Surgery for the treatment of the tuberculosis-destroyed lung: to protect or not to protect the bronchial stump?

We read with interest the paper by Bai et al. [1] regarding the efficacy of surgery, mainly pneumonectomies, in the treatment of tuberculosis (TB)-destroyed lungs and we congratulate them on their results. One of the most dreaded complications after pneumonectomy is the bronchopleural fistula (BPF), and this is particularly true for pneumonectomies performed for infectious diseases including TB. The authors report a very low incidence of BPF, but they do not give information about the method, if any, they use to reinforce the bronchial stump. It should be of great interest to know whether or not they protect the stump and to know which criteria they use to decide who can benefit from the bronchial stump coverage. For Wang et al. [2], the incidence of BPF was 9% when parietal pleura or the pericardium were used to protect the bronchial stump, and it was as high as 36% when they were not. According to Pomerantz [3], positive sputum at the time of surgery and polymicrobial contamination increases the risk of BPF, and he suggests using muscle flaps to protect the bronchial stump. In our experience, we used with satisfaction a muscle flap of the serratus anterior or a split latissimus dorsi flap [4] in all sputum-positive patients, most of whom also had a polymicrobial contamination of the destroyed lung. Both these flaps can be easily and quickly harvested and add only a minimal morbidity to the operation.