Complications of thoracic surgery: post-pneumonectomy bronchopleural fistula

Abstract

Bronchopleural fistula (BPF) describes an abnormal connection between a bronchus (main, lobar or segmental) and the pleural cavity. BPF is a recognized complication after pneumonectomy and is associated with significant morbidity and mortality. The risk of post-pneumonectomy BPF (PP-BPF) is greater in right sided operations, male patients, residual tumor, barotrauma, previous TB and active infection. If suspected, diagnosis of BPF should be made expeditiously with computed tomography scanning and bronchoscopy. The management depends on the timing of presentation, the size of the fistula and the clinical status of the patient. All patients require drainage of the infected pleural space and intravenous antibiotics. In early presentations, re-do thoracotomy followed by stump closure and reinforcement with a pedicled muscle flap is recommended. If the fistula is small (<5 mm) or the patient is not fit enough for major surgery, bronchoscopic repair using fibrin glue application, stents or closure devices can be attempted. Minimally invasive techniques can also be used as a temporizing measure while optimizing a patient for a major intervention. There are multiple case reports describing novel bronchoscopic techniques for management of BPF. The risk of BPF should be reduced in high-risk patient groups by implementing bronchial stump coverage (BSC) at the time of pneumonectomy. Overall, the literature is limited by the relative rarity of the problem. Much of the literature is based on retrospective studies and case series which leads to inherent biases preventing true comparative studies in operative techniques and outcomes. Metaanalysis of case reports and new randomized controlled trials may give more evidence to support the current findings. While some simple principles should be followed, management of BPF needs to be individualized to each patient's clinical picture.