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A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether bronchoscopic or other minimal access approaches to the closure of bronchopleural fistulae (BPFs) were effective compared to a conventional re-thoracotomy. Our search identified 1052 abstracts, from which we identified six case series of greater than two postpneumonectomy bronchopleural fistula patients. These series included reports of bronchial stenting, glue occlusion and scar obliteration of fistulae. No thoracoscopic techniques were reported except in case report form. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We identified 85 postpneumonectomy bronchopleural fistulae reported in the literature who underwent bronchoscopic procedures to attempt repair. There was a 30% cure rate using a range of bronchoscopic techniques in these series. Bronchoscopic techniques included cyanoacrylate or fibrin glue application, YAG laser therapy, injection of the vein sclerosant polidocanol and tracheo-bronchial stenting. The mortality was 40% in these patients reflecting the very high mortality with this complication. Many patients required multiple bronchoscopic procedures and also further drainage procedures of their empyemas. Bronchoscopic treatment has so far only been reported in small case series but may offer further treatment options in patients too unwell to undergo re-thoracotomy.

Patients and clinicians are faced with uncertainty as to the optimal treatment strategy for potentially resectable NSCLC in which there is clinical evidence of involvement of the ipsilateral mediastinum. Randomized controlled trials and meta-analyses have failed to demonstrate superiority of one bimodality strategy over another (chemotherapy plus surgery versus chemotherapy plus radiotherapy). One trial of trimodality treatment with chemotherapy, radiotherapy, and surgery demonstrated an improvement in progression-free, but not overall, survival versus chemotherapy and radiotherapy. There are a number of limitations to the data in this complex and heterogenous patient group. No randomized controlled trial has specifically studied patients with single-station N2 disease versus multistation N2 disease. When discussing treatment for fit patients with potentially resectable cN2 NSCLC, lung cancer teams should consider trimodality treatment with chemotherapy, radiotherapy, and surgery or bimodality treatment with chemotherapy and either surgery or radiotherapy. We advocate that all patients see both a thoracic surgeon and the oncology team to discuss these different approaches.