Transsternal bronchial closure: a narrative review

Bronchopleural fistula (BPF) after pneumonectomy remains a challenging and potentially life-threatening complication. The transsternal transpericardial approach has been described as an alternative route for selected central or postpneumonectomy BPFs, particularly when access through the previous thoracotomy is unsafe, technically difficult, or has failed. The objective of this review is to summarize the indications, technical principles, adjunctive strategies, outcomes, and limitations of the transsternal transpericardial approach for BPF repair.

A narrative review of the available literature was performed, focusing on studies, case series, and technical reports describing the transsternal transpericardial approach for BPF. Particular attention was given to patient selection, surgical technique, bronchial stump closure, use of reinforcement, endoscopic adjuncts, morbidity, mortality, recurrence, and the limitations of the current evidence.

The transsternal transpericardial approach provides anterior access to the central airway and allows bronchial stump reamputation and closure while avoiding direct dissection through a chronically infected or hostile pleural cavity. Published series suggest that this technique may achieve durable closure with acceptable morbidity and mortality in selected patients. However, reported outcomes vary considerably across studies, reflecting differences in patient condition, fistula characteristics, timing of repair, presence of empyema, and previous failed treatment attempts. Recently, bronchoscopic and video-assisted techniques have been described as adjuncts to improve diagnosis, fistula localization, operative planning, and intraoperative guidance.

The transsternal transpericardial approach may represent a valuable surgical option for carefully selected patients with central or postpneumonectomy BPF, especially when conventional transthoracic repair is not feasible or has failed. Nevertheless, the available evidence is limited mainly to retrospective series, small cohorts, case reports, and technical descriptions. Therefore, definitive conclusions regarding superiority over other approaches cannot be drawn, and treatment should be individualized according to fistula anatomy, patient condition, pleural sepsis, and surgical expertise.