Late postpneumonectomy bronchopleural fistula

The incidence of late postpneumonectomy bronchopleural fistula (PBPF) is very small after the 3rd postoperative week due to the existence of fibrothorax providing an effective natural protection against fistula formation. However, the development of late PBPF is a serious complication characterized by high morbidity and mortality. We present our modest experience in treating 11 patients with late PBPF using the transsternal transpericardial approach.

Between 1996 and 1999, 11 male patients with a mean age of 61 years were treated in our department for late PBPF (diameter > 5 mm). The interval between pneumonectomy and fistula creation ranged from 1 to 10 years. The initial operation was right pneumonectomy in all cases due to lung cancer. pTNM stage was either II or IIIA. Bronchoscopically no recurrence was observed and empyema was present in all cases.

The initial treatment consisted of tube thoracostomy. We proceeded to direct bronchial stump repair transpericardially with omental flap coverage and finally open window thoracostomy. Neither deaths nor major complications occurred perioperatively. The ICU and hospital stay ranged from 5 to 10 and 30 to 45 days, respectively. During a follow-up of 10 to 28 months no recurrence was observed.

1. The management of late large PBPF can be only surgical. 2. Fibrothorax and empyema makes the approach through thoracotomy impossible and dangerous for dissection and repair. 3. Bronchial stump repair through the transpericardial approach by median sternotomy is very effective in late PBPF cases where the patient's general condition is good, allowing a major intervention.