Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

Background. Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed. Methods. All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis. Results. Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease ( p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV 1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin ( p = 0.05), right pneumonectomy ( p = 0.0109), bronchial stump reinforcement ( p = 0.007), completion pneumonectomy ( p < 0.01), timing of chest tube removal ( p = 0.01), and the amount of blood transfusions ( p < 0.01). Similarly, the development of BPF was significantly associated with benign disease ( p = 0.03), lower preoperative FEV 1 ( p = 0.03) and DLCO ( p = 0.01), right pneumonectomy ( p < 0.0001), bronchial stump reinforcement ( p = 0.03), timing of chest tube removal ( p = 0.004), increased intravenous fluid in the first 12 hours ( p = 0.04), and blood transfusions ( p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure ( p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis. Conclusions. Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.