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Management Strategies for Complex Bronchopleural Fistula

Division of Thoracic Surgery 1 Department of Medicine 2 Division of Plastic Surgery UCSF-Mount Zion San Francisco, California, USA 3 Division of Cardiothoracic Surgery Washington Hospital Healthcare System Fremont, California, USA

For reprint information contact: David M Jablons, MD Tel: 1 415 885 3887 Fax: 1 415 353 9525 Division of Thoracic Surgery, UCSF-Mount Zion, 1600 Divisadero Street, Room C-322, San Francisco, CA 94115, USA.

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.

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