Asian Cardiovasc Thorac Ann 1999;7:49-51
© 1999 Asia Publishing EXchange Pte Ltd
Postpneumonectomy Bronchopleural Fistula Formation and Surgical Management
Ünal Açikel, MD,
Erdem Silistreli, MD,
Nilgün Özelsancak, MD,
Özalp Karabay, MD,
Eyüp Sabri Uçan, MD,1,
Eyüp Hazan, MD,
Öztekin Oto, MD
Department of Thoracic & Cardiovascular Surgery Turkey
1 Department of Pulmonary Medicine Dokuz Eylul University School of Medicine  zmir, Turkey
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For reprint information contact: Erdem Silistreli, MD Tel: 90 232 277 5867 Fax: 90 232 277 2165 email: silistre{at}cs.med.deu.edu.tr Mithatpasa Cad No. 257/5, Balcova, zmir 35340, Turkey.
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Abstract
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Bronchopleural fistulas and empyema are the most challenging problems after lung resection. We reviewed 4 cases of successful surgical treatment of postpneumonectomy bronchopleural fistulas. Three of the patients had empyema. Primary suturing and pleural decortication were performed in one patient, decortication and fistula repair with additional omentopexy were carried out in the other 3 patients. Recurrence in one patient was successfully treated by thoracoplasty; the others have had no recurrence on follow-up. We recommend aggressive surgical intervention as the most effective treatment for bronchopleural fistula and empyema after pulmonary resection.
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Introduction
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Bronchopleural fistula formation after pneumonectomy procedures is not a frequent complication and the incidence has been reported as 0% to 28% in different publications.1 When encountered, it causes significant morbidity and mortality.2 Conservative therapeutic management is generally ineffective and mortality rates range between 20% and 70%. The cause of mortality is usually pneumonia developing from contamination of healthy lung tissue by the empyema material via the fistula, with consequent adult respiratory distress syndrome.3 Various closing techniques had been described. In this paper, we report our experience of 4 cases of bronchopleural fistula after pulmonary resection.
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Methods
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Between 1990 and 1997, 148 patients underwent various pulmonary resection procedures in our institution for pulmonary malignancy, bronchiectasis, hydatid cyst, or pneumatocele (Table 1
). Pneumonectomy was performed in 26 of these patients for the management of pulmonary carcinoma (Table 2). In 2 cases (8.3%), bronchopleural fistula and empyema developed in the late postoperative period. Two other patients were treated for these complications after undergoing pneumonectomy in another institute. Tumor cells were not detected in the bronchial resection border in these 4 patients after their first operation. Three patients had received radiotherapy 1 month after the resection and the other had radiotherapy 6 months before and 2 months after the resection. General characteristics of the patients are shown in Table 3.
Case 1
Our first patient was a 63-year-old male who developed cough and fever 7 months after a pneumonectomy that was performed because of stage IIIa squamous cell carcinoma. Bronchopleural fistula was diagnosed by bronchoscopy. The bronchial stump was exposed by thoracotomy. After debridement of infected material, an air leak was detected and repaired primarily with interrupted polypropylene sutures. The omentum was prepared via a left paramedian laparotomy with care to protect its vascular structure. It was extended to the left hemithorax via a fenestration on the diaphragm and fixed to the bronchial stump. There was no postoperative complication.
Case 2
A 60-year-old male was treated with antibiotics and closed drainage in another center because of empyema and opening of the bronchial stump 2 months after a pneumonectomy for stage IIIa adenocarcinoma. The stump had been closed with fibrin glue using bronchoscopy and video-assisted thoracoscopy. After 3 days, reopening of the stump was detected because of signs of infection. On admission to our institute 18 months later, the patient underwent debridement and decortication and the bronchial stump was repaired by the same suture technique. A video-assisted thoracoscopic examination was preformed postoperatively. There was no post-operative complication.
Case 3
A 58-year-old male who had been treated with radiotherapy because of laryngeal carcinoma 15 years previously, underwent a right pneumonectomy in our institution because of squamous cell carcinoma. He received radiotherapy postoperatively. Three months later, a bronchopleural fistula was detected. This was also repaired by omentoplasty. The fistula opened again 10 days later. Right parietal pleural decortication, 2nd to 7th costal resection, and thoracoplasty with a muscular flap were performed successfully with no complications on follow-up.
Case 4
A 58-year-old male who was diagnosed with stage IIIb squamous cell carcinoma, was treated by resection and preoperative radiotherapy. As soon as regression to stage IIIa was observed, he underwent a right pneumonectomy procedure. Postoperative radiotherapy was given. After 4 months, cerebral metastases were detected and chemotherapy was applied. Five months later, a broncho-pleural fistula was diagnosed by bronchoscopy following complaints of cough with sputum and fever (Figure 1). Surgery was carried out for debridement and pleural decortication and the stump was repaired with interrupted monofilament sutures and omentoplasty. Successful closure of the stump was confirmed by bronchoscopy in the postoperative period (Figure 2) and also viewed via a video-assisted thoracoscopic system (Figure 3). However, reopening of the fistula by approximately 2 mm was detected 2 months later by bronchoscopy. The patient is still being followed up but he needs no further surgical intervention.
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Discussion
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One of the most catastrophic complications after thoracic surgery is bronchopleural fistula formation. The incidence of postpneumonectomy empyema varies from 2% to 13% and its existence without bronchopleural fistula is rarely reported.4,5 Bronchopleural fistula is generally encountered on the right side and predominantly in males (15:1), with no significance of age.3 All of our 4 patients were male and the complication was on the right side in 3 of them. Bronchopleural fistula is detected mainly after treatment for neoplastic diseases (97%). The time interval between the operation and fistula formation varies between 2 and 200 days. The incidence of aspiration pneumonia is less frequent in patients developing bronchopleural fistula in the late postoperative period but it is the primary factor in early mortality due to this complication. However, fistula development in the later period is more common.3 In our patients, fistulas developed in the late postoperative period and there was no incidence of aspiration pneumonia or mortality. Histological type and stage of the malignancy are not significant factors in this complication.3 Success rates of treating these fistulas have been reported in the range of 75% to 85%.6 Mortality at rates of 19.5% to 71% occurred mostly within the first 2 weeks and rarely after 3 months.7–9
Three of our patients were treated successfully with no recurrence. Endoscopic closure of postresection bronchopleural fistula can be performed in selected patients with a success rate reported by Scappaticci and colleagues10 of 83%. We recommend the use of bronchoscopy for confirmation of the diagnosis in cases of suspected bronchopleural fistula and surgical closure of the stump within 12 to 24 hours. Delay may lead to invasion of infection and a higher risk of recurrence of the fistula with an increased risk of mortality.
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References
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Miller JI Jr. Postsurgical empyemas. In: Shields TW, editor. General thoracic surgery. 4th ed. Baltimore: Williams & Wilkins, 1994:694–700.
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Abstract
Introduction
