Bronchial Stump Dehiscence: Update on Prevention and Management Moishe Liberman, MDCM, FRCSC, and Stephen D. Cassivi, MD, MSc, FRCSC, FACS Bronchial stump dehiscence is a serious complication and is associated with important morbidity and increased mortality. Because of this, efforts to prevent and treat these occurrences are essential. Etiology, risk factors, diagnosis and prevention, as well as current treatment options with an emphasis on surgical repair with muscle flaps are reviewed and discussed. Semin Thorac Cardiovasc Surg 19:366-373 © 2007 Elsevier Inc. All rights reserved. KEYWORDS bronchopleural fistula, muscle flap, bronchial dehiscence, postpneumonectomy empyema The major difference between a thing that might go wrong and a thing that cannot possibly go wrong is that when a thing that cannot possibly go wrong goes wrong it usually turns out to be impossible to get at or repair. —Douglas Adams (1952-2001) B ronchial stump dehiscence is fortunately a rare event following anatomic pulmonary resection (segmentec- tomy, lobectomy, or pneumonectomy). The incidence ranges from 1% to 10% depending on patient characteristics, tech- niques used for closure, and surgical volume. 1 However, when this complication occurs, it is a source of major mor- bidity and is associated with increased mortality. Bronchial stump dehiscence is significantly more common after pneu- monectomy than with lesser anatomic resections. Etiology Bronchial stump dehiscence is defined as a disruption of a bronchial closure occurring after anatomic pulmonary resec- tion. Early failure (within a few days to a few weeks following surgery) is usually the result of a technical failure. This can be due to a stapler misfiring, loose or broken sutures, or undue tension of the closure with poor apposition of tissues. Late failure is typically secondary to weak bronchial tissue and infection (bronchitis, empyema), which leads to loss of integ- rity of the bronchial stump closure. The mortality of post- pneumonectomy empyema with a bronchopleural fistula has been reported to be 11% to 13%. 2,3 Risk Factors Predisposition to bronchial stump dehiscence can occur due to preoperative, intraoperative, and postoperative risk fac- tors. Preoperative risk factors relate to patient-specific char- acteristics such as comorbidities (diabetes, malnutrition), medications (steroids, antimetabolites), and prior treatments (radiation). Algar and colleagues found that early broncho- pleural fistula after pneumonectomy was significantly asso- ciated with COPD (P = 0.017), hyperglycemia (P = 0.003), hypoalbuminemia (P = 0.017), previous steroid therapy (P  0.001), and low predicted postoperative FEV 1 (P = 0.012). 1 Table 1 outlines risk factors for BPF. When possible, preoperative correction or mitigation of risk factors should be attempted. Malnutrition and infection should be aggressively treated. Steroids should be tapered to the lowest tolerable dose before surgery. Diabetes should be brought under tight control. Every attempt to curtail a pro- spective patient’s smoking habit should be made. Intraoperative techniques used to decrease the risk of BPF are described in a subsequent section. Postoperatively, the most important risk factor for BPF is positive pressure me- chanical ventilation. 4 Early return to spontaneous respiration without positive pressure mechanical assistance should be a priority following surgery to avoid the inherent barotrauma and risk to the bronchial stump closure. Preoperative radiotherapy is a significant risk factor for postoperative BPF; however, with muscle flap coverage the risk can be reduced. Sonett and associates reviewed 40 pa- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota. Address reprint requests to Stephen D. Cassivi, MD, MSc, FRCSC, FACS, Division of General Thoracic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail: cassivi.stephen@mayo.edu 366 1043-0679/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2007.11.002