Incidence, risk factors and management of bronchopleural fistulae after pneumonectomy

Postpneumonectomy bronchopleural fistula (BPF) remains a serious and often life-threatening complication. Over a seven-year period, seven cases of BPF occurred in a series of 100 consecutive pneumonectomies performed for lung carcinoma by the same surgical team. The incidence increased from 3% (1/33) prior to 1993 to 9% (6/67) thereafter. The presence of tumour within the main stem bronchus and the need for postoperative mechanical ventilation correlated significantly with the occurrence of BPF. However, it is likely that other risk factors, such as the introduction of systematic mediastinal lymph nodes dissection since 1992 and bronchial stapling since 1993, were involved. In four patients, closure of BPF was achieved by transposition of pedicled latissimus dorsi (LD) muscle flap and closed-chest irrigaiton of the pleural cavity. Patients were discharged after a median stay of 19 d; fistula recurred in one case and was successfully treated with an omental flap. No complications related to the LD division were observed. In conclusion, mediastinal lymph node dissection may increase the risk of post-pneumonectomy BPF. Systematic bronchial stapling should be used cautiously, especially if the tumour is present within the main stem bronchus. Treatment with predicted LD muscle flap or omental flap associated with closed-chest irrigation proved to be simple, time-saving and efficient.