Surgical strategies in the management of postoperative bronchopleural fistula: a narrative review

Background and Objective: Bronchopleural fistula (BPF) is a life-threatening condition characterized by abnormal communication between the bronchial tree and pleural space, often resulting in complications such as pneumothorax, empyema, and sepsis. Commonly occurring after pneumonectomy or lobectomy, BPF presents significant diagnostic and therapeutic challenges due to its multifactorial etiology, complex anatomy, and high morbidity and mortality rates. This narrative review aims to synthesize current knowledge on BPF pathophysiology, risk factors, classification, and management strategies while identifying knowledge gaps and opportunities for improving clinical outcomes. Methods: A comprehensive search of PubMed, Scopus, Web of Science, Cochrane Library and Google Scholar was conducted to identify peer-reviewed articles on BPF published between 2000 and 2024. The search included terms such as “bronchopleural fistula”, “pneumonectomy”, “lobectomy”, “air leak”, “pneumothorax”, “bronchial stump closure”, and “management strategies”. Eligible studies encompassed randomized controlled trials, observational studies, case series, systematic reviews, and expert opinions. Data on risk factors, diagnostic approaches, management strategies, and clinical outcomes were extracted and synthesized. Key Content and Findings: BPF is classified as acute, subacute, or chronic based on its onset, with varying clinical presentations and management needs. Advanced imaging modalities such as computed tomography (CT), CT bronchography, and bronchoscopy are pivotal for diagnosis, with innovations like CT-based scoring systems improving sensitivity and specificity. Management strategies range from conservative measures for smaller fistulas to advanced bronchoscopic techniques, including sealants, stents, and endobronchial valves, and surgical interventions like muscle flap transposition and omental pedicle reinforcement for larger, complex cases. Emerging therapies, including bioengineered scaffolds and 3D-printed stents, show potential in enhancing outcomes. Despite advancements, challenges remain in optimizing treatment protocols, particularly in tailoring interventions to fistula size, timing, and patient-specific factors. Conclusions: BPF remains a challenging complication of thoracic surgery, requiring a multidisciplinary approach for effective management. While advancements in diagnostic and therapeutic technologies have improved outcomes, significant knowledge gaps persist. Future research should focus on large-scale studies to evaluate the efficacy of emerging therapies and refine treatment algorithms. Enhanced collaboration across disciplines and the integration of innovative technologies are essential to reducing the morbidity and mortality associated with BPF and improving patient quality of life.