Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy

Between 1972 and 1993, 19 patients (15 males and 4 females) with bronchopleural fistulae and pleural empyema after pneumonectomy were treated with transsternal transpericardial operations and closure of the fistula. The underlying malignant disease was a non-small cell carcinoma in 12, a malignant epithelial mesothelioma in two, and an atypical carcinoid tumor in one case. One patient each presented with tuberculosis, chest trauma, and lung destroyed by bronchiectasis. Fistulas affected the right bronchial stump in 17, and the left in 2, cases after pneumonectomy. The time between pneumonectomy and transsternal transpericardial operation ranged between 1 month and 4 years. All patients were submitted to drainage and irrigation of the empyema cavity (2-4 weeks). In 16 patients a long bronchial stump was sutured or stapled, in three cases resection of a short stump with the distal trachea was followed by anastomosis of the trachea and left main stem bronchus. Irrigation of the pneumonectomy cavity was continued in all patients for 2 weeks. Transsternal transpericardial operation was successful in 15 patients. Two patients died in the first 30 days, of renal or respiratory failure without fistula recurrence. In two cases the fistula recurred; definitive healing was achieved using a great omentum flap and endoscopic application of fibrin glue and bone spongiosa. Transsternal transpericardial management of bronchus stump fistula after pneumonectomy is highly effective and offers advantages over the direct approach through the infected empyema cavity.