This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitrios Dougenis Permission Requests Google Scholar Articles by Apostolakis, E. Articles by Dougenis, D. PubMed Articles by Apostolakis, E. Articles by Dougenis, D. Related Collections Related Article

eComment: Routine or selective reinforcement of bronchial stump after pneumonectomy?

Department of Cardiothoracic Surgery, University Hospital of Patras, 22500 Rion Patras, Greece

The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients

We would like to make the following comment on the recent report by Beshay et al. [1].

The usefulness of bronchial stump reinforcement after a pneumonectomy procedure has been well documented. According to Asamura et al. [2], pneumonectomy is considered one of the principal risk factors for bronchopleural fistula formation. Bronchial reinforcement has been strongly supported especially in high-risk patients with administration of neo-adjuvant therapy, as reported in the recent work by Beshay et al. [1], as well as in diabetic patients [3]. Patients with a highly morbid pathology, such as the malignant pleural mesothelioma, usually present with anemia upon admission. After conduction of an extended surgical procedure, as is the extrapleural pneumonectomy [1], anemia is more profound due to increased blood losses intra-operatively. Additionally, creation of a muscular flap by mobilizing the latissimus dorsi muscle exposes the patient to an additional unfavorable procedure, increasing intra-operative time, and exaggerates further the blood losses, prolonging the post-operative hospital stay. A high percentage of these patients (60%) required blood transfusion [1]; this may contribute to an increased incidence of bronchopleural fistula, regardless of the type of bronchial stump coverage.

According to our experience, right bronchial stump reinforcement should be routinely performed in all patients who are undergoing a pneumonectomy procedure, while the left bronchial stump does not necessarily require this (except in very rare cases, because it is protected by the surrounding tissues and the neighboring aortic arch). In our cohort of 221 patients, we noticed bronchopleural fistula formation only in 3.2% (all presenting on the right side 5/91, in contrast to no fistula formation on the left side 0/130); a rather low percentage according to the literature. It is also worth mentioning that in 91% of our right pneumonectomy cases, we used a pleural flap with partial mobilization of the azygos vein that was attached to the bronchial stump, ensuring the integrity of the bronchial stump and maintaining an adequate vascular supply. The remaining was covered with intercostal muscle flap or pericardial fat pad. Our technique is not time-consuming (no more than 10 min) and relatively bloodless, in contrast to the much more copious procedures, such as the mobilization of latissimus dorsi or serratus anterior muscular flaps proposed in your article [1].

Furthermore, intercostal muscle flaps do not necessitate the removal of part of the 4th rib in order to create a hole on the thoracic wall for tunnelling the muscular flap [1]. Routine reinforcement of the bronchial stump, using either the pleura surrounding the azygos vein, a mobilized intercostal muscle or pericardial fat pad, is not associated with any postoperative complications presented after pneumonectomy.

In conclusion, application of our suggestion as a routine may protect patients from highly morbid conditions associated with these types of extended operations, leading sometimes to death or condemning patients by prolonging their postoperative hospital stay.

	References

Top References

 

1. Beshay M, Carboni G, Hoksch B, Reymond M, Schmid R. The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients. Interac CardioVasc Thorac Surg 2008;7:621–625.[Abstract/Free Full Text]
2. Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with ung cancer operations univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456–1463.[Abstract]
3. Sfyridis P, Kapetanakis E, Baltayiannis N, Bolanos N, Ánagnostopoulos D, Markogiannakis A, Chatzimichalis A. Bronchial stump buttressing with an Intercostals muscle flap in diabetic patients. Ann Thorac Surg 2007;84:967–971.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitrios Dougenis Permission Requests Google Scholar Articles by Apostolakis, E. Articles by Dougenis, D. PubMed Articles by Apostolakis, E. Articles by Dougenis, D. Related Collections Related Article