ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Gail E. Darling
Michael Johnston
Thomas K. Waddell
Andrew Pierre
Shaf Keshavjee
Robert Ginsberg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Darling, G. E.
Right arrow Articles by Ginsberg, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Darling, G. E.
Right arrow Articles by Ginsberg, R.
Related Collections
Right arrow Lung - cancer

Ann Thorac Surg 2005;79:433-437
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Risk of a Right Pneumonectomy: Role of Bronchopleural Fistula

Gail E. Darling, MDa,*, Adel Abdurahman, MDa, Qi-Long Yi, PhDb, Michael Johnston, MDa, Thomas K. Waddell, MDa, Andrew Pierre, MDa, Shaf Keshavjee, MDa, Robert Ginsberg, MDa

a Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
b Department of Biostatistics, Princess Margaret Hospital, Toronto, Ontario, Canada

Accepted for publication July 6, 2004.

* Address reprint requests to Dr Darling, Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada (E-mail: gail.darling{at}uhn.on.ca).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Footnotes
 References
 
BACKGROUND: The purpose of this study is to compare the morbidity and mortality of right versus left pneumonectomy.

METHODS: We used a retrospective review of pneumonectomies performed during the period 1990 to 2000 and included a meta-analysis of relevant literature.

RESULTS: There were 187 pneumonectomies: 68 right, 119 left. The primary study end point was in-hospital death. There were 11 deaths: 7 (10.3%) right, 4 (3.3%) left (p = 0.10). Six deaths were attributable to bronchopleural fistula and its subsequent complications. The risk of bronchopleural fistula was higher on the right (9 [13.2%]) versus left (6 [5.0%]; p = 0.0472), as was the mortality associated with bronchopleural fistula (4 of 9 [44%] right versus 2 of 6 [33%] left). Right pneumonectomies were more likely to require an intrapericardial or extended dissection (p = 0.003), hand-sewn bronchial closure (p < 0.0001), or the closure buttressed (p < 0.0001). By univariate analysis, factors associated with an increased mortality were bronchopleural fistula (p < 0.0001), hand-sewn closure (p = 0.001), and a history of smoking (p = 0.01). By multivariate analysis, the most important factor was bronchopleural fistula (odds ratio, 43.3; 95% confidence limits, 4.2 to 441.9; p = 0.002). A meta-analysis combining our results with those from the literature found increased mortality of right pneumonectomy with a relative risk of 3.39 (95% confidence limits, 2.10 to 5.48; p < 0.00001).

CONCLUSIONS: Right pneumonectomy is associated with a higher mortality even in the absence of induction therapy. This is primarily related to the increased risk of bronchopleural fistula on the right. The increased number of bronchopleural fistulas on the right may be attributable to more extensive resection. Addressing technical factors that contribute to early bronchopleural fistula may reduce the mortality of right pneumonectomy.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Footnotes
 References
 
After the first report of pneumonectomy for lung cancer by Graham in 1933, pneumonectomy became the standard of care in the treatment of lung cancer by the 1940s. However, it came to be appreciated that preservation of lung parenchyma is desirable. In recent surgical series, the incidence of pneumonectomy has decreased relative to other pulmonary resections but is still performed in 10% to 30% of patients offered curative resection for primary lung cancer [1].

Advances in perioperative management have improved surgical outcome for pulmonary resections, but pneumonectomy continues to be associated with increased mortality compared with lobectomy [2]. It has been suggested that the mortality of a right pneumonectomy is higher than that of a left. Of the reports examining perioperative mortality after pneumonectomy, few have specifically analyzed or compared right and left pneumonectomy. The purpose of this study was to determine the operative morbidity and mortality associated with right-sided versus left-sided pneumonectomy.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Footnotes
 References
 
A retrospective analysis was conducted of 187 patients who underwent pneumonectomy between 1990 and 2000 in the Division of Thoracic Surgery at the Toronto General Hospital, University Health Network, and Mount Sinai Hospital. One hundred eighty patients underwent operation for primary carcinoma of the lung, 5 for metastatic disease, 1 for aspergilloma, and 1 for tuberculous disease. Patients having extrapleural pneumonectomy for mesothelioma or carinal or completion pneumonectomy were excluded from this analysis.

The data retrieved included age, sex, medical comorbidities, smoking history, preoperative pulmonary function tests, echocardiograms, ventilation–perfusion scans, and resting and exercise pulse oximetry when available. If used, preoperative chemotherapy or radiotherapy was noted. The final pathologic stage was classified according to the 1997 international system for staging lung cancer [3]. Operative reports were reviewed in detail in an effort to determine the rationale for pneumonectomy versus lobectomy, intrapericardial or other extended dissection, the extent of lymph node dissection, hand-sewn versus stapled closure, and what, if any, tissue was used to reinforce the bronchial closure.

Intraoperative and postoperative complications occurring during hospitalization were noted, including empyema, pneumonia, arrhythmias, congestive heart failure, myocardial infarction, adult respiratory distress syndrome (ARDS), pulmonary embolus, sepsis, bronchopleural fistula (BPF), respiratory failure requiring intubation longer than 48 hours, and hemorrhage requiring transfusion or reoperation. All in-hospital deaths were considered operative deaths for the purpose of this analysis.

Meta-Analysis
In performing the meta-analysis, the criterion for inclusion was studies reporting results of pneumonectomy in which mortality data for right versus left were specified. Medline and Cancerlit were searched by the one of the authors (G.D.). Additionally, the references from other reports of pneumonectomy were hand searched. The literature search identified four studies that met the inclusion criterion. An additional paper reported a difference in mortality between left and right pneumonectomy, but actual patient numbers were not included in the paper (data obtained by personal communication, C. Deschamps, 2003). One study was excluded from the meta-analysis because it included only elderly patients [4]. Data from the four studies was combined with our own data set to complete the meta-analysis [5].

Statistical Analysis
Patient characteristics including preoperative and operative factors and postoperative outcomes were described as means or proportions. Patients with right-sided pneumonectomy were compared with patients with left pneumonectomy with respect to postoperative outcomes including in-hospital mortality. Differences in patient characteristics between these two groups were also examined. The {chi}2 or Fisher's exact test was applied to discrete variables, and the Wilcoxon rank sum test was applied to continuous variables. Multivariate logistic regression was applied to find the adjusted associations of the side of operation with, and to identify independent risk factors for, in-hospital mortality and the development of a BPF.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Footnotes
 References
 
There were 187 patients; 68% (128) were male. The mean age was 67.1 ± 11.5 years (range, 19 to 92 years). Right pneumonectomy (R) was performed in 68 (36%) and left pneumonectomy (L), in 119 (64%). The indication for surgery was primary bronchogenic carcinoma in 180 patients (including carcinoid tumors), metastatic cancer in 5, and septic lung disease in 2 (one each for aspergilloma and tuberculosis). Squamous cell cancer was the most common primary lung cancer histologic assessment, occurring in 53% of patients (96 of 180 of primary lung cancers) with adenocarcinoma occurring in 34% (61 of 180). There was no significant difference in stage of disease between right and left (p = 0.13; Table 1); however, 61% of patients having right-sided pneumonectomies had stage III or IV disease as compared with 46% on the left. Of 31 patients who had induction therapy, patients having right-sided resections were more likely to have been treated with induction therapy before surgery (R, 25% versus L, 13%; p = 0.07). There were no significant differences between the two groups with respect to medical comorbidities, preoperative pulmonary function testing, or smoking history.


View this table:
[in this window]
[in a new window]
  		Table 1. Lung Cancer Stagea
 
Morbidity
Complications were common, occurring in 39.6% (74 of 187) of all patients. There was no difference in the rate of complications overall between right (41.2%) and left (38.9%). The most common complication was atrial arrhythmia, documented in 10.7% of patients. Respiratory complications were more frequent in right pneumonectomies as compared with left, but this difference did not reach statistical significance (Table 2). Bronchopleural fistula was identified by fiberoptic bronchoscopy in 8% (R, 13.2% versus L, 5.0%; p = 0.0472), of whom 6 patients required mechanical ventilation. In only one of these patients did the BPF become apparent after mechanical ventilation was begun.


View this table:
[in this window]
[in a new window]
  		Table 2. Complications of Pneumonectomy
 
Of the septic complications, pneumonia occurred in 14 patients (R, 6 versus L, 8; not significant): 3 complicated by systemic sepsis and 1 with an associated empyema. Bronchopleural fistula was considered to have caused the pneumonia in 2 patients. Empyema occurred in 12 patients overall (6.4%), with no significant difference between R (10.3%) and L (5.9%). Empyema was associated with BPF in 7 patients (R, 4 versus L, 3) but no fistula was identified in 5 (R, 3 versus L, 2).

Mechanical ventilation was required in 8% (R, 11.8% versus L, 5.9%) of patients for respiratory failure. The cause of respiratory failure was multifactorial: pneumonia (4 patients), ARDS (2), congestive heart failure (1), atrial fibrillation without documented congestive heart failure (2), and BPF (6). When patients with ARDS were reviewed in detail, 1 patient was considered to have had postpneumonectomy pulmonary edema. One patient with a left pneumonectomy experienced ARDS as a complication of coagulopathy and died of multiorgan failure. Adult respiratory distress syndrome developed subsequently in 2 patients as a result of pneumonia and in an additional patient as a result of BPF.

With respect to nonrespiratory complications, myocardial infarction was more common with right-sided pneumonectomy (p = 0.017).

Mortality
Overall mortality was 6.4%, 10.3% (7 of 68) for R pneumonectomy and 3.3% (4 of 119) for L. Although this difference appeared important and supported our clinical impression and previous reports about the increased risk of R pneumonectomy, it did not reach statistical significance (p = 0.10, Fisher's exact test).

When our data were combined with data from the four studies identified in the literature in a meta-analysis [6–9], right pneumonectomy was clearly identified as a risk factor for death with a relative risk of 3.39 (95% confidence limits, 2.10 to 5.48; p < 0.00001; Fig 1).



View larger version (15K):
[in this window]
[in a new window]
  		Fig 1. Meta-analysis of mortality of right versus left pneumonectomy. (CI = confidence interval; df = degrees of freedom; RR = risk ratio.)

 
In an effort to explain the increased mortality of right pneumonectomy, the primary cause of death (Table 3) was determined by detailed review of the patient chart and was defined as the initiating event that led to death. Respiratory causes were the most common cause of death, and in 6 of the 11 deaths, a BPF was the initiating event that led to the patient's demise. All of these 6 patients suffered multiple complications secondary to the BPF including pneumonia, sepsis, and respiratory failure.


View this table:
[in this window]
[in a new window]
  		Table 3. Cause of Death
 
Potential risk factors for mortality after pneumonectomy were evaluated including age, comorbidities, and pulmonary function testing, but were not significant on univariate analysis. A history of smoking, current or previous, reported as number of pack-years, was associated with increased mortality on univariate analysis (p = 0.02, Wilcoxon rank sum test).

Overall, the stage of disease, histology, and the extent of pneumonectomy did not influence mortality. Because of a recent report of the increased risk of complications and death in patients having induction therapy [8], the use of induction therapy with either chemotherapy, radiation, or both in 31 patients was examined but was not associated with increased mortality.

Factors identified by univariate analysis as having an association with increased mortality were analyzed by multivariate logistic regression. The factors identified by multivariate analysis to be important for risk of in-hospital death after pneumonectomy were as follows: BPF (odds ratio, 43.3; 95% confidence limits, 4.2 to 441.9; p = 0.002), and other postoperative complications excluding BPF (odds ratio, 8.7; 95% confidence limits, 0.9 to 82.1; p = 0.06).

Bronchopleural Fistula in Right Pneumonectomy
Comparing right and left pneumonectomy, right-sided resections were more frequently complicated by BPF, and the mortality of a right BPF was higher (R, 44% versus L, 33%), although not statistically significant. In an effort to explain the increased incidence of BPF in right pneumonectomies, possible contributing factors, including extent of lymphadenectomy, extent of resection, technique of bronchial closure, use of tissue reinforcement of the bronchial stump, and preoperative radiation or chemotherapy, were examined.

Complete lymphadenectomy was rarely performed. There was no significance difference in tumor stage between right-sided and left-sided resections (Table 1); however, there was a trend toward higher stage disease on the right (IIIa/b, IV), and more extensive resections, including significantly more intrapericardial pneumonectomies, were performed on the right (R, 45.6% versus L, 26.9%; p = 0.004). Patients having right pneumonectomy were more likely to have received induction therapy (R, 25.0% versus L, 13.4%; p = 0.07). The right bronchial stump was more likely to have been hand-sewn (R, 35.3% versus L, 8.4%; p < 0.0001) and buttressed (R, 75.0% versus L, 43.7%; p < 0.0001) rather than stapled. Local intrathoracic tissues were almost exclusively chosen for reinforcement of the bronchial stump. In patients experiencing a BPF, 3 of 6 left-sided stumps were not covered as compared with 2 of 10 on the right.

Variables that may have contributed to the development of BPF were analyzed by univariate analysis. (Table 4) The only statistically significant variables were right-sided resections and hand-sewn closures.


View this table:
[in this window]
[in a new window]
  		Table 4. Technical Factors Related to Bronchopleural Fistula Rates
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Footnotes
 References
 
The mortality of pulmonary resection has diminished during the years, with current mortality rates for pneumonectomy reported in the range of 5% to 12% [6, 7, 9–15]. However, there are little data in the literature regarding the risk of a right versus left pneumonectomy. Wahi and associates [6], in a series of 197 patients, were the first to report that a right pneumonectomy was associated with a higher mortality (12%) than left (1%), with an overall mortality of 7%. Au and colleagues [4] also found significant increased mortality for right pneumonectomy compared with left in elderly patients (37% versus 6%; p = 0.001). Bernard and coworkers [9], reporting on 639 patients, found that right pneumonectomy was associated with increased mortality on univariate analysis, but this was not confirmed on multivariate analysis.

Martin and associates [8] reported the in-hospital mortality for patients having pneumonectomy was 13.0% for right-sided resections and 0% for left-sided resections, for an overall mortality of 6.2%. All patients had induction chemotherapy, and 18.1% of their patients also received preoperative radiation. In their series, the causes of death related to right pneumonectomy were respiratory failure and ARDS in 6 patients dying while in hospital. Primary respiratory failure and ARDS were not major causes of death in our series overall, nor in patients receiving neoadjuvant chemotherapy or radiation.

Combining the data from these reports [4, 6, 8, 9] with our own in a meta-analysis allowed us to statistically confirm the clinical impression of many thoracic surgeons that a right-sided pneumonectomy is indeed associated with increased risk.

Previous reports of mortality in pneumonectomy have focused on respiratory failure, ARDS, and postpneumonectomy pulmonary edema syndrome as causes of the increased mortality after pneumonectomy as compared with lobectomy. These same factors likely play a role in the increased mortality of a right compared with left pneumonectomy. It was postulated that the increased risk of right pneumonectomy may be related to the increased load on the right ventricle of the entire cardiac output going through the smaller left lung, resulting in increased pulmonary artery pressures, pulmonary hypertension, and right ventricular failure. Alternatively, the loss of the larger right lung might compromise pulmonary function, leading to respiratory failure. With these hypotheses in mind, poor pulmonary reserve, on the basis of preoperative pulmonary function testing, has been reported as a risk factor for increased mortality after pneumonectomy by some authors [6, 10, 16–18] but not others [4, 19, 20]. We did not find that preoperative pulmonary function was a predictor of mortality in our logistic regression analyses, although we had preoperative pulmonary function data available on only a third of our patients. Nevertheless, only 8% of our patients developed postoperative respiratory insufficiency, which compares favorably with the incidence in the literature of 5% to 15% [21]. This may reflect the fact that surgeons in our center elected not to resect patients with borderline respiratory function.

Increased perioperative fluid resuscitation [7, 9, 15, 17, 22] as a cause of volume overload of the right ventricle and pulmonary circulation has also been reported as a predictor of poor outcome after pneumonectomy. In our centers, intraoperative and postoperative fluid restriction is the standard of care, and this may account for the low rate of postpneumonectomy pulmonary edema in this series.

This report implicates the development of a BPF as the major cause of mortality after right pneumonectomy, although BPF has been identified as an independent predictor of mortality after pneumonectomy by other authors [14, 23] and was more prevalent after right pneumonectomy (R, 9.8% versus L, 3.8%) [14]. The overall incidence of BPF in our series was 8%, which compares favorably with the incidence reported in the review by Cerfolio of 4.5% to 20% [24] and reported in most recent series (0.5% to 9.8%) [1, 14, 25–28].

The increased frequency of BPF on the right side is likely multifactorial. It should be noted that the right bronchial stump is more exposed in the pleural space and less likely to be naturally buttressed by mediastinal tissues as compared with the left. This anatomic difference alone is likely a significant factor in the increased risk of developing a BPF on the right side.

Devascularization of the bronchial stump is also a recognized risk factor for BPF [24]. This may occur because of extensive dissection required for a proximal tumor or because of extensive lymphadenectomy. De Perrot and colleagues [1] noted an increase in postpneumonectomy BPF from 3% to 9% coincident with an increase in mediastinal lymphadenectomy and the use of bronchial staplers in their center. During the period studied in this series, lymph node sampling rather than complete lymphadenectomy was the standard approach, and therefore lymphadenectomy leading to devascularization of the bronchial stump is less likely to be a major contributing factor in our series. However, more extensive resections were performed on the right than the left, and this may have required a more extensive dissection around the main bronchus with potential devascularization of the bronchial stump. In our series, hand-sewn closure was identified as a risk factor for BPF whereas others have implicated the use of staplers in the development of BPF [26–28]. Because we routinely use staplers for bronchial closure, the use of a hand-sewn closure reflects more extensive proximal dissection or a technically difficult bronchial stump. In closing a very proximal right bronchial stump, attention must be directed to ensuring that there is no tension on the bronchial closure. The cartilaginous ring at the origin of the right main bronchus has a tendency to keep the bronchus open. It has been suggested that a portion of this ring should be resected to allow the bronchus to be closed without tension.

In our series of 187 pneumonectomies combined with data from 4 other reports in a meta-analysis, we found that right-sided resections were associated with a higher mortality than those on the left. A higher rate of BPF on the right appeared to be a factor in the increased mortality of right pneumonectomy in our series. This may be related to anatomy, more extensive surgical dissection, potential devascularization, more intrapericardial dissections, and hand-sewn closures. Recognizing the increased vulnerability and risk of a right-sided bronchial stump and addressing technical factors that contribute to early BPF may help to reduce the morbidity and mortality of right pneumonectomy.


   Footnotes
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Footnotes
References
 
*Dr Ginsberg died on March 1, 2003.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Footnotes
 References
 

  1. De Perrot M, Licker M, Robert J, et al. Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy Scand J Thorac Cardiovasc Surg 1999;33:171-174.
  2. Wada H, Nakamura T, Nakamoto K. Thirty day operative mortality for thoracotomy in lung cancer J Thorac Cardiovasc Surg 1998;115:70-75.[Abstract/Free Full Text]
  3. Mountain CF. Revisions in the International System for Staging of Lung Cancer Chest 1997;111:1710-1717.[Abstract/Free Full Text]
  4. Au J, el-Oakley R, Cameron EW. Pneumonectomy for bronchogenic carcinoma in the elderly Eur J Cardiothorac Surg 1994;8:247-250.[Abstract]
  5. Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F. Systematic reviews of trials and other studies Health Technol Assess 1998;2(19):1-276.
  6. Wahi R, McMurtrey MJ, DeCaro LF, et al. Determinants of perioperative morbidity and mortality after pneumonectomy Ann Thorac Surg 1989;48:33-37.[Abstract]
  7. Swartz DE, Lachpapelle K, Sampalis J, et al. Perioperative mortality after pneumonectomy: analysis of risk factors and review of the literature Can J Surg 1997;40:437-444.[Medline]
  8. Martin J, Ginsberg RJ, Abolhoda A, et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy Ann Thorac Surg 2001;72:1149-1154.[Abstract/Free Full Text]
  9. Bernard A, Deschamps C, Allen MS, et al. Pneumonectomy for malignant disease: factors affecting early morbidity and mortality J Thorac Cardiovasc Surg 2001;121:1076-1082.[Abstract/Free Full Text]
  10. Nagasaki F, Flehinger BJ, Martini N. Complications of surgery in the treatment of carcinoma of the lung Chest 1982;1:25-29.
  11. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty day operative mortality for surgical resection in lung cancer J Thorac Cardiovasc Surg 1983;86:654-658.[Abstract]
  12. Kohman LJ, Meyer JA, Ikins PM, et al. Random versus predictable risks of mortality after thoracotomy for lung cancer J Thorac Cardiovasc Surg 1986;91:551-554.[Abstract]
  13. Roxburgh JC, Thompswon J, Goldstraw P. Hospital mortality and long- term survival after pulmonary resection in the elderly Ann Thorac Surg 1991;51:800-803.[Abstract]
  14. Alexiou C, Beggs D, Rogers M, et al. Pneumonectomy for non-small cell lung cancer: predictors of operative mortality and survival European Journal of Cardio-Thoracic Surgery 2001;20:476-480.
  15. Harpole DH, deCamp MM, Daley J, et al. Prognoistic models of thirty-day mortality and morbidity after major pulmonary resection J Thorac Cardiovasc Surg 1999;117:969-979.[Abstract/Free Full Text]
  16. Putnam JB, Lammermeier DE, Colon R, et al. Predicted pulmonary function and survival after pneumonectomy for primary lung carcinoma Ann Thorac Surg 1990;49:909-914.[Abstract]
  17. Patel RL, Townsend ER, Fountain SW. Elective pneumonectomy: factors associated with morbidity and operative mortality Ann Thorac Surg 1992;54:84-88.[Abstract]
  18. Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for lung resection J Thorac Cardiovasc Surg 1995;109:275-281.[Abstract/Free Full Text]
  19. Pate P, Tenholder MF, Griffin JP, et al. Preoperative assessment of the high risk patient for lung resection Ann Thorac Surg 1996;61:1494-1500.[Abstract/Free Full Text]
  20. Gebitekin C, Martin PG, Satur CM, et al. Results of pneumonectomy for cancer in patients with limited ventilatory function Eur J Cardiothorac Surg 1995;9:347-351.[Abstract]
  21. Zwischenberger JB, Alpard SK, Bidani A. Early complications: respiratory failure Chest Surg Clin N Am 1999;9:543-564.[Medline]
  22. Zeldin RA, Nanmandin D, Landtwing DE, et al. Post pneumonectomy pulmonary edema J Thorac Cardiovasc Surg 1984;87:359-365.[Abstract]
  23. Dyszkiewicz W, Pawlak K, Gasiorowski L. Early post pneumonectomy complications in the elderly Eur J Cardiothorac Surg 2000;17:246-250.[Abstract/Free Full Text]
  24. Cerfolio R. The incidence, etiology and prevention of postresectional bronchopleural fistula Semin Thorac Cardiovasc Surg 2001;13:3-7.[Medline]
  25. Deschamps C, Bernard A, Nichols III FC, et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence Ann Thorac Surg 2001;72:243-247.[Abstract/Free Full Text]
  26. Hubaut JJ, Baron O, Al Habash O, et al. Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer Eur J Cardiothorac Surg 1999;16:418-423.[Abstract/Free Full Text]
  27. al-Kattan K, Cattelani L, Goldstraw P. Bronchopleural fistula after pneumonectomy for lung cancer Eur J Cardiothorac Surg 1995;9:479-482.[Abstract]
  28. Sonobe M, Nakgawa M, Ichinose M, et al. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer Eur J Cardiothorac Surg 2000;18:519-523.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
K. A. Kesler, Z. T. Hammoud, K. M. Rieger, L. E. Kruter, M. Yu, and J. W. Brown
Carinaplasty Airway Closure: A Technique for Right Pneumonectomy
Ann. Thorac. Surg., April 1, 2008; 85(4): 1178 - 1186.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. de Perrot, K. McRae, M. Anraku, K. Karkouti, T. K. Waddell, A. F. Pierre, G. Darling, S. Keshavjee, and M. R. Johnston
Risk Factors for Major Complications After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma
Ann. Thorac. Surg., April 1, 2008; 85(4): 1206 - 1210.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
P. G. Sfyridis, E. I. Kapetanakis, N. E. Baltayiannis, N. V. Bolanos, D. S. Anagnostopoulos, A. Markogiannakis, and A. Chatzimichalis
Bronchial Stump Buttressing With an Intercostal Muscle Flap in Diabetic Patients
Ann. Thorac. Surg., September 1, 2007; 84(3): 967 - 971.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
Z. Mansour, E. A. Kochetkova, X. Ducrocq, M.-D. Vasilescu, G. Maxant, A. Buggenhout, J.-M. Wihlm, and G. Massard
Induction chemotherapy does not increase the operative risk of pneumonectomy!
Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 181 - 185.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
L. A. Clemson, E. Walser, A. Gill, J. E. Lynch, and J. B. Zwischenberger
Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate
Ann. Thorac. Surg., November 1, 2006; 82(5): 1924 - 1926.
[Abstract] [Full Text] [PDF]

Home page
 Asian Cardiovasc. Thorac. Ann.Home page
D. Chichevatov, A. Gorshenev, and E. Sinev
Preventive diaphragm plasty after pneumonectomy on account of lung cancer.
Asian Cardiovasc Thorac Ann, August 1, 2006; 14(4): 265 - 272.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
M. Dancewicz, J. Kowalewski, and J. Peplinski
Factors associated with perioperative complications after pneumonectomy for primary carcinoma of the lung
Interactive CardioVascular and Thoracic Surgery, April 1, 2006; 5(2): 97 - 100.
[Abstract] [Full Text] [PDF]

Home page
 MMCTSHome page
J. Hendriks, P. Lauwers, and P. Van Schil
Extrapericardial pneumonectomy
MMCTS, June 28, 2005; 2005(0628): 83.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Gail E. Darling
Michael Johnston
Thomas K. Waddell
Andrew Pierre
Shaf Keshavjee
Robert Ginsberg
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Darling, G. E.
Right arrow Articles by Ginsberg, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Darling, G. E.
Right arrow Articles by Ginsberg, R.
Related Collections
Right arrow Lung - cancer

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS