There is no standard treatment for post-pneumonectomy bronchopleural fistula and the successful management is a challenge to the thoracic surgeon. Most of the treatment options are staged procedures.Transsternal transpericardial closure (TSTP) is attractive as it is a one stage operation, that avoids the infected pneumonectomy space and does not result in patients disfigurement. The single disadvantage of TSTP closure is that it does not address the problem of the pneumonectomy space.Herein, we report a case of chronic BPF after pneumonectomy successfully closed via the transsternal transpericardial approach.The relevant literature is reviewed to throw light on the indications and the results of this operation.

1. TRANSSTERNSL
TRANSPERICARDIAL CLOSURE OF
POSTPNEUMONECTOMY
BRONCHOPLEURAL FISTULA
Professor
Abdulsalam Y Taha
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION
 Bronchopleural fistula (BPF) is a
communication between the bronchial tree
and the pleural space.
 Types:
Postresectional (postlobectomy &
postpneumonectomy)
Without lung resection
● Postpneumonectomy BPF is more serious
and more difficult to treat than
postlobectomy BPF.

3. INTRODUCTION
 Early( acute) BPF: up to 2 weeks after
pneumonectomy.
 Late (chronic): even years after operation.
 Regardless the time of occurrence or cause
of BPF, it is always serious. Once
postpneumonectomy BPF occurs, then the
patient's life is in danger as there is
immediate flooding of the remaining single
lung with fluid or pus( drowning).

4. INTRODUCTION
 BPF is usually associated with empyaema,
this will complicate the picture.
 The diagnosis is based on clinical &
radiographic grounds.
 Cough, expectoration of serosanguinous or
purulent fluid, SOB and fever.
 CXR: a new gas-fluid level or lowering of a
previous gas-fluid level.

5. INTRODUCTION
 Immediate management: positioning of
patient with pneumonectomy side lower
down and tube thoracostomy drainage of the
pleural space.
 Antibiotics.
 Supportive measures: correction of anaemia
& malnutrition.
 Late management: definite closure of BPF
and obliteration of the space.

6. INTRODUCTION
 There is no standard treatment for this complication
and the successful management is a challenge to
the thoracic surgeon.
 Most of the treatment options are staged
procedures.
 Transsternal transpericardial closure (TSTP) is
attractive as it is a one stage operation, that avoids
the infected pneumonectomy space and does not
result in patients disfigurement.

7. INTRODUCTION
 TSTP was first used in Italy in 1961 and then
used extensively in the former Soviet Union.
 It can be used for late postpneumonectomy
BPF which failed to close by other methods
 Or as a primary repair option.
 It can be used for R or L side fistulae.
 Technique….

8. INTRODUCTION
 The single disadvantage of TSTP closure is
that it does not address the problem of the
pneumonectomy space.
 Herein, we report a case of chronic BPF after
pneumonectomy successfully closed via the
transsternal transpericardial approach.
 The relevant literature is reviewed to throw
light on the indications and the results of this
operation.

9. CASE
 A 38 yrs old lady.
 Fever, SOB & productive cough for few months.
 R pneumonectomy 2 yrs earlier in another city for
BGC.
 No op notes but a histopathological report of
bronchial tumour: large-cell anaplastic carcinoma.
 O/E: toxic-looking dyspnoic patient. Bronchial
breathing on R chest.

10. CASE

12. A gas-fluid level
getting lower with
repeat films.

13. CASE
 The clinical & radiographic picture was consistent
with postpneumonectomy BPF.
 Initial management:
 Tube thoracostomy: air & thick offensive pus.
 Antibiotics.
 Position: semi-recumbent avoiding lying on L side.
 Significantly improved despite persistent large air
leak.
 Continuous irrigation of the pleural space via a
catheter in 2nd intercostal space with N/S and
antibiotics.

15. Irrigating catheter
and
a chest tube
in right pleural space.

16. CT scan:
thickened pleura

17. CT scan:
R side
mediastinal
shift

18. CT scan: RMB communicates with pneumonectomy space.

19. CASE
Fiberoptic bronchoscopy: no
evidence of recurrent tumour, long
bronchial stump opening into the
pleural space at bronchus
intermedius level.

20. DEFINITE MANAGEMENT
 Under GA via a single lumen ET tube in supine
position.
 Median sternotomy.
 Dissection of thymus off the pericardium.
 Opening of anterior pericardium; retracted by stay
sutures.
 Dissection & encirclement of AA; retracted to left.
 Retraction of SVC to the right.

21. TSTP CLOSURE
 R main pulmonary artery is dissected and
encircled by a tape; divided and its 2 ends
are sutured by 2 layers of continuous 4-0
prolene.
 R bronchial stump was dissected and
encircled by a tape; divided and its 2 ends
are sutured by 2-0 vicryl sutures. The
proximal stump was enforced by thymic
tissue.

22. TSTP CLOSURE
 Haemostasis.
 Anterior mediastinal drain.
 Routine wound closure.
 In theatre extubation.
 Air leak immediately & completely stopped.
 ICU admition.
 Mediastinal drain removed after 24 hrs.

23. POSOPERATIVE MANAGEMENT
 Irrigation of pneumonectomy space
continued for 3 weeks.
 Open window thoracostomy was done 3
weeks later for drainage of the space.
 Discharged home well.
 Follow-up for 6 months: no recurrence of
fistula.
 Home management: frequent dressing
change.

24. TSTP REPAIR
OF BPF

25. TSTP REPAIR
OF
BPF

26. TSTP REPAIR
OF
BPF

27. TSTP REPAIR
OF
BPF

28. TSTP REPAIR
OF
BPF

29. TSTP REPAIR
OF
BPF

30. DISCUSSION
 Postpneumonectomy empyaema (PNE) occurs in
3% of cases.
 80% of PNE have a BPF.
 Mortality of PNE with a BPF is 11 to 13%.
 Small uncomplicated BPFs may heal spontaneously.
 In 20% of patients, BPFs will close with drainage
only.
 The remaining 80% of cases (persistent BPFs)
require surgery.

31. DISCUSSION
 The occurrence of a BPF after
pneumonectomy is an infrequent but severe
complication accompanied by a high
morbidity and mortality.
 The incidence of BPF after pulmonary
resection varies from 0.5% to almost 10% in
different series and has reached 28% after
pneumonectomy for TB.

32. DISCUSSION
 In the early postoperative phase and up to 2 weeks
after lung resection, immediate operation through the
pneumonectomy cavity with resection and reclosure
of the stump is the recommended surgical
procedure.
 However, the management of chronic BPF and
empyaema has been a subject of controversy. Both
the time of intervention and the type of surgical
technique reported by various authors differ.
 No technique can be applied to all patients.
 Even for similar defects, an individual treatment plan
must be made.

33. DISCUSSION
Bronchoscopic cauterization of the
fistula, application of fibrin glue and
bone spongiosa are only effective in a
limited number of patients and are
accompanied by a high percentage of
relapses.
Recently, a video-assisted approach
through the mediastinum is described.

34. DISCUSSION
 Various systemic factors and therapeutic
interventions often contribute to the risk of
PNE and BPF, including age in men above
70, preoperative radiation, malnutrition, and
prolonged steroid therapy. In addition,
technical factors such as prior lung resection,
infection at a long bronchial stump site, and
residual sepsis in the pleural space may
further contribute to the development of this
complication.

35. PREVENTION
PNE & BPF are best prevented by:
 Minimization of preoperative sepsis.
 Careful closure of the bronchial stump.
 At the time of pneumonectomy, care should
be taken to avoid devascularization and
excessive length.
 The use of vascularized flaps to reinforce the
bronchial stump.

36. DISCUSSION
The goals of surgery in
postpneumonectomy BPF are:
Drainage of the infected
pneumonectomy space.
Closure of the BPF
Obliteration of the space.

37. DISCUSSION
Drainage can be achieved by tube
thoracostomy initially and later by
open window thoracostomy.
Obliteration of the space can be
achieved by thoracoplasty,
thoracomyoplasty or omentoplasty.

38. DISCUSSION
 Thoracoplasty is resection of most of the ribs
on one side in 3 stages to allow the muscles
of the chest wall to fall down and obliterate
the pleural space. The operation results in
significant disfigurement of the patient.
 Thoracomyplasty is a plastic operation in
which muscles of chest wall like latissimus
dorsi, serratus anterior, pectoralis major or
rectus abdominus are mobilized as
vascularized flaps to obliterate the pleural
space and reinforce the bronchial stump
closure.

39. THORACOMYOPLASTY
AND
THORACO-OMENTOPLASTY

40. DISCUSSION
Muscle-flap closure of BPFs has been
associated with a more than 80%
success rate.
The main disadvantage of the previous
methods of fistula repair is the access
via infected pneumonectomy cavity and
a long period of hospitalization.

41. DISCUSSION
 TSTP closure of BPF was first described in
Italy in 1961. In 1985, its use was renovated
in North America by Baldwin and Mark.
 This approach has valid theoretical
advantages: a relatively well-tolerated
median sternotomy, the avoidance of dealing
directly with areas of postoperative scarring
and chronic sepsis, and the avoidance of
chest wall deformity.

42. DISCUSSION
 The single disadvantage is that the residual
empyaema space is not dealt with at the
same session, unlike thoracoplasty or
thoracomyoplasty.
 Ginsberg and colleagues have suggested
that the TSTP approach is the most effective
method for closure when other strategies
have failed, or when a direct approach
through the thoracotomy space is not
warranted.

43. DISCUSSION
 Prior to surgery the pneumonectomy cavity
needs to be drained by a chest tube, and
rinsed and cleaned with normal saline
solution or povidone iodine daily.
 Preoperative bronchoscopic inspection of the
size and length of the bronchial stump as
well as its course is necessary. If the stump
is shorter than 1 cm, a direct closure is
improbable.

44. DISCUSSION
 Shorter stumps can be amputated level with
the carina and the resultant defect is either
primarily closed or the omentum is used for
closure.
 The distal bronchial stump can be resected
or left in situ after cauterization of the
mucosa.
 The detection of a cancerous tissue is a
contraindication for this operation.

45. CONCLUSIONS
 BPF after pneumonectomy is associated with
significant morbidity and mortality.
 It has no standard therapy.
 The successful management is a challenge
to the thoracic surgeon.
 TSTP approach is highly effective and offers
advantages over the direct approach through
the infected empyaema cavity.

46. THANKS FOR LISTENING