Bronchopleural fistula (BPF) occurs in 1.5% to 7% of patients after pneumonectomy. BPFs can have devastating consequences, with mortality of 25% to 71% and prolonged hospital stays involving multiple procedures for survivors.1,2 Presentation may be acute or delayed: The majority of patients present within 3 months postoperatively, most of whom do so within the first 12 days after surgery.2,3 Late-onset BPF can be more difficult to diagnose and generally is seen in the setting of empyema. The basic principles of successful BPF 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 82-1).4,5 Right pneumonectomy is associated with a fourfold to fivefold higher incidence of BPF than left pneumonectomy, likely related to anatomic differences between the right and left mainstem bronchi.6 A right pneumonectomy stump has minimal mediastinal coverage of the bronchial stump compared with a left-sided stump, which retracts underneath the aorta into the mediastinum when properly fashioned (Fig. 82-1). 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. The blood supply on the right travels from the trachea via local branches in the subcarinal space, which are often disrupted by dissection and lymph node removal.
Table 82-1Risk Factors for Bronchopleural Fistula After Pneumonectomy |Favorite Table|Download (.pdf) Table 82-1Risk Factors for Bronchopleural Fistula After Pneumonectomy
|Right pneumonectomy |
|Completion pneumonectomy after previous ipsilateral lung resection |
|Devascularization of bronchial stump |
|Long bronchial stump |
|Tension at stump suture or staple line |
|Persistent disease at bronchial stump |
|Surgery for benign disease |
|Postoperative mechanical ventilation |
|Poor pulmonary reserve |
|Low preoperative FEV1 and DLCO |
|Chronic steroid use |
|Preoperative infectious process or empyema |
|Preoperative chemotherapy or radiation therapy |
|Blood transfusion |
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 vertical orientation, which may permit collection of fluid in the stump and lacks direct vascular branches from the aorta, relying instead on the trachea and local branches in the subcarinal space that are often disrupted during lymph node removal.
Technical factors related to BPF formation include devascularization of the bronchial stump by excessive dissection; a long bronchial stump with increased pooling ...