TRANSSTERNAL CLOSURE OF BRONCHOPLEURAL FISTULA AFTER PNEUMONECTOMY

Background. Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula. Met hods. From 1974 through 1995, 55 patients underwent transsternal, tran spericardial closure of a bronchopleural fistula. Mean age was 62.7 ye ars (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. Th e fistula was right-sided in 41 patients (74.5%), and the bronchial st ump was less than 2 cm in 25 (45.5%). Treatment of the concomitant emp yema was by closed drainage in 2 patients, by repeated needle aspirati on in 17, and by open thoracostomy in 36 patients. Reamputation and cl osure of the stump was possible in 51 patients; in 4 a primary carinal resection was done. Results. Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients di ed late during hospitalization, total hospital mortality, 23.6% (70% c onfidence interval 17.3% to 31.0%). Recurrent fistula symptoms were ca used by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital st ay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, th ere were no recurrent fistulas. All patients with benign lesions are a live and well. Of 37 cancer patients, 29 died, more than half due to m alignancy. Risk factors for death included recurrent fistula, short in terval between pneumonectomy and onset of fistula, and closing techniq ue. Risk factors for recurrent fistula were a short bronchial stump an d the nonuse of an open thoracostomy. Conclusions. Long-term results o f transsternal closure are good, but hospital mortality is high. The p resent treatment of patients with large postpneumonectomy bronchopleur al fistula includes early open thoracostomy, improvement of nutritiona l status, transsternal closure using resorbable sutures, and closure o f the pleural space 3 weeks later. (C) 1997 by The Society of Thoracic Surgeons.