Clinical Bottom Line

pneumonectomy and co-factors. The manual closure seems to be the more preferable method in high-risk patients. An additive support suture following stapling on the bronchial stump did not decrease the risk of BPF. Deschamps et al. [7] analysed factors affecting the incidence of empyema and BPF after pneumonectomy in 713 patients who underwent pneumonectomy for different conditions. Univariate analysis demonstrated that the development of BPF was significantly associated with bronchial stump reinforcement (P = 0.03). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (P = 0.009). The group concluded that multiple perioperative factors were associated with an increased incidence of BPF after pneumonectomy including the prophylactic reinforcement of the bronchial stump with viable tissue; however, mechanical stump closure had a protective effect against the development of BPFs. It is important to note, however, that although this study did not demonstrate a reduced incidence of BPFs with tissue reinforcement, the group practice included the routine reinforcement of stumps in patients deemed most likely to develop BPFs and therefore represent a selection bias. AI-Kattan et al. [6] studied the outcomes in 471 pneumonectomies that were performed by one surgical team for primary lung cancer. In this study, all operations were performed using a uniform hand suture technique. There were 7 cases of BPF (incidence of 1.5%). This study demonstrated clearly the importance of surgeons’ experience as the senior author performed 374 pneumonectomies with 2 fistulas (0.5%), while other surgeons in training performed 97 pneumonectomies with 5 fistulas (5.1%). The group concluded that suture closure to the bronchial stump after pneumonectomy provides a cheap and reliable technique that is applicable in all situations and can be taught to surgeons in training with an acceptable risk.