Surgical strategy for closure of postoperative bronchopleural fistula: a narrative review

Postoperative bronchopleural fistula (BPF) remains one of the most severe complications after pulmonary resection due to its frequent association with empyema, aspiration, respiratory failure, and sepsis. Although numerous surgical and endoscopic options have been described, the literature is heterogeneous with respect to fistula timing, pleural contamination, residual cavity status, and definition of success. This review aimed to synthesize the evidence on postoperative BPF management with emphasis on surgical strategy selection and the role of minimally invasive interventions.

A primary PubMed/MEDLINE search was performed using a predefined strategy combining controlled terms related to BPF, postoperative pulmonary resection, and operative or minimally invasive closure techniques. The search covered the period from February 2006 to February 2026. Backward citation tracking and selective inclusion of seminal historical and contextual publications were also performed.

The risk of postoperative BPF is highest after pneumonectomy, particularly right-sided, and is increased in patients with diabetes, chronic obstructive pulmonary disease, neoadjuvant treatment, prior surgery, and prolonged postoperative mechanical ventilation. Evidence on stump closure technique is mixed: stapled and hand-sewn closure appear broadly comparable in modern practice, whereas routine prophylactic stump coverage remains controversial and is best applied selectively in high-risk patients. For established BPF, treatment should be stage-adapted. Direct stump reclosure with vascularized flap reinforcement is preferred for early, technically salvageable fistulas. In chronic BPF, complicated by empyema and sepsis, staged open treatment and pleural space management are central. In this scenario, modified Clagett-type pathways and flap-based cavity obliteration achieved durable control in most reported series. Endoscopic strategies are most effective in selected small fistulas, whereas covered stents and Amplatzer-based devices provide the most reproducible results for central defects.

Postoperative BPF should be managed according to timing, stump condition, presence of pleural sepsis, and pleural cavity complications. Early salvageable fistulas are best approached with direct stump repair and vascularized reinforcement, whereas chronically contaminated cases more often require staged open treatment and definitive cavity obliteration. Endoscopic techniques are valuable adjuncts in selected patients but do not replace surgery in complex postoperative BPF.