Natural History of Bronchopleural Fistula After Pneumonectomy: A Review of 96 Cases

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1 Natural Hstory of Bronchopleural Fstula After Pneumonectomy: A Revew of 96 Cases Peter H. Hollaus, MD, Franz Lax, MD, PhD, Basem B. EI-Nashef, MD, Herwg H. Hauck, MD, Paolo Luccarn, MD, and Nestor S. Prdun, MD Department of Thoracc Surgery, Pulmologsches Zentrum, Venna, Austra Background. Varous therapeutc approaches to bronchopleural fstula have been reported. Its natural hstory, whch may be key to the best therapeutc management, early detecton, and possbly, preventon of fstula formaton, has receved lttle attenton. Methods. The cases of 96 patents wth bronchopleural fstula after pneumonectomy seen over a 13-year perod (1982 to 1995) were retrospectvely analyzed. Cancer, TNM stage and hstology, age, sex, sde and sze of the fstula at prmary bronchoscopc dagnoss, tme of occurrence after operaton (days), cause of death, and survval after fstula formaton (days) were analyzed. Management conssted of bronchoscopc closure wth fbrn sealant or decalcfed spongy calf bone or both, repeat thoracotomy wth resecton of the bronchal stump, thoracoplasty, or open wndow thoracostomy. Results. Except for one nstance, all total stump dehscences occurred wthn 90 days after operaton. Sxty-four patents (67%) ded durng the observaton perod; n 25, the cause of death was aspraton pneumona. Only 2 patents who ded of aspraton pneumona had development of a fstula after 90 postoperatve days. The aspraton rate dropped wth ncreasng nterval between operaton and fstula occurrence (p = 0.000). Patent survval after fstula formaton was postvely correlated to ths nterval (p = 0.002). Successful fstula closure was acheved by surgcal nterventon n 21 patents and endoscopcally n 11 patents. The overall postoperatve mortalty rate rrespectve of treatment method was 31%. Conclusons. The ncdence of aspraton pneumona declnes sharply f bronchopleural fstula occurs more than 3 months after operaton. Formaton of fbrothorax apparently represents a natural protecton aganst fstula formaton and subsequent fatal aspraton pneumona. Close follow-up durng the frst 3 postoperatve months should detect bronchopleural fstula before aspraton occurs. (Ann Thorac Surg 1997;63:1391-7) 1997 by The Socety of Thoracc Surgeons B ronchopleural fstula (BPF) after pneumonectomy represents the most dreaded complcaton n thoracc surgery. Nevertheless, dagnoss and therapeutc management reman major problems. Mortalty rates range from 20% to 70% n the lterature, the most common cause of death beng aspraton pneumona wth subsequent adult respratory dstress syndrome. Most authors dscuss therapeutc approaches, and to date, no data have been reported about the ncdence and the clncal course of aspraton pneumona. In a retrospectve analyss of 96 patents, the natural hstory of BPF after pneumonectomy s examned. The objectve of the study was to obtan data characterzng the natural hstory of ths type of fstula, thus dentfyng rsk factors and the best therapeutc management to prevent aspraton pneumona. Patents and Methods From January 1982 to June 1995, 797 patents underwent pneurnonectomy because of neoplastc dsease (766 or 96%), tuberculoss (17, 2%), and other reasons, eg, empy- Accepted for publcaton Nov 12, Address reprnt requests to Dr Hollaus, Department of Thoracc SurgeD,, Pulmologsches Zentrum, Venna, Sanatorumstral~e 2, A-1145 Venna, Austra. ema, pulmonary atresa, and cysts (14, 2%) (Table 1). Of these 797 patents, 96 (90 men and 6 women) (12%) had development of BPF. These 96 patents are the subject of ths retrospectve study. Age, sex, sde of fstula, and TNM stage and hstology of the cancer were extracted from hosptal records. The perod between operaton and fstula formaton and survval after fstula formaton were examned. If the fstula occurred after dscharge from the hosptal, tme of onset was deduced from the clncal symptomatology (fever, cough, hemoptyss, dyspnea, and fetd breath). The sze of the fstula n mllmeters at the tme of prmary bronchoscopy was recorded. Causes of death and tme between fstula dagnoss and therapeutc nterventon were analyzed. Fstula sze was documented n 87 patents and classfed nto three groups: group 1, mnfstula (1 mm); group 2, total bronchal stump dehscence (dehscence of more than 25 ram); and group 3 (~1 mm to total stump dehscence). For dentfcaton of rsk factors, a group of 177 patents who underwent pneumonectomy from 1992 to 1995 and dd not have development of BPF was compared wth the study group. In both groups, tangental resecton wth automatc staplng devces was performed. No routne mechancal ventlaton was employed postoperatvely by The Socety of Thoracc Surgeons /97/$17.00 Publshed by Elsever Scence Inc PII S (97)

2 1392 HOLLAUS ET AL Ann Thorac Surg BRONCHOPLEURAL FISTULA 1997;63: Table 1. Dstrbuton of Sex, Mean Age, and Sde of Pneumonectomy for All Patents Seen Between 1982 and 1995 Varable Total Male Female Sex Rato Sex :1 Mean age (y) Rght :1 Left :1 Fstulas larger than 5 mm were treated wth total thoracoplasty ncludng resecton of the frst rb or wth open wndow thoracostomy n the case of multple-organ falure resultng from sepss. Repeat thoracotomy wth resecton and resuturng of the bronchal stump followed by coverage wth a muscular flap was consdered only for patents seen wth early empyema. Small fstulas (<5 ram) underwent endoscopc treatment wth fbrn sealant or decalcfed spongy calf bone. If bronchoscopc treatment faled, total thoracoplasty or open wndow thoracostomy was performed, dependng on the patent's general condton. All data were entered n a personal computer (Compaq PC, IBM compatble, Wndows 95, Pentum) and evaluated by a statstcal program (SPSS for Wndows, verson 6.1). Evaluaton of data was performed by crosstabulaton and correlaton. The appled sgnfcance level was Results The rato of rght to left pneumonectomy was 1:1.2 n the control group versus 2.4:1 n the fstula group (Table 2, see Table 1). Male sex was predomnant n the fstula group (male to female rato, 15:1). Thus, rght sde and male sex were sgnfcant rsk factors (p = 0.000). Age showed no sgnfcant relevance for fstula formaton. In the fstula group, pneumonectomy had been performed because of neoplastc dsease n 93 patents (97%), destroyed lung n 2 (2%), and pulmonary atresa n I patent (1%). Comparson of TNM stages between the fstula group and the control group dd not reveal any sgnfcant dfferences (Table 3). Therefore, TNM stage was not dentfed as a rsk factor for postoperatve fstula development. Nor dd hstology show any correlaton (Table 4). Fstula sze at the tme of dagnoss was documented n 87 patents. Group 1 ncluded 28 patents (32%); group 2, 26 patents (30%); and group 3, 33 patents (38%). Fstula sze was not documented for 9 patents. Total bronchal stump dehscence (group 2) occurred almost exclusvely wthn 3 months after operaton. In only 1 patent dd t develop after ths perod. There were no sgnfcant dfferences between the three groups n terms of patent survval. Therefore, fstula sze was not lkely an nfluence on death caused by aspraton pneumona n these patents. The nterval between operaton and fstula formaton ranged from 2 to 1,199 days (mean _+ standard devaton, 88 ± 178 days) and survval after fstula formaton, from 1 day to 2,208 days (258 ± 465 days) (Fg 1). Seventy-sx fstulas (79%) developed wthn 90 days after operaton, 28 of them durng the frst 2 postoperatve weeks before dscharge from the hosptal. Twenty fstulas (21%) occurred between postoperatve days 90 and 1,199. Of these 20 patents, only I patent ded of aspraton pneumona. Except for 2 patents, all patents who ded of aspraton pneumona had development of the BPF wthn 90 days after operaton (nterval, 2 to 82 days; mean tme, 28.2 days). Patent survval ranged from 1 day to 78 days (mean survval, 21.5 days) even though aggressve treatment had been gven (Fg 2). The mortalty rate was hghest durng the frst 2 postoperatve weeks (29%). Forty-eght fstulas (50%) developed between postoperatve days 15 and 90. The mortalty rate was stll hgh n ths subset (35%). Survval showed a sgnfcant postve correlaton to the nterval between operaton and fstula occurrence wthn the frst 3 postoperatve months (p = 0.002) (Fg 3). Sxty-four patents (67%) ded durng the observaton perod. Forty-two ded wthn 90 days after operaton. Death was caused by aspraton pneumona n 25 patents, cardac falure n 7, empyema wth sepss n 4, and local or dstant tumor recurrence n 19. One patent ded of pulmonary embolsm, 1 of cerebral hemorrhage, and 2 of cachexa. No postmortem examnaton was done on 5 outpatents. Only I patent (1%) n whom the BPF developed after 90 postoperatve days ded of aspraton pneumona (Table 5, Fg 4). The ncdence of aspraton pneumona decreased the later BPF developed (p ). Examnng each sde of fstula occurrence separately revealed no sgnfcant correlaton between the nterval from operaton to fstula Table 2. DstrbuHon of Sex, Mean Age, and Sde of Patents Wth Bronchopleural Fstula Varable Total Male Female Sex Rato Sex :1 Mean age (y) Rght :1 Left :1

3 Ann Thorac Surg HOLLAUS ET AL ;63: BRONCHOPLEURAL FISTULA Table 3. Stage Dstrbuton ''b Fstula Group Control Group ~ Stage (n = 93) (n = 177) I 36 (39) 47 (27) II 22 (24) 35 (20) IIIA 30 (32) 75 (42) IIIB 5 (5) 20 (11) a Numbers n parentheses are percentages. 6 There were no sgnfcant dfferences between groups. "The control group underwent pneumonectomy from 1992 to 1995 and dd not have fstula formaton. development and survval after fstula formaton. Aspraton pneumona occurred wth proportonal frequency on both sdes, a fndng also applcable to survval. Eleven patents (11%) were treated wth thoracc dranage only. In 1 patent, the BPF closed wthout reoperaton. Seven patents ded before any further surgcal treatment could be started, and 3 patents had local tumor recurrence that led to fstula blockage. Forty-nne fstulas (51%) were treated surgcally. Twenty-one of the patents underwent total thoracoplasty. The fstula was larger than 5 mm n 18, and the remanng 3 patents had small fstulas and advanced empyema at admsson. Nne patents ded n the early postoperatve course. Causes of death were aspraton pneumona n 5, cardac falure n 2, and pulmonary embolsm and progressve sepss orgnatng from the empyema n 1 each. The remanng 12 patents havng thoracoplasty were cured. Nne patents underwent repeat thoracotomy. Three ded of aspraton pneumona, and 1 ded of cardac falure. Successful fstula closure was acheved n 3 patents. One patent left the hosptal wth chronc empyema and permanent dranage (e, a 50-mL dranage bottle wthout a water seal; the bottle s changed daly and can be worn under clothng, and the chest tube s changed every 3 weeks). Fstula closure faled n 2 patents, who had successful treatment by total thoracoplasty. In 19 patents, open wndow thoracostomy was performed as an emergency procedure. Fve ded of pneumona and 2 of cardac falure. The condton of 3 patents mproved after operaton, and they subsequently under- Table 4. Hstology "b Fstula Group Control Group Hstology (n = 93) (n = 177) Squamous cell carcnoma 59 (63) 98 (55) Adenocarcnoma 19 (20) 61 (34) Small cell carcnoma 8 (9) 10 (6) Large cell carcnoma 1 (1) 2 (1) Mscellaneous 6 (6) d 6 (3) 6 Numbers n parentheses are percentages, b There were no sgnfcant dfferences between groups, c The control group underwent apneumonectomv from 1992 to 1995 and dd not have fstula formaton. Four patents had undfferentated carcnoma, and 1 patent each had carcnosarcoma and bronchoalveolar carcnoma. ~ One patent each had mesotheloma, undfferentated carcnoma, melanoma, and carcnosarcoma, and 2 patents had neuroendocrne carcnoma. IlJll ", I mmmmnnn ' mmmmmmn, Fg 1. Postoperatve ncdence of fstula formaton. po~operatve days went successful thoracoplasty. Nne patents were dscharged wth an open wndow thoracostomy. Durng the observaton perod, three thoracc wndows closed spontaneously, and 3 patents had substantal reducton n wndow sze. Thrty-sx patents (38%) were treated bronchoscopcally. Fbrn sealant and decalcfed spongy calf bone [13] were used to acheve fstula closure. Fve patents ded n the hosptal of aspraton pneumona. Fstula closure was successful n 11 patents, but only 4 had healng of the concomtant empyema. Thus, only 4 patents left the hosptal wthout dranage; the remanng 7 patents were dscharged wth chronc empyema and permanent dranage. In 8 patents, permanent fstula closure faled, and they were also dscharged wth chronc empyema and permanent dranage. In 4 patents, open wndow thoracostomy became necessary because of progressve sepss orgnatng from the empyema; they survved. Eght patents requred thoracoplasty; 2 ded postoperatvely of sepss and empyema, and 6 left the hosptal wthout dranage. The overall postoperatve mortalty rate regardless of treatment method was 31%. After successful fstula closure and defntve clearance of empyema, no recurrence was observed. ~ I.0:.8~.6'.4, ;.2' I Fg 2. Survval after development of aspraton pneumona. J a o 0 ' days 8O

4 HOLLAUS ET AL Ann Thorac Surg BRONCHOPLEURAL FISTULA 1997;63: l- 1 :~-~f5 -" ~ cause fdeathct~..... r-- Fg 3. Overall survval after fstula formaton. days 5 ~0 >~ nterval Fg 4. Pneumona as cause of death versus other causes. Comment Bronchopleural fstula remans the most dreaded complcaton n thoracc surgery. Its ncdence and the development of postpneumonectomy empyema s reported to range between 2% and 13% [1, 2]. We observed solated empyema wthout fstula only occasonally, whch leads us to the assumpton that BPF s the man cause of postpneumonectomy empyema. Ths s supported by the fact that no empyema recurrence was observed after successful fstula closure. Varous groups [3-7] have covered the subject of adequate therapy for bronchal stump dehscence and fstula formaton. All agree on the mportance of early chest tube dranage to prevent aspraton. If a patent s seen wth aspraton pneumona, even mmedate operaton cannot save hs or her lfe. Ths emphaszes the mportance of early fstula dagnoss and treatment. Sepss orgnatng from the empyema was the cause of early postoperatve death n only 3 patents. Thus, even advanced empyema can be successfully controlled by early dranage and operaton. The lterature dealng wth fbrn sealng of BPF s sparse. Except for reports about fstulas after smaller lung resectons [8, 9], only a small number of patents wth fstulas after pneumonectomy have been studed [9-11]. All the fstulas were small and most were successfully closed. Becker [12] reported successful closure n 35 of 45 patents. However, no dstncton was made between patents who had pneumonectomy and those who had lesser resectons. All groups consdered endoscopc sealng a worthwhle alternatve to surgcal treatment, as there s a good chance to avod thoracotomy. We acheved endoscopc fstula closure n 11 of 36 patents. However, fstula closure does not necessarly mean eradcaton of empyema. The 4 patents we reported as free from fstula and empyema were dscharged and are stll alve. Although when frst seen, they had postve bacterologc cultures n the chest tube dranage, ntrathoracc nfecton was stll at an early phase and responded well to pleural antbotc rrgaton after successful fstula closure. Therefore, endoscopc treatment wth fbrn sealant or spongy bone may result n complete cure only n early empyema. Persstent empyema after fstula closure should not be regarded as a treatment falure, as the patent s saved from lfe-threatenng aspraton. Even f the fstula cannot be closed permanently, temporary fstula closure allows rrgaton of the pleural space wth antbotcs wthout danger of aspraton. Reducton of dranage volume as a sgn of empyema control allows dscharge wth permanent dranage. Ths method seems preferable to open wndow thoracostomy or thoracoplasty, whch are the only alternatves n many nstances of advanced empyema. Progresson of empyema durng treatment makes surgcal nterventon (e, thoracoplasty or open wndow thoracostomy) nevtable. Our overall peroperatve mortalty rate of 31% s n accordance wth the lterature, whch reports mortalty Table 5. Causes of Death n Patents Wth Bronchopleural Fstula Varable Days 0-14 Days Day >90 No. of fstulas 28 (29) 48 (50) 20 (21) Hosptal mortalty 19 (20) 17 (18) 1 (1) Aspraton pneumona 10 (10} 11 (11) 1 (1) Cardac 3 (3) 3 (3) 0 Bran metastass 2 (2) 0 0 Empyema wth sepss 2 (2) 2 (2) 0 Mscellaneous 2 (2) 1 (1) 0 Numbers n parentheses are percentages based on 96 patents. Ths ncludes pulmonary, embolsm, cerebral hemorrhage, and cachexa.

5 Ann Thorac Surg HOLLAUS ET AL ;63: BRONCHOPLEURAL FISTULA rates of 19.5% [4], 23% [5], and up to 71% [13], whch ncludes fstulas after smaller lung resectons such as lobectomy, blobectomy, and segmentectomy. Hankns and assocates [7] reported a mortalty rate of 46% n a subset of patents wth postpneumonectomy fstula. One of the most mportant factors nfluencng mortalty s the nterval to postoperatve fstula formaton. Incdence reaches ts peak n the second and thrd postoperatve weeks and declnes rapdly later. Many patents n whom BPF develops represent a serous problem because they smply do not get a dagnoss. They may have to travel long dstances for treatment. If a fstula develops after dscharge, t s very lkely the patent wll not see a surgeon early enough and wll de of aspraton pneumona at home. Another problem s the dffculty of dagnosng BPF. Many physcans are not famlar wth ts clncal symptomatology, and the danger of aspraton pneumona s underestmated; aspraton s often msdagnosed as pulmonary edema, and duretcs are appled. Thus, early dranage as prophylaxs for aspraton s mssed. In some patents fstulas develop 5 to 10 years after operaton. Because postoperatve follow-up has concluded, the patent often does not get adequate treatment. To date, only very few rsk factors have been reported. As mentoned by Asamura and assocates [13], the rght sde s a sgnfcant rsk factor for fstula formaton, whch s n agreement wth our data. Fstulas develop sgnfcantly more often n men than n women. The pathogenetc mechansm remans unclear. The nfluence of TNM stage on fstula formaton could not be verfed from our data unlke data of others [13]. Only malgnant nvason of the bronchal stump tself promotes fstula formaton [13]. Aspraton pneumona was the man cause of death early n the dsease. Only 2 of 25 patents wth aspraton pneumona early survved. There s a strong correlaton between the nterval from operaton to fstula formaton and survval (p = 0.002) durng the frst 3 months after operaton. The hgh mortalty rate n the early postoperatve perod may be explaned by postoperatve ventlaton/perfuson msmatch and mucous congeston caused by the procedure and anesthesa; ths exposes the contralateral lung to a hgh rsk of aspraton damage. In many patents, fstulas are at an ntal stage when dagnostc bronchoscopy s performed and often enlarge before defntve treatment s started. Patents wth late fstula formaton often show a poor clncal symptomatology and are not ntally referred to a thoracc surgeon; therefore, early fstulas are usually dagnosed more easly than late ones. However, sze at prmary bronchoscopy nfluences the therapeutc management of many thoracc surgeons and pulmonologsts, as t s the only evaluable nformaton about the fstula tself. The earler the fstula forms, the bgger the leak s. The fndng that only one total bronchal stump dehscence occurred more than 3 months after operaton suggests that formaton of fbrothorax, whch should be suffcently establshed after ths perod, helps to stablze the bronchal stump. Even f BPF occurs, the danger of fatal aspraton s vrtually excluded by the many small compartments that have formed n the empty hemthorax. These are flled wth smaller amounts of flud that can be coughed up easly, even f they are asprated. The hypothess that total stump dehscence bears a hgher rsk of massve aspraton than mnfstulas could not be verfed statstcally. Fstula sze and aspraton rate dd not correlate. In the early postoperatve perod, even mnfstulas can cause slent aspraton wth subsequent pneumona and are as dangerous as total stump dehscence, although ar leakage s much smaller. The rsk of aspraton vrtually dsappears 3 months after operaton. Before that, aspraton occurs ndependently of fstula sze and s responsble for a hgh mortalty, no matter whch treatment s chosen. Even aggressve ntensve care therapy does not mprove ths dscouragng outcome. Aspraton more than 3 months after pneumonectomy s better tolerated because patents have almost reganed ther normal coughng and muscular capablty, and ths allows them to remove small amounts of asprated flud more easly. We observed 1 patent wth a documented fstula of 2 mm who refused any therapeutc nterventon over 5 years and s stll alve. Thus, the nterval between operaton and onset of BPF appears to be the most mportant factor nfluencng clncal course and outcome. Patents who undergo pneumonectomy and are free from fstula formaton for 3 months have escaped death caused by aspraton. Although BPF occurs more frequently on the rght sde, we could not fnd any dfference n ts natural hstory that could be attrbuted to the affected sde. Rght- and left-sded fstulas showed exactly the same patterns n sze, survval, nterval between operaton and ther formaton, and aspraton. Formaton of fbrothorax seemngly develops on both sdes wth comparable progress, although the volume of the left hemthorax s smaller. Whether the bgger sze of the rght hemthorax represents one of the natural dsadvantages promotng fstula formaton remans unresolved. Conclusons The nterval between prmary operaton and fstula formaton s the most mportant factor characterzng the rsk of fatal aspraton pneumona. The ncdence of aspraton pneumona drops dramatcally after postoperatve day 90. Mortalty s hghest durng the frst 2 postoperatve weeks (27% of all deaths) and declnes steadly later, as does the ncdence of total stump dehscence, whch rarely occurs later than 3 months after operaton. These fndngs suggest that the formaton of fbrothorax wth ts multple small flud compartments provdes an effectve natural protecton aganst fstula formaton and aspraton. However, fstulas can develop many years after pneumonectomy. The major goal of therapeutc nterventon must be the preventon of aspraton pneumona, as t s the man cause of death n patents wth postpneumonectomy BPF. Ths goal can easly be accomplshed by chest tube

6 1396 HOLLAUS ET AL Ann Thorac Surg BRONCHOPLEURAL FISTULA 1997;63: dranage. Repeat thoracotomy or endoscopc nterventon should be performed as soon as possble n early empyema. If advanced empyema s present at admsson, such as n late fstulas, dsnfecton of the pleural space remans the prmary approach. Fstula closure can then be acheved smultaneously at bronchoscopy or later by surgcal nterventon. Progressve sepss orgnatng from the empyema durng conservatve or endoscopc treatment can be successfully controlled wth open wndow thoracostomy. Wth specal regard to prognoss and postoperatve tme, we propose the followng classfcaton of BPF: Fstula I. Occurrence n the frst 2 postoperatve weeks. Mortalty and rsk of aspraton are hgh. Fstula II. Occurrence between postoperatve days 14 and 90. Fbrothorax n state of formaton prevents massve aspraton n many patents. However, mortalty s stll hgh, as many patents who are already dscharged fal to seek adequate treatment. Fstula IlL Occurrence after postoperatve day 90. Fbrothorax has formed and prevents massve aspraton by formaton of multple small flud compartments. Mortalty caused by aspraton pneumona has vrtually dsappeared. Close clncal follow-up durng the frst 3 postoperatve months (chest roentgenograms and serologc ndces of nflammaton such as erythrocyte sedmentaton rate, whte blood cell count, and c-reactve proten) should allow early fstula detecton and antcpaton of aspraton. Patents must be nformed about the clncal symptoms that may herald fstula formaton and must be encouraged to seek assstance at a thoracc surgcal unt as soon as possble. Further studes are necessary to defne those patents who are potental canddates for pneumonectomy but should be excluded from operaton when the rsk of bronchal stump dehscence wth ts substantal mortalty seems too hgh. References 1. Mller JI Jr. Postsurgcal empyemas. In: Shelds TW, ed. General thoracc surgery. 4th ed. Baltmore: Wllams & Wlkns, 1994: Rau HG, Wedemann K, Vogt Moykopf I. Postoperatve Komplkatonen. In: Heberer G, Schldberg FW, Sunder Plassman L, Vogt Moykopf I, eds. Lunge und Medastnum. 2nd ed. Berln, Hedelberg: Sprnger, 1991: Baldwn CJ, Mark ]BD. Treatment of bronchopleural fstula after pneumonectomy. J Thorac Cardovasc Surg 1985;90: Hankns JR, Mller JE, Safuh A, Satterfeld JR, McLaughln JS. Bronchopleural fstula: thrteen years" experence wth 77 cases. J Thorac Cardovasc Surg 1978;76: Malave G, Foster ED, Wlson JA, Munro DD. Bronchopleural fstula--present-day study of an old problem: a revew of 52 cases. Ann Thorac Surg 1971;1l: Weber J, Gr/bner D, AI-Zand K, Beyer D. Empyema after pneumonectomy--empyema wndow or thoracoplasty. Thorac Cardovasc Surg 1990;38: Hankns JR, Mller JE, McLaughln JS. The use of chest wall muscle flaps to close bronchopleural fstulas: experence wth 21 patents. Ann Thorac Surg 1978;25: Glover W, Chavs TV, Danel TM, Kron IL, Spotntz WD. Fbrn glue applcaton through a flexble fberoptc bronchoscope. Closure of bronchopleural fstulas. J Thorac Cardovasc Surg 1987;93: York EL, Lewall DB, Hrj M, Gelfand ET, Modry DL. Endoscopc dagnoss and treatment of postoperatve bronchopleural fstula. Chest 1990;97: Onotera RT, Unruh HW. Closure of a post-pneumonectomy bronchopleural fstula wth fbrn sealant. Thorax 1988;43: Torre M, Quan E, Ravn M, Nerl FP, Maol M. Endoscopc glung of bronchopleural fstula [Update]. Ann Thorac Surg 1994;58: Becker HD. Treatment of postoperatve bronchal fstulas by endoscopc fbrn applcaton. In: Schlag G, Wolner E, Eckersberger F, eds. Fbrn sealng n surgcal and nonsurgcal felds: cardovascular surgery, thoracc surgery. New York: Sprnger, 1995: Asamura H, Naruke T, Tsuchya R, Goya T, Kondo H, Suemase K. Bronchopleural fstulas assocated wth lung cancer operatons. Unvarate and multvarate analyss of rsk factors, management and outcome. J Thorac Cardovasc Surg 1992;104: Prdun N, Redl H, Schlag G. En neues bologsches lmplantat zum Verschlut~ bronchopleuraler Fsteln. Z Herz Thorax Gef~t~chr 1987;1(Suppl 1): Suarez J, Clagett OT, Brown AL. The postpneumonectomy space. Factors nfluencng ts oblteraton. J Thorac Cardovasc Surg 1969;57: Smth DE, Karsh AF, Chapman JP, Takaro T. Healng of the bronchal stump after pulmonary, resecton. J Thorac Cardovasc Surg 1963;46: Wllams NS, Lews CT. Bronchopleural fstula: a revew of 86 cases. Br J Surg 1976;63: O'Meara JB, Slade PR. Dsappearance of flud from the postpneumonectomy space. J Thorac Cardovasc Surg 1974; 67: INVITED COMMENTARY Bronchopleural fstula wth assocated empyema after pneumonectomy, although uncommon, s a serous and potentally lethal complcaton. Ths s renforced by ths retrospectve revew presented by Hollaus and assocates of 96 patents n whch 65 patents (67%) ded. Although there was a wde spectrum of presentatons, t s of nterest that of the 49 patents ntally treated wth operaton by a varety of procedures, 20 (41%) ded and 21 (43%) were dsmssed wth healed wounds. Of the 36 patents ntally treated wth bronchoscopy, 5 (14%) ded, n 11 (31%) the fstula healed, and only 4 (11%) left wth a healed wound. Also, 12 patents who had faled bronchoscopc treatment underwent secondary surgcal procedures, wth two addtonal deaths by The Socety of Thoracc Surgeons /97/$17.00 Publshed by Elsever Scence Inc PII S (97)00249-X