TRANSSTERNAL TRANSPERICARDIAL OPERATIONS IN THE TREATMENT OF BRONCHOPLEURAL FISTULAS AFTER PNEUMONECTOMY

Between 1972 and 1993, 19 patients (15 males and 4 females) with bronc hopleural fistulae and pleural empyema after pneumonectomy were treate d with transsternal transpericardial operations and closure of the fis tula. The underlying malignant disease was a non-small cell carcinoma in 12, a malignant epithelial mesothelioma in two, and an atypical car cinoid tumor in one case. One patient each presented with tuberculosis , chest trauma, and lung destroyed by bronchiectasis. Fistulas affecte d the right bronchial stump in 17, and the left in 2, cases after pneu monectomy. The time between pneumonectomy and transsternal transperica rdial operation ranged between 1 month and 4 years. All patients were submitted to drainage and irrigation of the empyema cavity (2-4 weeks) . In 16 patients a long bronchial stump was sutured or stapled, in thr ee cases resection of a short stump with the distal trachea was follow ed by anastomosis of the trachea and left main stem bronchus. Irrigati on of the pneumonectomy cavity was continued in all patients for 2 wee ks. Transsternal transpericardial operation was successful in 15 patie nts. Two patients died in the first 30 days, of renal or respiratory f ailure without fistula recurrence. In two cases the fistula recurred; definitive healing was achieved using a great omentum flap and endosco pic application of fibrin glue and bone spongiosa. Transsternal transp ericardial management of bronchus stump fistula after pneumonectomy is highly effective and offers advantages over the direct approach throu gh the infected empyema cavity.