TREATMENT STRATEGIES FOR BRONCHOPLEURAL FISTULA

Successful management of chronic postoperative bronchopleural fistula remains a challenge for thoracic surgeons. Forty-two patients (33 refe rred from other institutions) were treated for major postoperative bro nchopleural fistula since 1978. Factors associated with bronchopleural fistula included right pneumonectomy (n 23), left pneumonectomy (n = 8), long bronchial stump (n = 16), pneumonia (n 13), radiation therapy (n = 12), stapled bronchial closure (n = 8), prolonged mechanical ven tilation (n = 7), recurrent carcinoma (n = 6), and tuberculosis (n 2). Patients had undergone an average of 3.3 surgical procedures to corre ct their bronchopleural fistulas during a mean interval of 24 months b efore our treatment. Bronchopleural fistulas were located in the right main bronchial stump (n = 23), left main bronchial stump (n = 8), rig ht lobar bronchial stumps (n = 10), and tracheobronchial anastomosis ( n = 1). Thirty-five patients were treated by suture closure of the bro nchial stump, buttressed with vascularized pedicle flaps of omentum (n = 19), muscle (n = 13), or pleura (n = 2). In seven cases, direct sut ure closure was not possible, and omental (n = 6) or muscle (n = 1) fl aps were sutured over the bronchopleural fistula. Suture closure witho ut pedicle coverage was performed successfully in one case. Initial re pair of the fistula was successful in 23 of 25 patients treated with o mentum, in nine of 14 patients treated with muscle and in neither of t wo patients treated with pleural flaps. In nine patients with persiste nt or recurrent bronchopleural fistula after our initial repair, four underwent a second procedure (three successful) and five were managed with drainage only. The fistula was successfully closed in 11 of 12 pa tients who had received high-dose radiation therapy (nine with omentum ). Overall, successful closure of bronchopleural fistula was achieved in 36 of 42 patients (86%). Four in-hospital deaths resulted from pneu monia and sepsis, two in patients with recurrent bronchopleural fistul a after pleural flap closure. In 16 patients the empyema cavity was ob literated during definitive repair of the fistula. The cavity resolved with drainage in four others, nine had draining cavities at follow-up , and one was lost to follow-up. Ten patients required a total of 17 C lagett procedures and one had a delayed myoplasty. Direct surgical rep air of chronic bronchopleural fistula may be achieved in most patients after adequate pleural drainage by suture closure and aggressive tran sposition of vascularized pedicle flaps. Omentum is particularly effec tive in buttressing the closure of bronchopleural fistulas.