How I Do It The pleural and human fibrin glue sandwich: a quick and effective post-pneumonectomy bronchial stump coverage technique Francesco Leo, M.D., Ph.D. a, *, Domenico Galetta, M.D. a , Lorenzo Spaggiari, M.D., Ph.D. a,b a Thoracic Surgery Department, European Institute of Oncology, via Ripamonti 435, 20100 Milan, Italy; and b University of Milan School of Medicine, Milan, Italy Abstract BACKGROUND: Protection of the bronchial stump after pneumonectomy reduces the incidence of bronchopleural fistula. However, which technique provides the most satisfactory results remains open for debate. MATERIALS AND METHODS: We describe a study in which a bronchial stump coverage technique was performed using 2 layers of human fibrin glue (Tissucol; Baxter, Deerfield, IL USA) with an interposed patch of parietal pleura. From July 2005 to June 2007, this technique was used in 31 consecutive patients after standard pneumonectomy by a single surgeon. RESULTS: None of the patients developed early or late bronchopleural fistula, and no clinical adverse reaction was recorded. During the same period, alternative stump coverage techniques were used by different surgeons in 71 pneumonectomies. In this group, the rate of fistula was 6% (4 patients). CONCLUSION: These preliminary data demonstrate the feasibility of the technique and suggest that it is at least equivalent to the other type of flaps used. The main advantages of this technique are the restoration of the natural separation between the mediastinum and pleural cavities, as well as the reduced operating time (duration 5 minutes). © 2008 Elsevier Inc. All rights reserved. KEYWORDS: Bronchopleural fistula; Pneumonectomy; Human fibrin glue Bronchopleural fistula occurs in approximately 5% of patients after pneumonectomy, more frequently on the right side. The development of postoperative bronchopleural fis- tula increases the risk of mortality by 20%. 1 Side and bronchial devascularization, preoperative radiotherapy, and residual tumor on the stump all are considered risk factors contributing to the occurrence of bronchopleural fistula. 2 In order to reduce this complication, several methods of bronchial stump coverage have been described. The tech- niques can be divided into 2 different groups: avascular coverage (parietal pleura, pericardium, azygous vein) and vascularized flaps (intercostal, dentate, latissimus dorsi, omentum). The primary function of all bronchial coverage avascular methods is the mechanical isolation of the bronchial stump from the pleural cavity. This represents the ideal scaffold for tissue ingrowth from the surrounding mediastinal pleura, and also provides protection against fluid spillage in the case of microfistula. Unfortunately, none of these methods is fail-proof. For example, the availability of tissue may be limited (azygous vein), or the procedure can prolong oper- ating time (pericardium). * Corresponding author. Tel.: +39.02.57489665; fax: +39.02.57489698. E-mail address: francesco.leo@ieo.it Manuscript received June 23, 2007; revised manuscript January 7, 2008 0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.01.022 The American Journal of Surgery (2008) 196, e35– e37