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2000;8:78-84Asian Cardiovasc Thorac AnnAnthony, Timothy S Hall and David M Jablons

Junaid H Khan, Sarah B Rahman, Doff B McElhinney, Adam L Harmon, James PManagement Strategies for Complex Bronchopleural Fistula

This information is current as of March 1, 2013

http://asianannals.ctsnetjournals.org/cgi/content/full/8/1/78

located on the World Wide Web at:The online version of this article, along with updated information and services, is

Surgeons of Asia.Cardiovascular Surgery and affiliated journal of The Association of Thoracic and Cardiovascular

is the official journal of The Asian Society forThe Asian Cardiovascular & Thoracic Annals

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ASIANCARDIOVASCULAR& THORACICANNALS 78 2000, VOL. 8, NO. 1

MANAGEMENT STRATEGIESFOR COMPLEX BRONCHOPLEURAL FISTULA Khan

For reprint information contact:

David M Jablons, MD Tel: 1 415 885 3887 Fax: 1 415 353 9525

Division of Thoracic Surgery, UCSF-Mount Zion, 1600 Divisadero Street, Room C-322, San Francisco, CA 94115, USA.

REVIEWPAPER

MANAGEMENT STRATEGIESFOR

COMPLEXBRONCHOPLEURAL FISTULA

Junaid H Khan, MD, Sarah B Rahman, MD1,

Doff B McElhinney, MD, Adam L Harmon, MD3,

James P Anthony, MD2

, Timothy S Hall, MD,David M Jablons, MD

Division of Thoracic Surgery1Department of Medicine

2Division of Plastic Surgery

UCSF-Mount Zion

San Francisco, California, USA3Division of Cardiothoracic Surgery

Washington Hospital Healthcare System

Fremont, California, USA

ABSTRACT

The management of complex bronchopleural fistula remains a major therapeutic

challenge for the thoracic surgeon. Although the incidence of bronchopleural

fistula following lung resection has decreased in recent years to 1% to 2%, when

it occurs, it is associated with significant morbidity and mortality. Using illustrative

cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed

and operative strategies are discussed. Algorithms for the diagnosis and treatment

are suggested on the basis of cases described in the literature. The best way to

prevent a fistula is to rigorously follow the surgical techniques described, with

minimal devascularization of the bronchus and prophylactic coverage of the stump

in high-risk patients. Successful management of a fistula is combined with treatment

of the associated empyema cavity. Definitive repair should be accomplished

expeditiously, minimizing the number of procedures performed. When treatment is

protracted, secondary complications are more likely and survival is adversely

affected. The first step should be control of active infection and adequate drainage

of the hemithorax, followed by timely repair of the bronchopleural fistula when

possible and reinforcement of the stump with vascularized tissue. If a residual

cavity is present it must also be obliterated with a pedicled muscle flap.

(Asian Cardiovasc Thorac Ann 2000;8:7884)

INTRODUCTION

Bronchopleural fistula is a communication between a

bronchus and the pleural space. The most common cause

is failure of bronchial closure after partial or complete

lung resection. Other etiologies include infection (necro-

tizing pneumonia, coccidioidomycosis, aspergillosis),

inflammatory conditions (sarcoid), and trauma (penetra-

ting or blunt). Bronchopleural fistula is a rare problem,

occurring in 2% of cases of lung resection (up to 10%

after pneumonectomy). When it occurs, it is associated

with mortality ranging from 15% to 75%, significant

morbidity, and increased hospital stay for those who

survive.17 A bronchopleural fistula can occur at any time

but the peak incidence is within the first 3 weeks

postoperatively. A bronchopleural fistula that occurs within

the first few days after surgery should be considered a

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2000, VOL. 8, NO. 1 79 ASIANCARDIOVASCULAR& THORACICANNALS

Khan MANAGEMENT STRATEGIESFOR COMPLEX BRONCHOPLEURAL FISTULA

primary failure in surgical repair. In patients who have

had previous irradiation, fistulas occur earlier and are

associated with higher mortality.4 A bronchopleural fistula

invariably results in a contaminated pleural space since

there is a communication between an intubated airway

and the hemithorax. A small air leak after lobectomy is

common, usually due to dissection of the fissures or

pleural adhesions. However, it is critical to be able to

differentiate anastomotic or bronchial stump leaks from

those coming from the lung parenchyma. Parenchymal

leaks have a high likelihood of closure with conservative

management by tube thoracostomy, whereas bronchial

stump leaks usually require reoperation. Fistulas that do

not resolve with conservative treatment in 7 days are a

clinical challenge and will be the focus of this paper.

CASE REPORTS

CASE 1

A 74-year-old man with diabetes and a recent 10-kg

weight loss underwent right pneumonectomy and media-

stinal node dissection for squamous cell carcinoma of the

right upper lobe. He had an uncomplicated resection and

initial postoperative course but developed a symptomatic

bronchopleural fistula 17 days postoperatively. After initial

stabilization, he underwent 3 separate attempts at closure

of the fistula over 13 months, including bronchoscopic

administration of fibrin glue, stump revision with buttressed

intercostal muscle flap, and omental transposition, before

presenting with a small residual fistula to our institution.

At thoracotomy, the fistula could not be closed primarily

because of dense fibrosis of the mediastinum and an

intercostal muscle flap was used as a bronchial patch. The

remaining pleural cavity was small and it was filledcompletely with a limited thoracoplasty and rectus

abdominis muscle flap. He is doing well 3 years post-

operatively.

CASE 2

A 47-year-old man on steroid therapy for emphysema

underwent a right pneumonectomy and mediastinal node

dissection for squamous cell carcinoma of the right lower

lobe after negative surgical staging. A stapling device

was used to close the bronchial stump. He presented 14

days postoperatively with acute respiratory distress and

copious serosanguineous sputum. He was stabilized witha tube thoracostomy and intubated for respiratory failure,

then taken back to the operating room where a dehisced

bronchial stump was revised primarily with interrupted

sutures. The azygous vein was mobilized to cover the

stump. Postoperatively, he required mechanical ventilation

due to a contralateral pneumonia and developed a large

air leak that progressively increased to the point where

he became difficult to ventilate. He was transferred to our

institution with respiratory acidosis and hypoxemia. A

double-lumen endotracheal tube was placed and selective

ventilation of the left side was achieved with improved

gas exchange. He was started on intravenous antibiotics

and a second chest tube was placed to drain a loculated

pleural fluid collection. His nutrition was supplemented

with a feeding tube and his steroid dose was decreased

as his sepsis resolved. At reoperation 2 months after the

initial surgery, the azygous patch was noted to be necrotic

and primary closure of the bronchial stump was performed

with pedicled intercostal muscle used to buttress the repair.

The pleural cavity was filled with 2 additional intercostal

muscle flaps. He did well initially but subsequently

required a small Eloesser flap for drainage of a 2-cm

residual pocket. He is doing well 10 months after his

fistula repair.

CASE 3

A 45-year-old man underwent a right middle and lower

lobectomy for necrotizing pneumonia. He presented one

week later with a bronchopleural fistula. There was gross

contamination of the pleural space and an open drainage

procedure using thoracoplasty of the 5th through 8th ribs

was performed. He presented to our institution 14 months

postoperatively with increasing respiratory distress,persistent drainage, and an open bronchopleural fistula

through his thoracoplasty. The fistula could not be closed

primarily but the hole was obliterated with a pedicled

intercostal muscle flap. The residual pleural space was

filled with a pedicled rectus abdominis flap. He is currently

doing well 5 months postoperatively.

CASE 4

A 32-year-old woman ejected during a truck accident

presented with a large pneumothorax, massive subcuta-

neous emphysema, multiple rib fractures, and respiratory

distress. A massive air leak was noted after placement of

a chest tube. Bronchoscopy confirmed the diagnosis of a

left mainstem dehiscence 1-cm distal to the carina. A long

single-lumen endotracheal tube was placed into the right

mainstem bronchus over the bronchoscope to isolate

ventilation. She underwent primary repair via a right

thoracotomy and buttressing of the repair with a pedicled

intercostal muscle flap. The pleural space was irrigated

with antibiotic solution and closed primarily. She did well

postoperatively.

PATHOPHYSIOLOGY

In early surgical series, a complete pneumonectomy was

complicated by bronchopleural fistula in up to 28% ofcases, which may have been related to the presence of

bacteria at the bronchial stump, given that up to 60% of

patients had positive sputum cultures at the time of

resection.1 Although new antimicrobial drugs have

minimized the risk of perioperative infection as a cause

of bronchial stump breakdown, aggressive resection of

more advanced disease, often after multimodality treatment

with radiation or chemotherapy, has provided a new

challenge in bronchial wound healing.

In the current era, the overall incidence of bronchopleural

fistula following pulmonary resection ranges from 2% to

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10%.4,6,8,9 Asamura and colleagues4 have defined several

independent risk factors for the development of broncho-

pleural fistula. These include a large extent of lung

resection, residual or recurrent cancer at the bronchial

stump, preoperative radiation, and diabetes. In addition,

local factors such as empyema, pneumonia, and bron-

chiectasis also impair wound healing and are implicated

in fistula development. Prolonged postoperative mechani-cal ventilation or systemic infection with adult respiratory

distress syndrome, as well as steroids, malnutrition, active

tuberculosis, preexisting pneumonic infection, and age

over 60 years are other predisposing factors.2,6,8

Technical factors thought to be associated with the

development of bronchopleural fistula include devitaliza-

tion and devascularization by excessive peribronchial

dissection, excessively tight closure, and long bronchial

stump. All of these factors contribute to poor healing of

the bronchial stump or anastomotic suture line. There is

controversy regarding the contribution of mediastinal node

dissection and the difference between stapled and hand-

sewn closure of the bronchus as risk factors.4,6,1012

Bronchoscopic evaluation after carinal and lobar resection

has demonstrated incomplete healing as late as 7 weeks

postoperatively.13 Impaired mucociliary function has also

been documented following bronchial anastomosis in lung

transplant patients.14 Preoperatively, a single 16-Gy dose

of cobalt irradiation in dogs (equivalent fractionated 36

Gy) has been associated with a 60% decrease in blood

flow at the bronchial anastomosis.15 Because healing is

by secondary intention, local wound conditions and healing

capabilities of individual patients become more critical to

a successful result.16 Our first 3 cases demonstrate typicalrisk factors for bronchopleural fistula development. In

the first case, an elderly diabetic man with recent weight

loss underwent right pneumonectomy, the second was a

patient taking steroids who underwent a right

pneumonectomy, and the third was a lung resection in a

grossly infected field.

The pathophysiology of traumatic bronchopleural fistula

is quite different. Traumatic fistula may be major or

minor, a difference that is primarily determined by whether

the injury is to the airway or is limited to the parenchyma.

Penetrating injury (gunshot wound, knife, or fracturedrib) is usually to the parenchyma and is usually self-

limited. Blunt trauma is more commonly associated with

major airway injury (airway injury in the neck is associated

with penetrating trauma). The mechanisms for injury in

blunt trauma include anteroposterior compression of the

chest with lateral traction on the carina, closed glottis

with increased intrathoracic pressure leading to increased

airway pressure and disruption, and deceleration injury

causing a shearing injury at the carina.17 As in our case

4, these patients usually have large air leaks after tube

thoracostomy and must undergo immediate exploration

and repair.

DIAGNOSIS

A history of fever and sudden onset of continuous cough

with serosanguineous or purulent sputum in any patient

after lung resection should raise the suspicion of a

bronchopleural fistula. Though most patients eventually

develop some symptoms of sepsis, the presentation can

also be insidious with only malaise, anorexia and fever.

At the other end of the spectrum, acute respiratory distressmay occur if a large fistula allows sufficient fluid to flood

the contralateral lung (as in our case 2), or if a tension

pneumothorax occurs, or if a broncho-arterial fistula

develops.4,5,7 The physical examination may reveal

subcutaneous emphysema or decreased breath sounds if

residual lung exists on the affected side. An auscultatory

squeak with the Valsalva maneuver has also been noted.12

If aspiration has occurred, breath sounds may be coarse

on the contralateral side and tracheal shift may occur if

a large volume of air collects in the pleural space.

Laboratory analysis often reveals leukocytosis. Sputum

cultures may identify the causative organism. Pleural

fluid obtained via thoracentesis or thoracoscopy frequently

demonstrates an infection. Staphylococcus aureus and

Pseudomonas aeruginosa are the most common organisms

reported.18

An upright chest radiograph is the best initial screening

test for the diagnosis of bronchopleural fistula. Broncho-

pleural fistula should be suspected when there is: a new

air-fluid level; a fall of 2 cm or more in the air-fluid level

of a postpneumonectomy chest radiograph; a change in

a residual airspace or new appearance of an airspace; or

the return of the tracheal air column to midline in a

previously shifted mediastinum. Evidence of aspirationpneumonia in the contralateral lung and subcutaneous

emphysema are also suggestive findings. The location of

an airspace in the presence of residual lung tissue must

be differentiated between intraparenchymal (lung abscess)

and intrapleural (empyema), since the two conditions are

treated differently. Computed tomography can help

confirm the diagnosis of bronchopleural fistula and

delineate between an intrapleural and intraparenchymal

process and may aid in planning any surgical treatment

by demonstrating relationships to major airways.19

Bronchoscopy can help define the extent of the broncho-pleural fistula and differentiate between stump dehiscence

and a distal parenchymal leak. Bronchoscopy can also

help diagnose recurrent or persistent cancer at the

anastomosis or closure. Bronchography was used in the

past but is rarely employed today due to risk of contrast

pneumonitis in the remaining lung.1 The diagnosis is

usually straightforward if the presentation is early.

However, an occult bronchopleural fistula (usually delayed

or less extensive) manifesting as a postpneumonectomy

space infection sometimes remains a diagnostic problem.

Several methods are available to confirm the diagnosis.

The simplest include placement of a chest tube and



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inspection for an air leak. Injection of methylene blue

into the pleural cavity with subsequent appearance of the

color in the sputum confirms the diagnosis, as does

endobronchial injection of dye subsequently appearing in

the pleural space.2 Ventilation nuclear scintigraphy may

be helpful in a difficult case.6,20 Thoracoscopy has also

been used for confirmation of the diagnosis and location

of the fistula as well as a method for initial drainage of

the associated empyema.6,21 Clinical suspicion remains

the key to the early diagnosis of bronchopleural fistula

since history, physical examination, and a plain upright

chest radiograph are all that is needed to make the diagnosis

in most cases.

PREVENTION

The best way to manage a postoperative bronchopleural

fistula is to prevent its development at the time of

pulmonary resection. Since wound healing of the bronchial

stump or the anastomotic suture line is the single most

important factor in the development of bronchopleural

fistula, strategies directed at prevention must facilitate

optimal wound healing. The blood supply to the bronchial

cartilage and mucosa is tenuous and easily damaged. The

bronchial blood supply should be protected at all times

with minimal peribronchial dissection, and minimal

handling of the bronchial mucosa. All anastomoses must

be without tension. The bronchial stump should be short

to avoid pooling of secretions, which can contribute to

subsequent infection and mucosal breakdown. A positive

margin for cancer must be resected since it will un-

doubtedly lead to a bronchopleural fistula. The use of a

stapling device for the bronchus is controversial, insofar

as the longer bronchial stump may predispose to retentionof secretions, infection, and eventually recurrence of the

fistula. In theory, there should be less inflammation,

ischemia, and hematoma formation with the device but

no study has shown a difference between the stapled and

hand-sewn anastomosis in the development of broncho-

pleural fistula. We prefer stapled closure when possible,

with minimal peribronchial dissection.

Although nonoperative risk factors cannot always be

eliminated, their effects can be minimized by preoperative

preparation. Steroids can be weaned, nutritional supple-

mentation started, and any contralateral pneumonia orsystemic infection treated with appropriate antibiotics.

The first 2 patients clearly benefited from weaning from

their steroids and nutritional supplementation before

definitive repair. In high-risk patients, we and others

prophylactically use tissue adhesive and a pedicled

vascularized flap to cover the bronchus.6

SURGICAL TREATMENT

The general guidelines and priorities for management of

bronchopleural fistulas are presented in Figures 1 to 3.

Treatment priorities in patients with bronchopleural fistula

are protection of the airway, control of infection, aggressive

Figure 1. Algorithm for initial management of bronchopleural fistula.

ETT = endotracheal tube, IV = intravenous.

Figure 2. Algorithm for surgical options for management of broncho-

pleural fistula.

Figure 3. Algorithm for the management of the pleural space.

Pleural Space

Management

Minor Contamination Major Contamination

Antibiotic irrigation and closure

Clagett procedure

Prolonged drainage

Debridement

Muscle flap

Omental flap

Diaphragmatic flap

Eleosser flap

Thoracoplasty

Bronchopleural Fistula

Stable Airway

Stable Hemodynamics

Airway Compromise

Hemodynamic Compromise

See Figure 2

Intubation:

Long ETT

Double Lumen ETT

Chest Tube

Central Access

IV AntibioticsAirway and Hemodynamic

Stability

Bronchopleural Fistula

Stable Airway and Hemodynamics

Large Small

Proximal

Early or LateDistal Proximal Distal

Chest tube

Fibrin glue

If persistent, primary

repair, resection

Chest tube

Fibrin glue

Primary repair, re-resection

Buttress with vascularized tissue

Buttress with vascularized tissue: muscle,

omentum, pericardium, diaphragm primary

repair, revision, re-resection

Chest tube

Fibrin glue



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nutritional rehabilitation, and minimization of operative

procedures. The management approach depends on

whether the presentation is early or late. An early

postoperative fistula diagnosed from a large air leak should

be treated with immediate reexploration and revision of

the bronchial stump with open drainage of the hemithorax,

if significant contamination exists or the patient is septic.

Unstable patients should have an immediate tube

thoracostomy to prevent a tension pneumothorax and be

stabilized with intravenous antibiotics before undergoing

surgery (Figures 1 and 2). Direct closure is possible in

nearly 80% of patients with a combination of stump

resection, revision, or completion pneumonectomy, and

covering of the stump with vascularized tissue. A minority

of patients cannot have the fistula closed primarily and

require a muscle flap to obliterate the hole.6 In high-risk

patients, even when direct closure is easily achieved, we

buttress the repair with an intercostal muscle flap.

Mortality is related in part to the degree of contamination

of the pleural space. Late-developing fistulas are moredifficult to diagnose and to manage. Most of these patients

unfortunately have had multiple operations and there is

frequently a delay in both diagnosis and treatment, which

contributes to morbidity following definitive management.

Bronchopleural fistula invariably leads to a contaminated

pleural space. Thus, although bronchopleural fistula and

empyema are two distinct entities, their treatment in this

setting is inevitably coupled.

As with any critically ill patient, airway control, ventilatory

support, and hemodynamic stability must be addressed

first. Patients are at risk of aspiration into the contralateral

lung and should be kept in the reverse Trendelenburg

position with the good lung up at all times.7,22 Intubation

and positive pressure should be avoided if possible until

the fistula is controlled to avoid exacerbating the air leak.

A large air leak may make ventilation difficult.23,24 A

double-lumen endotracheal tube or isolated contralateral

mainstem bronchus intubation over a bronchoscope may

be required to allow positive pressure ventilation of the

remaining good lung without loss of minute ventilation

through the fistula and to prevent soilage of the contra-

lateral lung. Hypoxemia due to increased oxygen demand

from the hypermetabolic state associated with critical

illness, along with decreased oxygen delivery due to theincreased arteriovenous shunting, anemia, and pneumonitis

is the most common problem. Preoperative resuscitation

with intravenous fluids, antibiotics, and chest drainage

must be used to stabilize the critically ill patient before

definitive repair of the fistula is undertaken.22 Our case

2 illustrates the importance of airway management to

maximize gas exchange and the need for proper fistula

control. The ventilatory difficulties in this patient were

overcome by using a double-lumen endotracheal tube.

At the time of surgery, general anesthesia with spontaneous

ventilation and packing of the remaining ipsilateral lung

parenchyma and chest can also be used to facilitate

exposure. High-frequency jet ventilation is also helpful,

insofar as it delivers small tidal volumes at a high

frequency and can improve alveolar mixing and gas-

exchange with maintenance of mean airway pressure but

reduced peak pressure.22 A thoracic epidural with local

anesthetic is the ideal postoperative analgesic; however,

patient-controlled analgesia is a viable option if an epidural

is not available. Patient-controlled analgesia in com-

bination with opiate and nonsteroidal antiinflammatory

agents may help to reduce the proinflammatory cytokine

cascade.25 Judicious preoperative preparation, direct

visualization for the intubation, and adequate perioperative

analgesia can minimize the perioperative decline in

pulmonary function and improve outcome in attempting

definitive repair of a bronchopleural fistula.

Traumatic bronchopleural fistulas are a special subset of

all fistulas. Small distal parenchymal leaks due to

penetrating trauma are usually self-limiting and resolve

within 48 hours with simple chest tube drainage and lungreexpansion. Those that do not resolve spontaneously

with simple chest tube drainage can often be repaired via

thoracoscopy using stapling devices and newer techniques

such as intrapleural and intrabronchial administration of

fibrin glue.7,26,27 Blunt trauma usually results in proximal

main airway injury. As case 4 illustrates, they usually

present early and are not associated with a pleural space

problem. The diagnosis is usually simplified due to the

massive air leak after chest tube placement. These patients

should be immediately explored and repaired primarily.

There are 2 equally important aspects in the surgical

management of all bronchopleural fistulas: closure of thefistula itself, and management of the pleural space.

Although the two components are inherently integrated,

we will discuss each independently for the sake of clarity.

FISTULA CONTROL

The incisions advocated for the management of proximal

bronchopleural fistula include the standard ipsilateral

thoracotomy, contralateral thoracotomy, and median

sternotomy with transpericardial approach.36,28 Ipsilateral

thoracotomy allows for repair of the fistula and treatment

of the infected pleural cavity at the same time. The

contralateral thoracotomy and sternotomy approaches have

the advantage of avoiding dissection in an inflamed hilum.However, these approaches may lead to soilage of an

otherwise sterile space, are limited to cases with a long

bronchial stump, and usually require a second procedure

to deal with the contaminated pleural cavity.

Primary repair should be done if possible, with repeat

resection and revision. If revision is not technically

possible, a pedicled muscle flap is sewn with interrupted

sutures to the edges of the fistula to achieve an airtight

seal. Muscle is used to buttress the repair in high-risk

patients. Additional muscle (intercostal, pectoralis,

latissimus, rectus) is placed as necessary to obliterate the



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cavity with or without a thoracoplasty. Any small residual

cavity that persists can be managed by simple tube

drainage. In case 2, the corrections initially attempted

failed. Definitive repair was carried out using vascularized

muscle. Azygous and pleural flaps are not well vascula-

rized and often fail (as with the previous procedures with

this patient). We prefer to use muscle, pericardium, and

even occasionally diaphragm to buttress the repair.

Several conservative methods for closure of small (< 3

mm) or distal bronchopleural fistula have been described,

including bronchoscopic and thoracoscopic application

of fibrin glue and monomeric N-butyl-2-cyanoacrylate

tissue adhesive.26,27 If the fistula is proximal or occurs

late, conservative measures usually fail as the pleural

space becomes contaminated. A large proximal fistula

should be repaired primarily and the repair buttressed

with vascularized tissue. A completion pneumonectomy

or stump revision may be necessary. If a large fistula is

distal, an initial attempt at conservative treatment is

acceptable as long as the pleural space is drainedsufficiently and ventilation is adequate. Definitive repair

should be performed if these conservative measures do

not work within 7 days. Algorithms for management are

presented in Figures 1 to 3.

PLEURAL SPACE CONTROL

Pleural spaces associated with bronchopleural fistula are

considered infected until proven otherwise. A priority in

the management of any bronchopleural fistula is to

overcome active infection. Infection is controlled by

intravenous antibiotics and adequate drainage of the pleural

space (open or closed). Most patients are effectively

drained with a tube thoracostomy. However, in cases of

chronic empyema cavities, open drainage is usually

necessary initially. Factors such as nutrition and physical

rehabilitation should also be maximized to help combat

the infection. The best approach to management of the

pleural space depends on the degree of contamination. In

early small fistulas with minimal contamination and low

risk of aspiration, simple antibiotic irrigation and drainage

(i.e., a modified Clagett procedure) is appropriate in 80%

of cases.18 In the Clagett procedure, the residual cavity

is irrigated with antibiotic fluid and drained until the

cultures are negative, after which the residual space can

be allowed to close on its own.18,29,30 Large intrathoracicdefects can be obliterated with transposed muscle or by

thoracoplasty. In case 4, an initial thoracoplasty failed but

the patient was eventually managed successfully with a

vascularized muscle flap (intercostal muscle flap) to

buttress the repair of the fistula and the residual cavity

was filled with a rectus flap.

Abrashanoff31 described the first use of a muscle flap to

close a bronchopleural fistula in 1911. Before the advent

of effective antibiotics, thoracoplasty was used extensively

for tuberculosis. Thoracoplasty alone will frequently not

close the fistula because of the noncompliance of the

chest wall and a muscle transposition is usually required.

Thoracoplasty is cosmetically disfiguring but is indicated

in certain patients (especially those with large rigid cavities

preventing obliteration by isolated rib removal alone) as

it affords the only chance for elimination of infection in

some circumstances. Thoracoplasty requires resection of

thickened pleura, removal of 2 to 5 ribs (preserving the

first rib) and preservation of intercostal muscle tissue for

transposition.18,3235 Today, many options are available

before resorting to thoracoplasty. If only a partial lung

resection was done at the first operation, a decortication

can be performed to assist the remaining lung expand to

help fill the cavity without the use of thoracoplasty.

Different muscle groups (latissimus dorsi, pectoralis major,

serratus anterior, pectoralis minor, rectus abdominis,

intercostal) have been transposed successfully into the

chest, as has omentum, all with varying degrees of

success.3540 Our first choice in muscle transposition is

either the latissimus dorsi if it has not been divided at

thoracotomy or intercostal muscle if limited muscle

volume is needed. Where greater muscle mass is required,a rectus muscle and subcutaneous flap is recommended.

Infected tissue must still be debrided. Major contamination

requires debridement and obliteration of the cavity with

vascularized tissue and thoracoplasty, or open drainage

with an Eloesser flap. Small cavities are usually amenable

to a single muscle transposition, however, large spaces

frequently require a combination of muscle transposition

and limited thoracoplasty. An algorithm for management

of the pleural space is presented in Figure 3.

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2000;8:78-84Asian Cardiovasc Thorac AnnAnthony, Timothy S Hall and David M Jablons

Junaid H Khan, Sarah B Rahman, Doff B McElhinney, Adam L Harmon, James PManagement Strategies for Complex Bronchopleural Fistula

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