The devil is in the details

Due to the morbidity and mortality associated with pneumonectomy, reducing risk factors for bronchopleural fistula (BPF) development is crucial for the survival of these patients. Our recent publication has revived the discussion amongst surgeons about the optimal management of the pneumonectomy stump to prevent this complication. To address concerns raised by Zieliński,1Zieliński M. More details of surgical technique necessary.J Thorac Cardiovasc Surg Tech. 2024; XX: XX-XXXGoogle Scholar clarification of the technical aspects for these cases is provided below. The pneumonectomy stump was closed either manually (ie, handsewn) with Vicryl sutures (Ethicon) or a stapler. In our experience, staplers are reliable and reproducible for bronchial closure in cases of normal tissue thickness. For thickened bronchial tissue, our group agrees that the handsewn technique offers more precise control over the closure. There were fewer than 20 cases with handsewn closures and therefore these patients were excluded from the analysis to minimize confounding variables and to focus emphasis on flap influence on fistula rates. The larger muscle flaps (latissimus dorsi, serratus anterior, and pectoralis major) were harvested by plastic surgery with electrocautery on the low setting (<25) to prevent thermal spread and protect the vascular pedicle. Intrathoracic flaps (intercostal muscle, pericardial fat/thymus, pericardium, and pleura) were performed by thoracic surgeons; these flaps were harvested sharply or with electrocautery on the low setting. All flaps were secured to the bronchial stump with absorbable sutures in an interrupted fashion. In our case series, the BPF rate was 6.3% after standard pneumonectomy and 22.6% after extrapleural pneumonectomy; the combined BPF rate of all groups was 10.6%. Another important clarification: We reported fistulas that occurred at any point in the patient's lifetime. Within the BPF cohort, only 9 patients (22.5%) developed this complication within 30 days of pneumonectomy—these early BPFs could be related to surgical technique or flap failure. A majority of the fistulas (77.5% [n = 31]) developed outside of the perioperative period, with some patients developing this complication months or years later (n = 13 after 6 months, n = 4 after 1 year). It is unclear what factors led to late BPF development, but they are unlikely to be explained by flap failure. Of the 21 patients who received a therapeutic flap, 13 had concomitant thoracoplasty with 2 to 5 ribs removed. All therapeutic flaps were performed by plastic surgery; patients received 1 to 3 tissue flaps to close the space. The most frequently utilized combination was latissimus dorsi, serratus anterior, and pectoralis major. A separate publication reporting our success with therapeutic flaps closing the postpneumonectomy space is upcoming. We agree that the granular details of operative technique can be underappreciated in the analysis of large cohort studies, but the aim of our study was to identify trends rather than advocate for a specific flap or technique. Furthermore, if each surgeon in our group had a slightly different technique, that only strengthens the argument that the results should be reproducible outside of our institution. Attention to detail and meticulous technique can help prevent some of these complications, but surgical decision making before the operation (ie, flap vs no flap, nutritional optimization) also influences the outcome. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.