Bronchopleural fistula and the role of contemporary imaging

Published:December 18, 2013DOI:
      One of the most morbid postoperative complications after a lobectomy or a pneumonectomy is a bronchopleural fistula (BPF). The diagnosis and identification of BPF may be challenging, often requiring repeat imaging and invasive tests, including bronchoscopy, thoracoscopic exploration, or even open exploration. The purpose of this article is to review the types and presentations of BPF and to describe the role of noninvasive imaging for diagnosis and surgical treatment planning. We focused on multidetector computed tomography and advanced postprocessing applications such as multiplanar reconstructions, virtual bronchoscopy, and volume rendering images, including minimum-intensity and maximum-intensity projections. Both multidetector computed tomography and nuclear scintigraphy are reliable noninvasive imaging modalities that can be used expeditiously in an outpatient setting and may prove to be a more cost-effective strategy to identify the fistula as well as conduct postoperative surveillance. These modalities can be used for accurate and efficient testing for earlier diagnosis and treatment planning, thereby significantly improving patient outcome. Additional advanced postprocessing techniques using already acquired imaging data can provide complementary information that is both visually accessible and anatomically meaningful for the surgeon. Better understanding of the potential uses and benefits of these techniques will eventually improve the diagnostic accuracy, optimize preoperative planning, and facilitate follow-up for patients with BPF with improved patient outcomes.

      CTSNet classification

      Abbreviations and Acronyms:

      2D (2-dimensional), 3D (3-dimensional), BPF (bronchopleural fistula), CT (computed tomography), MDCT (multidetector computed tomography), TB (tracheobronchial), VB (virtual bronchoscopy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Deschamps C.
        • Bernard A.
        • Nichols III, F.C.
        • Allen M.S.
        • Miller D.L.
        • Trastek V.F.
        • et al.
        Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence.
        Ann Thorac Surg. 2001; 72 (discussion 8): 243-247
        • Sirbu H.
        • Busch T.
        • Aleksic I.
        • Schreiner W.
        • Oster O.
        • Dalichau H.
        Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management.
        Ann Thorac Cardiovasc Surg. 2001; 7: 330-336
        • Cerfolio R.J.
        The incidence, etiology, and prevention of postresectional bronchopleural fistula.
        Semin Thorac Cardiovasc Surg. 2001; 13: 3-7
        • McManigle J.E.
        • Fletcher G.L.
        • Tenholder M.F.
        Bronchoscopy in the management of bronchopleural fistula.
        Chest. 1990; 97: 1235-1238
        • Turk A.E.
        • Karanas Y.L.
        • Cannon W.
        • Chang J.
        Staged closure of complicated bronchopleural fistulas.
        Ann Plast Surg. 2000; 45: 560-564
        • Algar F.J.
        • Alvarez A.
        • Aranda J.L.
        • Salvatierra A.
        • Baamonde C.
        • Lopez-Pujol F.J.
        Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis.
        Ann Thorac Surg. 2001; 72: 1662-1667
        • Panagopoulos N.D.
        • Apostolakis E.
        • Koletsis E.
        • Prokakis C.
        • Hountis P.
        • Sakellaropoulos G.
        • et al.
        Low incidence of bronchopleural fistula after pneumonectomy for lung cancer.
        Interact Cardiovasc Thorac Surg. 2009; 9: 571-575
        • Khan J.H.
        • Rahman S.B.
        • McEihinney D.B.
        • Harmon A.L.
        • Anthony J.P.
        • Hall T.S.
        • et al.
        Management strategies for complex bronchopleural fistula.
        Asian Cardiovasc Thorac Ann. 2000; 8: 78-84
        • Gudbjartsson T.
        • Gyllstedt E.
        • Pikwer A.
        • Jönsson P.
        Early surgical results after pneumonectomy for non-small cell lung cancer are not affected by preoperative radiotherapy and chemotherapy.
        Ann Thorac Surg. 2008; 86: 376-382
        • Darling G.E.
        • Abdurahman A.
        • Yi Q.L.
        • Johnston M.
        • Waddell T.K.
        • Pierre A.
        • et al.
        Risk of a right pneumonectomy: role of bronchopleural fistula.
        Ann Thorac Surg. 2005; 79: 433-437
        • Taghavi S.
        • Marta G.M.
        • Lang G.
        • Seebacher G.
        • Winkler G.
        • Schmid K.
        • et al.
        Bronchial stump coverage with a pedicled pericardial flap: an effective method for prevention of postpneumonectomy bronchopleural fistula.
        Ann Thorac Surg. 2005; 79: 284-288
        • Hollaus P.H.
        • Lax F.
        • el-Nashef B.B.
        • Hauck H.H.
        • Lucciarini P.
        • Pridun N.S.
        Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases.
        Ann Thorac Surg. 1997; 63 (discussion 6-7): 1391-1396
        • Seo H.
        • Kim T.J.
        • Jin K.N.
        • Lee K.W.
        Multi-detector row computed tomographic evaluation of bronchopleural fistula: correlation with clinical, bronchoscopic, and surgical findings.
        J Comput Assist Tomogr. 2010; 34: 13-18
        • Westcott J.L.
        • Volpe J.P.
        Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak.
        Radiology. 1995; 196: 175-181
        • Arnold P.G.
        • Pairolero P.C.
        Intrathoracic muscle flaps: a 10-year experience in the management of life-threatening infections.
        Plast Reconstr Surg. 1989; 84 (discussion 9): 92-98
        • Gonfiotti A.
        • Santini P.F.
        • Jaus M.
        • Janni A.
        • Lococo A.
        • Raffaella De Massimi A.
        • et al.
        Safety and effectiveness of a new fibrin pleural air leak sealant: a multicenter, controlled, prospective, parallel-group, randomized clinical trial.
        Ann Thorac Surg. 2011; 92 (discussion 24-5): 1217-1224
        • Sivrikoz C.M.
        • Kaya T.
        • Tulay C.M.
        • Ak I.
        • Bilir A.
        • Doner E.
        Effective approach for the treatment of bronchopleural fistula: application of endovascular metallic ring-shaped coil in combination with fibrin glue.
        Ann Thorac Surg. 2007; 83: 2199-2201
        • Tanaka S.
        • Yajima T.
        • Mogi A.
        • Kuwano H.
        Successful management of a large bronchopleural fistula after lobectomy: report of a case.
        Surg Today. 2011; 41: 1661-1664
        • Walsh M.D.
        • Bruno A.D.
        • Onaitis M.W.
        • Erdmann D.
        • Wolfe W.G.
        • Toloza E.M.
        • et al.
        The role of intrathoracic free flaps for chronic empyema.
        Ann Thorac Surg. 2011; 91: 865-868
        • Wu G.
        • Li Z.M.
        • Han X.W.
        • Wang Z.-G.
        • Lu H.-B.
        • Zhu M.
        • et al.
        Right bronchopleural fistula treated with a novel, Y-shaped, single-plugged, covered, metallic airway stent.
        Acta Radiol. 2013; 54: 656-660
        • Lauckner M.E.
        • Beggs I.
        • Armstrong R.F.
        The radiological characteristics of bronchopleural fistula following pneumonectomy.
        Anaesthesia. 1983; 38: 452-456
        • Merritt R.E.
        • Reznik S.I.
        • DaSilva M.C.
        • Sugarbaker D.J.
        • Whyte R.I.
        • Donahue D.M.
        • et al.
        Benign emptying of the postpneumonectomy space.
        Ann Thorac Surg. 2011; 92 (discussion 81-2): 1076-1081
        • Sarkar P.
        • Patel N.
        • Chusid J.
        • Shah R.
        • Talwar A.
        The role of computed tomography bronchography in the management of bronchopleural fistulas.
        J Thorac Imaging. 2010; 25: W10-W13
        • Nair A.
        • Godoy M.C.
        • Holden E.L.
        • Madden B.P.
        • Chua F.
        • De Ost
        • et al.
        Multidetector CT and postprocessing in planning and assisting in minimally invasive bronchoscopic airway interventions.
        Radiographics. 2012; 32: E201-E232
        • Lawler L.P.
        • Fishman E.K.
        Multi-detector row CT of thoracic disease with emphasis on 3D volume rendering and CT angiography.
        Radiographics. 2001; 21: 1257-1273
        • Wu C.M.
        • Urban B.A.
        • Fishman E.K.
        Spiral CT of the thoracic aorta with 3-D volume rendering: a pictorial review of current applications.
        Cardiovasc Intervent Radiol. 1999; 22: 159-167
        • De Wever W.
        • Vandecaveye V.
        • Lanciotti S.
        • Verschakelen J.A.
        Multidetector CT-generated virtual bronchoscopy: an illustrated review of the potential clinical indications.
        Eur Respir J. 2004; 23: 776-782
        • Polverosi R.
        • Vigo M.
        • Baron S.
        • Rossi G.
        [Evaluation of tracheobronchial lesions with spiral CT: comparison between virtual endoscopy and bronchoscopy].
        Radiol Med. 2001; 102: 313-319
        • McAdams H.P.
        • Palmer S.M.
        • Erasmus J.J.
        • Patz E.F.
        • Connolly J.E.
        • Goodman P.C.
        • et al.
        Bronchial anastomotic complications in lung transplant recipients: virtual bronchoscopy for noninvasive assessment.
        Radiology. 1998; 209: 689-695
        • Shitrit D.
        • Valdsislav P.
        • Grubstein A.
        • Bendayan D.
        • Cohen M.
        • Kramer M.R.
        Accuracy of virtual bronchoscopy for grading tracheobronchial stenosis: correlation with pulmonary function test and fiberoptic bronchoscopy.
        Chest. 2005; 128: 3545-3550
        • Dialani V.
        • Ernst A.
        • Sun M.
        • Lee K.S.
        • Feller-Kopman D.
        • Litmanovich D.
        • et al.
        MDCT detection of airway stent complications: comparison with bronchoscopy.
        AJR Am J Roentgenol. 2008; 191: 1576-1580
        • Allah M.F.
        • Hussein S.R.
        • El-Asmar A.B.
        • Zoair H.M.
        • Mohamed G.A.
        • Metwaly A.M.
        • et al.
        Role of virtual bronchoscopy in the evaluation of bronchial lesions.
        J Comput Assist Tomogr. 2012; 36: 94-99
        • Mark J.B.
        • McDougall I.R.
        Diagnosis and localization of bronchopulmonary air leaks using ventilation scintigraphy.
        Chest. 1997; 111: 286-289
        • Nielsen K.R.
        • Blake L.M.
        • Mark J.B.
        • DeCampli W.
        • McDougall I.R.
        Localization of bronchopleural fistula using ventilation scintigraphy.
        J Nucl Med. 1994; 35: 867-869
        • Raja S.
        • Rice T.W.
        • Neumann D.R.
        • Saha G.B.
        • Khandekar S.
        • MacIntyre W.J.
        • et al.
        Scintigraphic detection of post-pneumonectomy bronchopleural fistulae.
        Eur J Nucl Med. 1999; 26: 215-219