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Ann Thorac Surg 1997;63:1396-1397
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St SW, Rochester, MN 55905

See also page 1391.

Bronchopleural fistula with associated empyema after pneumonectomy, although uncommon, is a serious and potentially lethal complication. This is reinforced by this retrospective review presented by Hollaus and associates of 96 patients in which 65 patients (67%) died. Although there was a wide spectrum of presentations, it is of interest that of the 49 patients initially treated with operation by a variety of procedures, 20 (41%) died and 21 (43%) were dismissed with healed wounds. Of the 36 patients initially treated with bronchoscopy, 5 (14%) died, in 11 (31%) the fistula healed, and only 4 (11%) left with a healed wound. Also, 12 patients who had failed bronchoscopic treatment underwent secondary surgical procedures, with two additional deaths.

Treatment should result in an alive patient with a healed wound. Prevention is paramount. Meticulous closure of the bronchus, leaving a short bronchus to prevent pooling of secretions and subsequent infection, and not contaminating the pleural space during the course of the procedure are all important in preventing this complication. Also, a previously irradiated bronchus should be reinforced with vascularized tissue at the time of the initial operation.

Our current treatment plan after stabilization of the patient is (1) open drainage by an Eloesser flap or reopening of the original thoracotomy, (2) reclosure of the bronchus reinforced with vascularized tissue, preferably transposed muscle, and (3) when the fistula is healed, obliteration of the pleural space by a Clagett maneuver. Although invasive and time consuming, this can lead to a successful outcome in many patients. Pairolero and associates [1] reported on 45 patients with a postpneumonectomy empyema of whom 28 had an associated bronchopleural fistula. Following the above plan, the bronchopleural fistula was successfully closed in 24 of the 28 patients (86%). There were three operative deaths (11%), all in patients in whom the fistula could not be successfully closed. Of 31 patients in the entire group, Clagett closure was ultimately successful in 26 (84%).

My colleagues and I continue to believe aggressive treatment of postpneumonectomy bronchopleural fistula and empyema provides the best opportunity for a successful long-term result.

Reference

1. Pairolero PC, Arnold PG, Trastek VF, Meland NB, Kay PP. Postpneumonectomy empyema: the role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990;99:958–68.[Abstract]

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Victor F. Trastek Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Trastek, V. F. Search for Related Content PubMed Articles by Trastek, V. F. Related Collections Related Article