Review on bronchopleural fistula: did a surgeon review it?

We read with interest the recently published review by Lois and Noppen in CHEST (December 2005)1 on bronchopleural fistula (BPF) and found it confusing. Even though the article is focused mainly on the endoscopic treatment of BPF, the authors widely discussed all of the clinical aspects of the problem. In the proposed classification, the subgroup “nonpostoperative” does not contain BPF patients but only those with pneumothorax. BPF and pneumothorax do not share etiology, clinical presentation, diagnosis, prognosis, or treatment. They are simply different things. The main clinical signs of BPF are not precisely outlined in the article. When the fistula is small (on the order of a few millimeters), the symptoms are cough, particularly when the patients is turned on the side of the fistula, and, as the authors stated, a delay in cavity filling after pneumonectomy. When empyema is present, infectious symptoms are dominant. Concerning diagnosis, it is universally accepted that the “gold standard” for the diagnosis of BPF is bronchoscopy. The authors mentioned it at the end of the first paragraph in the “Diagnosis” section after methylene blue staining, bronchography, Xe ventilation study, CT scanning, and gas concentration scintigraphy. This message is misleading. In the “Prognosis” section of the article, the authors mainly discussed the problem of pneumothorax in intubated patients. This is not relevant in a discussion of BPF. Concerning the treatment of patients with BPF, there are few rules that the authors did not discuss. The vast majority of these patients had undergone pneumonectomy. The first step in treatment is bronchoscopy2 and drainage of the chest cavity. Afterward, a decision on surgical treatment is made (eg, Clagett procedure, direct repair, or thoracoscopy, depending on the dimension of the fistula and the time of onset). Moreover, in the “Treatment” section, mechanical ventilation is mentioned. This is not a therapy for patients with BPF. The paragraphs on the endoscopic treatment of BPF (in the “Bronchoscopy” section of the article) are well-written and exhaustive. Unfortunately, BPF is a surgical problem that can sometimes be successfully treated by endoscopy to avoid performing an aggressive surgical treatment. But, it remains a surgical problem. Did a thoracic surgeon review this review?