0 or Maxon 3/0 suture. The bronchopleural fistula developed in 11 cases of which 5/216 (2.3%) had the bronchus stump closed with a mechanical suture, and 6/308 (2.0%) cases had it closed with a manual suture. Of 11 cases of bronchopleural fistula 10 cases were noted after pneumonectomy. After the right side pneumonectomy, one fistula was discovered following the application of mechanical suture and six fistulas were found when the manual suture was used. After the left side pneumonectomy, no fistulae were discovered when the manual suture was used, and 3 those found were exclusively present when the mechanical suture was applied.