107: Surgical Approaches for Chronic Empyema and for Management of Chronic Bronchopleural Fistula

Empyema and bronchopleural fistula (BPF) are two distinct yet intimately related entities. They may occur together or independently, and they share similar etiologies. The management of each process has proved, over several centuries, to be a daunting task that requires sound clinical judgment and a resilient patient.

Hippocrates provided the first clinical description of empyema approximately 2400 years ago. In 229 bc he described the clinical presentation and physical examination findings in patients with empyema. Hippocrates is also credited with the first drainage procedure for empyema. This entailed partial rib resection, drainage, and daily packing.¹ Despite Hippocrates' detailing of the clinical presentation, natural history, and treatment of empyema, it was not until the nineteenth century that significant work on the subject was presented.

In 1843, Trosseau advanced thoracentesis for the treatment of empyema. French surgeon Sedillot described thoracotomy and empyema drainage. More extensive procedures, including thoracoplasty and decortication, were introduced by Estlander (1879) and Fowler (1893), respectively.² At the start of the twentieth century, most treatment strategies for acute empyema involved early rib resection and open drainage. Mortality rates with this approach averaged 30%. Graham and Bell, of the United States Army Empyema Commission, made a major advance in the treatment of early empyema. They recommended closed-tube drainage to manage early empyema. This strategy decreased the mortality rate from 30% to 4.3%.³

In 1935, Eloesser⁴ described an open thoracotomy technique that would permit skin and soft tissue to behave as a valve to allow lung expansion. In 1963, Clagett and Geraci⁵ introduced open window drainage for 6 to 8 weeks, followed by empyema cavity obliteration with antibiotic solution and window closure. The Clagett window remains useful in the treatment of chronic empyema. Muscle flap closure of BPF and the postresectional space has become increasingly popular.^6,7 Video-assisted thoracoscopy and fibrinolytic therapy also have roles in the management of empyema.^8,9

Empyema is defined as a purulent pleural collection (Fig. 107-1). Causes include bacterial pneumonia, tuberculosis, postresectional, posttraumatic, and intra-abdominal processes. Approximately 50% of empyemas are caused by bacterial infection. Postresectional causes account for 25%, and an additional 8% to 11% are caused by extension of an intra-abdominal process.¹⁰

Clinical Presentation

The presenting signs and symptoms of empyema are nonspecific. The most common symptoms are shortness of breath and fever. Patients also may complain of cough and chest pain. Sputum production may or may not be present. These symptoms are also present in patients with pneumonia. Empyema should be considered when a patient manifests these symptoms after a prolonged respiratory illness or a lung resection. Laboratory analysis is also relatively nonspecific and usually includes leukocytosis. C-reactive protein levels that exceed 100 mg/L may be useful as a diagnostic indicator of postpneumonectomy empyema, as described by Icard and colleagues.¹¹ Physical examination findings may be underwhelming, although in empyema necessitatis an undrained empyema may track through the soft tissues, causing cellulitis in the overlying skin.

Radiographic Evaluation

The radiographic workup of postpneumonic empyema should begin with a posteroanterior and lateral chest x-ray (Fig. 107-2). Hsu and colleagues¹² showed that an empyema appears as a wide air–fluid level on posteroanterior view and has a narrow anteroposterior width on lateral projection. Bilateral decubitus films may provide information regarding a freely flowing or loculated empyema. Radiographs also may differentiate among empyema, BPF, and lung abscess. In BPF, the air–fluid level is most commonly located in the posterior costophrenic sulcus.¹³ There is little difference in air–fluid level size between posteroanterior and lateral projections in the case of lung abscess. Schachter and colleagues¹⁴ presented the following qualities that distinguish empyema from lung abscess on plain film: (1) The air–fluid level extends to the chest wall; (2) its border tapers near the mediastinum or chest wall; and (3) the air–fluid level crosses the fissure.

Ultrasound also may be used to evaluate empyemic spaces. Major advantages include portability and identification of loculations or pleural fibrosis. This modality also may differentiate transudates from exudates.^15,16 Ultrasound also may guide catheter-based drainage of effusions, although a major limitation is the operator-dependent nature of this modality.

Chest CT scan is the mainstay in the diagnosis and management of empyema and BPF. CT characteristics specific to empyema include a thin, uniform, smooth wall along the exterior surfaces, in contrast with the irregular walls seen in lung abscesses (Fig. 107-3). The “split pleura” sign, which distinguishes the separated visceral and parietal pleural surfaces, can be seen in nearly 70% of empyemas (Fig. 107-4).¹⁷ The presence of empyema fluid separates the two hypervascular surfaces, which are readily identified on contrast-enhanced scans. One major pitfall is the difficulty of differentiating atelectasis or effusion from the diaphragm. Intra-abdominal ascites and subdiaphragmatic abscess also may make proper diagnosis of empyema challenging.

MRI may be applied to the diagnosis of parapneumonic effusions and empyema. The multiplanar imagery provides details specific to the location and relationship of the empyema to pleural structures. In addition, the pleural surfaces can be visualized adequately to identify a split-pleura sign. Even so, given the availability and current use of CT, as well as the cost of MRI, widespread use of MRI is limited as applied to empyema diagnosis.

Parapneumonic Effusions

As mentioned earlier, parapneumonic effusions account for the majority of empyemas. The approach should include plain films. Antibiotic therapy is the treatment of choice if the fluid thickness on decubitus studies is less than 1 cm.¹⁸ Diagnostic and therapeutic thoracentesis is indicated for larger collections and those that persist or enlarge despite medical therapy.

Natural History

The evolution from parapneumonic effusion to empyema involves three stages. Stage 1, the exudative stage, is characterized by freely flowing fluid. At this point, the pleural surfaces are inflamed and quite permeable. This stage corresponds to the uncomplicated parapneumonic effusion described by Light and colleagues.¹⁸ Stage 2, the fibrinopurulent stage, is characterized by bacterial infection and fibrin deposition. The fluid color may progress from clear yellow to purulent. Biochemical fluid analysis can guide management of these fluid collections. A pleural fluid pH of less than 7.00, pleural fluid glucose concentration less than 40 mg/dL, or a positive culture suggests a complicated parapneumonic effusion, and tube thoracostomy is indicated. Frank pus is an indication for tube thoracostomy. The organized phase, stage 3, occurs approximately 1 week after the initial infection. Fibroblastic ingrowth and collagen deposition occur. Progression of this phase over a period of 3 to 4 weeks may result in a thickened membrane, or “peel,” that results in trapped lung and potentially restricts pulmonary function (Fig. 107-5).

After chest tube placement and drainage, the patient should undergo surveillance chest x-ray and chest CT scan to assess (1) completeness of drainage and (2) lung expansion. If multiple loculations are present on the chest CT scan, intrapleural fibrinolytics or thoracoscopy should be performed. Daily intrapleural streptokinase 250,000 units/100 mL of saline may be administered via the chest tube, followed by chest tube clamping for 4 hours. This therapy can be discontinued when the volume of drainage is low or after lung re-expansion has been demonstrated.⁹ Fibrinolytic therapy is most applicable to the fibrinopurulent phase of parapneumonic effusions. Despite the reported success of fibrinolytic therapy, we favor video-assisted thoracic surgery (VATS) over lytic therapy. Thoracoscopy permits adhesiolysis and chest tube positioning under direct vision. In addition, the coagulum may be thoroughly removed, and if necessary, a limited decortication can be performed. The overall condition of the lung also may be assessed and the need for thoracotomy and complete decortication determined.⁸ During the fibrinopurulent stage of empyema, VATS offers decreased hospital stay, reduced cost, and improved cosmesis in comparison with thoracotomy.¹⁹

In the organized phase, a thick fibrous “peel” overlies the visceral pleura. Patients may have a restrictive pattern on pulmonary function testing. Findings suggestive of this phase include the persistence of an empyema cavity after 7 to 10 days of chest tube drainage, failure of full lung expansion on radiographs, and a thick “peel” on chest CT scan or at thoracoscopy.

Preoperative Assessment

In cases of empyema complicated by trapped lung, thoracotomy and decortication are indicated. Preoperative workup should include a chest CT scan and pulmonary function testing. Ventilation/perfusion lung scanning may be useful in selected patients when poor ipsilateral lung function may indicate the need for pneumonectomy.²⁰ Contraindications to this procedure include a debilitated, moribund patient, adequate drainage and expansion by lesser procedures, severe cardiopulmonary disease, and little or no perfusion to the affected lung.

Surgical Technique

The technique of decortication requires general anesthesia, usually through a double-lumen endobronchial tube. Packed red blood cells should be available perioperatively. The patient is placed in a full lateral decubitus position, and a serratus-sparing posterolateral or vertical axillary thoracotomy incision is made. The pleural cavity is entered through the fifth or sixth interspace after removing a portion of the overlying rib. The peel is incised initially with a no. 15 scalpel blade (Fig. 107-6). The peel is grasped, and a meticulous excision is performed using a combination of blunt and sharp separation of the peel and underlying visceral pleura. Some degree of ventilation to the affected lung will assist with identifying the proper dissection plane. The presence of air leaks indicates an incorrect dissection level. As the fibrinous covering is removed, the underlying lung will readily expand when ventilated. The dissection should be thorough and extend into the fissure and diaphragmatic lung surfaces. This extremely tedious procedure requires patience on the part of the surgeon and anesthesiologist.

Postresection Empyema

Postresectional empyema may occur after pneumonectomy and lesser resections, including wedge biopsy, segmentectomy, and lobectomy. The risk of occurrence is low at 0.01% for wedge resections and up to 2% for lobectomies.²¹ Postpneumonectomy empyema is more common, with an incidence of 5% after standard pneumonectomy.²² The mortality rate is as high as 50%.²³ Empyema from lesser resections usually occurs secondary to persistent parenchymal leak, with a resulting residual space that becomes secondarily infected. Chest tube drainage and directed antibiotic therapy usually are effective management. More extensive procedures, including VATS with drainage, modified Eloesser drainage, and myoplasty, may be needed in refractory cases. Airspace location may determine the muscle type used during myoplasty. Apical airspaces may be obliterated using the pectoralis major, serratus anterior, or latissimus dorsi muscle. The serratus and latissimus also may be used for posterior spaces. The omentum may be mobilized and passed along the anterior diaphragm for inferior spaces.²¹

Postpneumonectomy Empyema

Risk Factors/Presentation/Workup

Postpneumonectomy empyema (PPE) represents a serious complication that may occur early or late after pneumonectomy. PPE is accompanied by BPF in up to 80% of cases. Several risk factors that cause BPF may ultimately lead to PPE, as shown in Table 107-1. Preventive measures should include aggressive preoperative treatment of pleural sepsis with antibiotics and optimization of nutritional status. Perioperative measures include careful dissection around the bronchial stump with preservation of bronchial blood supply, appropriate stump length, minimization of intraoperative spillage, and liberal use of autologous flaps for stump coverage. Right pneumonectomy is associated with a higher rate of stump dehiscence, empyema, and BPF. This is likely because the stump is exposed to the pleural space on the right. The left bronchial stump usually retracts medially and subaortically, providing some degree of protection.

PPE may be insidious in onset. Symptoms of fatigue, cough, weight loss, and pain may be present. Radiographs may be helpful in cases of PPE with concomitant BPF. A decrease in the air–fluid level on plain film in a patient with the preceding complaints and risk factors should prompt further investigation.

Chest CT scan provides information on the volume and homogeneity of the pleural fluid, the position of the ipsilateral diaphragm, and the status of the remaining lung. In cases of PPE with BPF, CT scan may even provide the location of the opening.

Management

Initial management of PPE without BPF is the same as for other types of empyema—tube thoracostomy drainage. Flexible bronchoscopy should be performed to assess bronchial stump integrity. Mediastinal shift and volume loss may alter the dimensions of the pneumonectomy space significantly. Chest CT scan therefore is recommended before tube thoracostomy. Insertion is safest along the fourth interspace in the anterior axillary line.²⁴ The chest tube should be placed to water seal. If the mediastinum is stable but drainage is inadequate, a modified Eloesser flap can be created, as described by Thourani and colleagues²⁵ (Fig. 107-7). Between 3 months (for benign disease) and 12 months (for malignant disease), a single-stage complete muscle flap closure may be performed as described by Miller and colleagues.²⁶ Extrathoracic muscle flaps can be used to close the pleural space. Flaps used in order of decreasing frequency include latissimus dorsi, serratus anterior, pectoralis major, pectoralis minor, and rectus abdominis. Figure 107-8 shows each of these structures with respective blood supplies. The omentum also may be used to obliterate the postpneumonectomy space and may be more useful for bronchial stump coverage in postpneumonectomy BPF.

Nonresectional Postoperative Empyema

Nonresectional postoperative empyema may occur after esophageal surgery with intraoperative spillage or postoperative esophageal leak. Empyema also can complicate intra-abdominal surgery or infection. This may occur after gastric perforation, splenectomy, or pancreatic infection/resection. The management principles are the same as for postresectional empyema.

Tuberculous Empyema

The worldwide prevalence of tuberculosis caused by bacterial infection with Mycobacterium tuberculosis deserves mention because it relates to empyema and BPF. Tuberculosis causes nearly 3 million annual deaths in adults worldwide.²⁷ In the United States, factors such as HIV infection, IV drug abuse, and immigration patterns led to a 9.4% increase in reported tuberculosis cases in 1990.^28,29 The use of collapse therapy, including intrapleural pneumothorax, plombage, and thoracoplasty, was largely supplanted by antituberculous chemotherapy. The development of multidrug-resistant tuberculosis and its complications has led to a small but renewed role for surgery in the treatment of this disease.

Surgery in Tuberculous Empyema

The preoperative approach should include arterial blood gas determination, pulmonary function testing, and quantitative ventilation/perfusion scans. The latter is particularly helpful in determining the need for lobectomy versus pneumonectomy in the case of destroyed lung. Antituberculous chemotherapy should be administered preoperatively in an effort to produce a negative pleural or sputum culture.^30,31 Tube thoracostomy may be used to successfully drain small BPFs during this time. Empyema may be drained using a window thoracostomy or Clagett procedure. After several months, a thoracomyoplasty may be performed in patients treated initially by open-window thoracostomy.³² Muscle flap stump closure should be used in all patients undergoing lobectomy with a positive sputum culture, those with anticipated space problems, and all patients undergoing pneumonectomy.³⁰ The latissimus dorsi muscle is favored and used most commonly for this purpose.

Traumatic Hemothorax

Empyema may complicate traumatic hemothorax associated with blunt or penetrating trauma. Hemothorax also may complicate cardiac surgery, especially if one or both pleural spaces were opened at operation. Although a sterile hemothorax usually is reabsorbed after 1 month, secondary infection poses a significant problem. The initial diagnostic approach should include chest x-ray. Chest CT scan may provide useful information about the amount of hemothorax and the condition of the underlying lung.

Surgical Management

Thoracentesis should be performed if there is a free-flowing hemothorax. In chronic cases, the hemothorax is clotted, and thoracentesis is of no value. It may provide some information about the presence of infection but will result in inadequate drainage. Tube thoracostomy also may prove insufficient for evacuating a clotted hemothorax. We recommend the early resort to VATS for the treatment of hemothorax. Early thoracoscopic management can be used to adequately evacuate large, infected hemothoraces and obviates the need for thoracotomy and decortication.⁸ An algorithm for management of empyema and hemothorax is provided in Fig. 107-9.

Miscellaneous Etiologies

Extension of a subphrenic abscess may cause empyema. This accounts for a minority of cases. Other miscellaneous causes of empyema include ruptured lung abscess and generalized sepsis. The management depends on the overall patient status and includes control of the underlying condition and use of the approaches described previously.

Ancillary Nonoperative Approaches to Parapneumonic Effusions, Empyema, and Hemothorax

Fibrinolytic therapy with urokinase or tissue plasminogen activator has been increasingly used as an adjunct to tube thoracostomy drainage and video-assisted thoracoscopic drainage of parapneumonic effusions, empyema, and retained hemothorax.^33–35 The results of this adjunctive measure have been gratifying with successful nonoperative management (beyond tube thoracostomy) reported in over 80% of patients treated. Currently, the use of these fibrinolytic agents appears to have increasing utility in the management of these pleural problems.

Definition/Incidence/Risk Factors

BPF is a communication between the airway and pleural space (Fig. 107-10). The fistula may originate as proximally as the mainstem bronchus or as distally as a segmental bronchus. The incidence of BPF varies based on etiology. Postresectional BPF may occur after lesser resections, such as lobectomy or segmentectomy. The incidence of BPF after lobectomy ranges between 0.5% and 1.2%, and the incidence is 0.3% after segmentectomy.^36,37

Postpneumonectomy BPF

Incidence, Risk Factors

The reported mortality of 20% to 70% makes BPF the most serious complication of pneumonectomy. The incidence of BPF ranges from 1.3% to 5% for pneumonectomy performed for lung cancer.^36,38 Pomerantz and colleagues reported an incidence of BPF as high as 22% in patients undergoing pneumonectomy for mycobacterial infection. Stratification revealed that BPF occurred in 8 of 17 patients (47%) undergoing pneumonectomy for Mycobacterium infections other than tuberculosis.³⁰

As depicted in Table 107-1, several factors predispose to the development of BPF. Neoadjuvant therapy in the form of radiation or chemoradiation places the bronchial stump at increased risk for dehiscence and BPF development.³⁹ Right pneumonectomy is associated with a higher incidence of BPF. In the report of Asamura and colleagues, the overall incidence of postpneumonectomy BPF for lung cancer was 4.5%. Patients who underwent right pneumonectomy had an incidence of 8.6% versus 2.3% for those undergoing left pneumonectomy.³⁶ The increased risk of BPF after right pneumonectomy has been well explained. Cadaver studies have shown that the right mainstem bronchus usually has one bronchial artery, whereas there are two on the left. The right bronchial stump therefore is at increased risk of ischemia. The left mainstem bronchus retracts below the aortic arch and is buttressed, whereas the right mainstem stump has no coverage and remains exposed in the pleural space. Although pneumonectomy for mycobacterial infections is performed more commonly on the left lung, right pneumonectomy, when performed, is associated with a higher rate of BPF. In a 1991 study of patients undergoing surgery for mycobacterial infection, Pomerantz and colleagues³⁰ reported that seven of nine patients suffering BPF had undergone right pneumonectomy.

Other factors that predispose to BPF include a long bronchial stump, concomitant infection at the time of pneumonectomy, and prolonged mechanical ventilation. The presence of a long bronchial stump permits pooling of secretions in the stump, which can lead to stump breakdown secondary to chronic inflammation or infection (Fig. 107-11).⁴⁰

Clinical Presentation, Evaluation

The presentation of BPF spans a broad spectrum from vague complaints of fatigue to the massive expectoration of serous pleural fluid with aspiration into the remaining lung. Patients may complain of weakness, loss of appetite, and weight loss. They also may develop a fever and leukocytosis. These symptoms are indistinguishable from those observed in patients with empyema.

A decrease in the air–fluid level or development of a new airspace on chest x-ray may indicate the presence of a BPF (Fig. 107-12). CT scanning may have a role if empyema is suspected and can even identify the fistula is some cases.

Initial Management

If BPF is suspected, flexible bronchoscopy should be performed. The bronchial stump should be inspected closely for erythema, mucosal irregularities, granulation tissue, or the presence of a frank opening. The contralateral airway also should be evaluated, and any secretions should be evacuated and cultured. If the patient manifests a large BPF with massive expectoration of serosanguineous fluid, the pneumonectomy side should be placed dependently, thereby protecting the remaining lung. Concomitantly, the airway should be secured, depending on the degree of respiratory distress. The bronchus to the intact lung should be intubated directly with a single-lumen endotracheal tube. The bronchial portion of a double-lumen tube also can be inserted into the intact bronchus and the cuff inflated for protection. Emergency tube thoracostomy on the pneumonectomy side is performed. If the occurrence is within days of pneumonectomy and there is some question about stability of the mediastinum, the tube is placed to water seal. If several days or weeks have elapsed, special care is taken to place the tube anterior and near the fourth or fifth interspace. This takes into account the mediastinal shift and volume changes within the pleural cavity.

Treatment options for BPF are dictated by the following: (1) time of development in relation to pneumonectomy; (2) side of the BPF; (3) presence of empyema; (4) overall status of the patient; and (5) whether the event is initial or represents a failed attempt at fistula closure.

Surgical Therapy

Recommended management of early postpneumonectomy BPF begins with tube thoracostomy and drainage. This should be followed by thoracotomy, debridement, and identification of the bronchial stump. Saline solution is poured into the pleural space. The pleural cavity then is ventilated under positive pressure. Air bubbles should guide the surgeon to the fistula. The stump should be debrided to viable tissue and a hand-sewn closure performed. Chest tubes then should be placed in superior and dependent positions. Continuous irrigation with antibiotic solution is administered until cultures from the space are sterile.

An alternative approach to chronic BPF and empyema is a two-stage method introduced by Deschamps and colleagues.⁴¹ The first stage involves open pleural drainage and debridement through the prior thoracotomy incision. The fistula is identified and closed at this time. Extrathoracic muscle then is transposed into the pleural cavity to provide stump coverage. If the serratus anterior muscle was spared during the initial thoracotomy, it may be used. The cephalic portion of the previously transacted latissimus dorsi muscle also may be used for coverage (Fig. 107-13). The pectoralis major, rectus abdominis, or omentum also may be used. The wound is then packed, and dressing changes are recommended every 48 hours over a 4- to 6-day period. The second stage may be performed when healthy granulation tissue is present. The cavity is filled with Dab's solution: 0.5 g neomycin, 0.1 g polymyxin B sulfate, and 80 mg gentamicin in 1 L of saline. A watertight wound closure is performed in multiple layers.

Early reoperation and bronchial stump closure are recommended when BPF occurs within 7 days of the initial operation.²¹ Wright and colleagues⁴² even propose reoperation, stump closure, and coverage in patients who develop BPF fistula within 1 month of pneumonectomy.

Refractory Postpneumonectomy BPF

A less commonly employed but effective means of controlling refractory BPF is a transsternal, transpericardial approach. Originally described in 1960 by Padhi and Lynn⁴³, this approach provides adequate access to the carina and mainstem bronchi. Ginsberg and Saborio described this technique when a BPF had failed closure attempts via thoracotomy. They advocated its use in patients in whom redo thoracotomy is contraindicated and when carinal resection is necessary at the time of stump closure.⁴⁴

Postlobectomy BPF

As mentioned earlier, the incidence of BPF after lobectomy is less than 1%. The same factors that lead to postpneumonectomy BPF can complicate lobectomy. Patient presentation is the same, ranging from vague complaints of fatigue, chest pain, and fever to an airspace and empyema. Plain film and chest CT scan should be used to characterize the pleural cavity. If an air–fluid space is identified, drainage should be established using tube thoracostomy. If fluid is present, it should be cultured and a biochemical profile sent. Broad-spectrum antibiotics should be given. A flexible bronchoscopy is recommended to assess the integrity of the lobar stump and identify a BPF.

The effectiveness of therapy can be judged by assessing the patient's overall condition, including temperature, white blood cell count, and subjective complaints. Serial chest x-rays and chest CT scans should be performed to determine the adequacy of drainage. If there is no improvement or an increase in the airspace or fluid level, then drainage is inadequate. CT-guided or operative drainage should be performed. After complete drainage of the residual space and documented infection control, steps must be taken to close the fistula. Although BPFs following lesser resections can close spontaneously after treatment with drainage and antibiotics, a plan should be in order for stump closure and space obliteration. Cooper and Miller²¹ described the utility of using specific muscle flaps for this purpose. Table 107-2 lists the various flaps that can be used for stump coverage after lobectomy. The pectoralis, latissimus dorsi, or serratus anterior muscle can be used after upper lobectomy. The latissimus, serratus, and omentum may be used to obliterate spaces after lower lobectomy.²¹

Management goals for postlobectomy BPF mirror those for postpneumonectomy BPF: (1) early drainage and antibiotics; (2) stump coverage with extrathoracic muscle, omentum, or other well-vascularized autologous tissue (Fig. 107-14); and (3) obliteration of any residual space with extrathoracic muscle flaps or omentum.

Alternative Therapies

Small BPFs may close spontaneously. Persistent BPFs may pose a significant problem in patients who have undergone multiple thoracotomies or median sternotomy. Alternative approaches to control BPFs in this setting have been described. Lin and Ianettoni⁴⁵ reported the use of bovine albumin-glutaraldehyde tissue adhesive (Bioglue, Cryolife, Kennesaw, GA) in two patients with refractory BPFs. Hollaus and colleagues retrospectively analyzed bronchoscopic closure of BPFs in 45 patients. They found that small fistulas (<3 mm) are treated effectively by bronchoscopic fibrin glue application. Fistulas that exceed 8 mm are not amenable to this approach.⁴⁶

The experience with covered endobronchial stents for the management of benign and malignant airway stenoses has led some investigators to utilize this approach to right mainstem bronchial stump dehiscence following pneumonectomy.^47,48 In addition, the success noted with removable endobronchial valves for “endoscopic lung volume reduction” for pulmonary emphysema has led to the use of these devices for the management of BPF. Endobronchial valve deployment has been reported with successful control of postresectional bronchial stump dehiscence and peripheral parenchymal BPF.^34,35,49

BPF fistula is a dreaded complication of pneumonectomy because of the associated high mortality. The most efficient means of managing this life-threatening complication is prevention. Risk factors should be identified and considered during surgical planning. Flap coverage should be uniformly applied after right pneumonectomy. The use of muscle, pleural, or pericardial flap coverage also should be considered in patients with multiple risk factors.

The strategy for BPF management is greatly influenced by fistula size, time of development relative to the initial resection, availability of tissue for flap coverage, the presence of concomitant empyema, and overall patient condition. Regardless of the approach, certain principles should be adhered to during BPF management: (1) prompt antibiotic therapy; (2) early drainage; (3) infection control if empyema is present; (4) identification and closure of the BPF; (5) stump coverage after closure; and (6) obliteration of any residual space. Empyema and BPF are formidable entities that complicate thoracic surgery. Accurate diagnosis and organized treatment plans can manage these two processes successfully.

The management of intrathoracic “space” problems has been discussed and debated since the 1920s. Partly because of the rigid thorax, resectional surgery often leaves a portion of the chest unoccupied by normal organs. The result may be impaired ventilatory mechanics, a prolonged air leak, or an empyema. Surgical techniques that limit the residual space are important to minimize, if not prevent, these potentially life-threatening complications.