NATURAL-HISTORY OF BRONCHOPLEURAL FISTULA AFTER PNEUMONECTOMY - A REVIEW OF 96 CASES

Background. Various therapeutic approaches to bronchopleural fistula h ave been reported. Its natural history, which may be key to the best t herapeutic management, early detection, and possibly, prevention of fi stula formation, has received little attention. Methods. The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at pr imary bronchoscopic diagnosis, time of occurrence after operation (day s), cause of death, and survival after fistula formation (days) were a nalyzed. Management consisted of bronchoscopic closure with fibrin sea lant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thorac ostomy. Results. Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) die d during the observation period; in 25, the cause of death was aspirat ion pneumonia. Only 2 patients who died of aspiration pneumonia had de velopment of a fistula after 90 postoperative days. The aspiration rat e dropped with increasing interval between operation and fistula occur rence (p = 0.000). Patient survival after fistula formation was positi vely correlated to this interval (p = 0.002). Successful fistula closu re was achieved by surgical intervention in 21 patients and endoscopic ally in 11 patients. The overall postoperative mortality rate irrespec tive of treatment method was 31%. Conclusions. The incidence of aspira tion pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently rep resents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postope rative months should detect bronchopleural fistula before aspiration o ccurs. (C) 1997 by The Society of Thoracic Surgeons.