Bronchial stump insufficiency after pneumonectomy: etiology, risk factors, therapy

Abstract

Although the incidence of postpneumonectomy bronchopleural fistula has decreased in recent years due to new surgical refinements and a better understanding of the bronchial stump healing it remains a major problem. We reviewed our most recent experience on BPF after pneumonectomy to determine methods by which the risks may effectively be reduced. From 1983 to 1997, 315 patients underwent pneumonectomy for lung cancer, and other malignancy and benign causes (infection with destroyed lung). Main bronchial manual suture was performed in 204 cases and stapled suture in 111 cases. The overall main BPF rate was 3.7% (12/315). The mortality rate was high with 38.4% (5/12). Death was caused by aspiration pneumonia and ARDS in 3, empyema with sepsis and cachexia in 1, and distant tumor recurrence in 1 patient. Risk factors for BPFs were right pneumonectomy (p=0.03) and barotrauma due to postoperative mechanical ventilation (p=0.003). Other previous mentioned risk factors like age, preoperative infection and/or radiation, diabetes mellitus, steroid medication reached no statistical significance. Primary reexploration through the previous thoracotomy incision was performed in 9 patients. After debridement and refashioning the bronchial stump was reclosed with the hand suture technique. The stump was covered with intercostal muscle in 5, pericardial fat pad in 3, and omental flap in 2 patients. Three cases with a pinhole fistula and poor overall condition were treated endoscopically using fibrin sealant and spongy iliacal bone. In 2 patients the fistula persisted and the stump had to be surgically reclosed.¶Conclusions: Postpneumonectomy BPF is one of the most serious complications after lung surgery associated with a high mortality. BPF is more common after right pneumonectomy and is frequently associated with postoperative mechanical ventilation. Rethoracotomy with refashioning, reclosure and covering of the bronchial stump with a vascularized flap is recommended. Endoscopical treatment is reserved only for small BPF associated with poor general condition.