Management of microfistula following pulmonary resection

The symptoms and signs of cough and changes in the air-fluid pattern on chest radiograph are critical as warning signs of bronchopleural fistula. Drainage of the pleural space is a critical first step for all patients to limit endobronchial contamination and prevent drowing. Once nutritional status is optimized and treatment for infection is established, suture reclosure of the bronchial stump with vascularized flap coverage is curative for the acutely presenting fistula, usually fewer than 2 weeks after surgery. Patients who present with bronchopleural fistula at times more remote from resection are unlikely to have direct reclosure of their fistula. These patients may have closure of their fistula by either an anterior, transpericardial approach, thoracotomy with muscle flap to fill the pleural space, or muscle flap coverage of the fistula with a limited thoracoplasty to obliterate the pleural space. Patients who cannot undergo operations of this magnitude may be treated with endoscopically placed tissue adhesives to seal the fistula. These various treatment options are successful in 75% to 100% of cases, and have been responsible for significantly reducing the morbidity and mortality from bronchopleural fistula.