Antifungal-Based Conservative Management of Delayed-Onset Fungal Bronchopleural Fistula After Lung Cancer Surgery

Bronchopleural fistula (BPF) is a rare but potentially life-threatening complication after pulmonary resection. When associated with Aspergillus infection, management becomes particularly challenging because of tissue necrosis and impaired bronchial healing. Although surgical intervention is generally recommended, optimal management of delayed-onset fungal BPF remains controversial. We report two cases of postoperative Aspergillus fumigatus-associated BPF following lung cancer surgery that were managed primarily with antifungal therapy and pleural drainage. In the first case, a delayed-onset BPF developed 14 months after bilobectomy and resolved completely with percutaneous drainage and prolonged voriconazole therapy without additional surgery. In the second case, limited surgical closure failed to eliminate persistent air leakage; however, subsequent antifungal therapy combined with continued drainage resulted in complete fistula closure. These cases suggest that in carefully selected patients with localized, delayed-onset fungal BPF and clinical stability, antifungal-based conservative management may be considered in carefully selected patients as a potential adjunct or alternative to aggressive surgical intervention. Careful patient selection and multidisciplinary evaluation are essential.