Bronchopleural fistula (BPF) after pneumonectomy is an uncommon event seen in 1.5–7% of patients. This rate may double when pneumonectomy is performed for a primary infectious etiology such as tuberculosis. When it occurs, however, the consequences can be devastating, with prolonged hospital stays involving multiple procedures for survivors and up to 50% mortality. Most BPFs are seen in the early postoperative period. Al-Kattan and colleagues reported 7 cases in 471 pneumonectomies, all occurring within 15 days of surgery.1 Late-onset BPF can be more difficult to diagnose and generally is seen in the setting of empyema. The basic principles of management include protection of the remaining lung, control of sepsis, debridement of necrotic tissue, closure of the fistula reinforced with vascularized tissue, and obliteration of the pleural space.
Risk factors for the development of BPF after pneumonectomy include anatomic, technical, and patient factors (Table 72-1). Multiple authors have demonstrated that right pneumonectomy is associated with a four- to fivefold higher incidence of BPF than left pneumonectomy.2,3 This is likely related to anatomic differences between the right and left main stem bronchi. Specifically, there is minimal mediastinal coverage of the bronchial stump on the right side compared with the left, where the properly fashioned stump will retract underneath the aorta into the mediastinum (Fig. 72-1). The right mainstem bronchus is also oriented much more vertically than the left, which permits secretions to pool in the bronchial stump. Finally, the vascular supply to the left mainstem bronchus is augmented by direct vascular branches as the bronchus passes behind the aorta, whereas on the right the blood supply travels from the trachea and local branches in the subcarinal space, and these branches are often disrupted by lymph node removal. Technical factors can include devascularization of the bronchial stump by excessive dissection; long bronchial stump, which increases the risk of secondary infection; and closure under tension, as in the case of a thickened bronchial wall at the point of closure. Closure under tension also can be implicated in a predominance of right-sided BPFs because the diameter of the right mainstem bronchus at the point of transection generally is larger than the left.
Table 72-1. Risk Factors for Development of Bronchopleural Fistula after Pneumonectomy |Favorite Table|Download (.pdf)
Table 72-1. Risk Factors for Development of Bronchopleural Fistula after Pneumonectomy
- Devascularization of bronchial stump
- Long bronchial stump
- Tension at stump suture or staple line
- Persistent disease at bronchial stump
- Postoperative mechanical ventilation
- Poor pulmonary reserve
- Chronic steroid use
- Preoperative infectious process
- Preoperative chemotherapy or radiation therapy
Patients with right pneumonectomy are four to five times more likely to develop a BPF owing to the anatomic differences between the right and left mainstem bronchi. The right bronchus has a more ...