Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.