Bronchopleural fistula prevention after major pulmonary resection for primary lung cancer

Bronchopleural fistula (bpf) is a serious complication after pulmonary resection. Its incidence ranges from 1 to 4% and most of cases occur after right pneumonectomy [1]. Main bronchi, the intermediate bronchus and bronchial stumps of patients treated by previous omolateral thoracotomy or by induction therapy, are more subject to develop bpf [2]. Preoperatory radio-chemotherapy is an important risk factor because it damages bronchial hematic flow and interferes with the healing process [3]. Some authors practice bronchial stump protection and give great importance to bronchial artery preservation during linfoadenectomy [4]. The bronchial stump closure technique is very important to prevent bpf. One of the most used techniques is the Sweet suture, performed by simple interrupted stitches introduced from the pars membranacea to the cartilaginous rings. The Craaford technique provides cartilaginous ring removal near the suture and then a first suture with simple stitches; a purse string suture sacks sutured soft tissues and a second purse string suture surrounds the other bronchial angle; at the end, some interrupted stitches reinforce the bronchial stump closure. The Overholt technique provides a section of the posterior 2/3 of the bronchial tree and, then, a suture by interrupted stitches with pars membranacea sacking inside the cartilaginous rings. The arrival of the automatic stapler modified bronchial surgery results, even if it did not solve all bpf problems [5]. Recently, Sonobe [2] reviewed the most important bronchial stump closure techniques, describing four main methods. Personal experience: We performed, for 15 years, bronchial stump closure with an automatic surgical stapler reinforced by several simple interrupted stitches with adsorbable sutures at the distal side of the stapler line. In our opinion, in this way, we can decrease the bronchial tension due to automatic stapler compression by simple interrupted stitches. This suture technique does not avascularize the bronchial stump, because reinforcing stitches are at the distal side of the automatic stapler line. We reviewed major pulmonary resections performed during the last 5 years, enrolling 176 consecutive patients operated by the same surgeon: we observed 64 pneumonectomies (36.3%), 102 lobectomies (57.9%), ten bilobectomies (5.6%). Twenty patients (11.3%) were treated by neoadjuvant therapy; we observed two bpf (1.1%) of the upper left bronchus. These two patients did not receive induction therapy or previous omolateral thoracotomy; one was affected by diabetes mellitus type II in good general clinical conditions; lung function study revealed, for each one, only a moderate obstructive pattern. These two patients were not treated by mechanical ventilation after surgery. We observed the bpf resolution without surgery. In light of our personal experience, we observe that our bronchial stump closure technique, similarly to the Sonobe at al. experience, is a safe and reliable method to prevent bpf (bpf incidence=1.1%); this technique, on one hand allows to reduce the bronchial tension due to the cartilaginous component of the bronchus; on the other hand it does not avascularize the bronchial stump, guaranteeing a very good endurance of the bronchial stump even in patients previously treated by induction therapies.