Management of Recurrent Bronchopleural Fistula: A Multidisciplinary Approach for A Reconstructive Challenge

Urgent pneumonectomy for benign disease is rare but highly morbid, with a perioperative mortality approaching 50 percent. Late postpneumonectomy empyema (PPE) with bronchopleural fistula (BPF) poses a significant therapeutic challenge and carries a mortality risk of up to 40 percent. 

Case 

A forty-seven-year-old female underwent an Ivor Lewis esophagectomy for progressive achalasia, complicated by type II respiratory failure and septic shock in the early postoperative period. Cross-sectional imaging and bronchoscopy showed evidence of underlying right lung torsion. 

The lung was distorted at right thoracotomy, but the patient continued to deteriorate, requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). Surgical reexploration revealed a necrotic right lung, necessitating emergency right pneumonectomy. She progressed satisfactorily and was discharged home eight weeks postoperatively. 

The patient subsequently represented two years later with progressive weight loss, a cough, and dyspnea (particularly when lying on her left-hand side). Plain chest imaging demonstrated an empty right post-pneumonectomy space, with evidence of contralateral pneumonitis. A BPF was visualized at bronchoscopy, and the space was drained under thoracoscopic guidance. She was discharged with a chest drain in situ and on oral antimicrobials but required readmission for sepsis shortly thereafter. 

Reamputation of the right main bronchial stump with two-level bronchial stapling was performed via transsternal trans-pericardial approach, but recanalization of the BPF emerged within two weeks. 

Over the following three months, the space was successfully sterilized by means of sequential intrapleural irrigation with gentamicin and colistin, in combination with parenteral ceftriaxone and ceftolozane. 

Combined plastic and thoracic surgical input successfully achieved debridement of the postpneumonectomy space with obliteration by means of tissue transfer from the right thigh (a chimeric musculocutaneous anterolateral thigh flap with vastus lateralis muscle) anastomosed to the right thoracodorsal artery. She made a complete recovery and returned to her usual activities of daily living up until three years after the procedure. 

She represented during the peak of the COVID-19 pandemic with mucopurulent discharge from the previous surgical scar, raising a clinical suspicion of repeat recanalization of the BPF. Cross-sectional imaging confirmed secondary muscle atrophy of the vastus lateralis muscle from her initial free flap reconstruction, with a preserved blood supply. While surgical reexploration was necessitated, it was too high-risk in the current climate. She was managed conservatively with an intercostal chest drain and oral antibiotics and remained in good health for a further six months. 

Her most recent procedure was again combined, involving thoracic and plastic surgical input. She underwent full debridement and washout of the right thoracic cavity. To prevent recurrence, the dead space required obliteration with vascularized soft tissue. This demanded careful preoperative planning because of the risk of compromising the blood supply to the previous reconstruction. Potential reconstructive “lifeboats” had to be considered, which was challenging given the paucity of recipient vessels in the region, should another free flap be required. The existing free flap was successfully mobilized on its original recipient vessels, the skin paddle de-epithelialized, and vascularized tissues advanced into the thoracic cavity without complication. 

The patient continues to remain well at one-year follow up. 

Conclusion 

This case demonstrates the complexity of bronchopleural fistula management in both the early and late postoperative period. It highlights that, as the number of operations required increase, the surgical options can decrease, necessitating careful planning and detailed patient counselling. 

In these challenging cases a multidisciplinary approach between thoracic and plastic surgery is imperative. Collaborative working in this case allowed for careful preoperative planning and joint peri-operative decision making and ultimately resulted in a positive outcome for a surgically complex patient. 

References

1. Klapper, J, Hirji, S, Hartwig, M, D'amico, T, Harpole, D. Outcomes after Pneumonectomy for Benign Disease: The Impact of Urgent Resection. American College of Surgeons. 2014;219(3): 518-524.
2. Gharagozloo, F, Margolis, M, Facktor, M, Tempesta, B, Najam, F. Postpneumonectomy and Postlobectomy Empyema. Thorac Surg Clin. 2006;16(1): 215-222.
3. Topcuoglu , M.S, Kayhan, C.E.M, Ulus, T. Transsternal Transpericardial Approach for the Repair of Bronchopleural Fistula With Empyema. Annals of Thoracic Surgery. 2000;69(1): 394-397.
4. Torbic, H, Glasser, N, Rostas, S, Alquwaizani, M, Hacobian, G. Intrapleural Antimicrobial Irrigation for Postpneumonectomy Empyema in Patients With Lung Cancer. Journal of Pharmacy Practice. 2015;28(5): 469-472.

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