Transsternal bronchial closure: a narrative review

Introduction

The transsternal trans pericardial approach was first described with the objective to have direct access to the main airway. One of the main indications for this approach is postpneumonectomy bronchopleural fistula (BPF), which is one of the most feared complications due to its high rates of morbidity and mortality. Its incidence varies widely across different series but can complicate up to 10% of pneumonectomies (1). This condition is particularly challenging because it may develop weeks or months after the initial operation, when postoperative scarring, inflammation, and chronic pleural contamination create a hostile surgical field (2). In addition, postpneumonectomy fistulas are usually located deep and centrally, limiting exposure and making direct access to the bronchial stump difficult through a previous lateral thoracotomy (3). In this setting, the transsternal transpericardial approach emerged as an alternative route for definitive repair of central bronchial fistulas. By avoiding the infected pleural cavity and allowing access through relatively healthy mediastinal planes, this approach provides direct exposure of the carina and main bronchial stump, while permitting adequate control of the mediastinal vascular structures (4). The extrapleural transpericardial concept was initially described by Padhi and Lynn in 1960 through an anterior thoracic incision with division of multiple costal cartilages (5). One year later, Abruzzini described transsternal bronchial closure through a median sternotomy, establishing the basis for the technique that is currently recognized as the transsternal transpericardial approach (6).

Although large clinical series were not reported during the following decades, the period between 1961 and 1989 was characterized by scattered case reports, technical descriptions, and related anterior or transpericardial approaches to the main bronchus. The technique subsequently gained wider recognition after the report by Ginsberg et al., who described its use in patients with chronic postpneumonectomy BPF (7). Since its original description, the fundamental principles of the technique have remained largely unchanged. However, efforts have been made to reduce its morbidity and mortality by incorporating new minimally invasive procedures, such as video-assisted technique or endoscopic approach to assist the technique in order to improve results. This review highlights the surgical technique of transsternal bronchial closure, different variables related to the procedure and its impact on the patient, different alternatives for reinforcement of the bronchial stump and novel endoscopic techniques that complement an adequate surgical treatment. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1084/rc).

Methods

This study was conducted as a structured narrative review with a systematic literature search performed in PubMed/MEDLINE. A systematic review of the literature was performed to summarize the available evidence regarding the transsternal transpericardial approach for bronchial closure in patients with BPF, with particular emphasis on postpneumonectomy BPF. The review focused on the historical development of the technique, surgical indications, operative steps, technical considerations for bronchial stump closure and reinforcement, postoperative outcomes, and the role of adjunctive endoscopic or minimally invasive techniques.

A literature search was conducted in PubMed to identify relevant publications. The search strategy included combinations of medical subject headings (MeSH) and free-text terms related to BPF and transsternal or transpericardial bronchial closure, including “bronchopleural fistula”, “postpneumonectomy bronchopleural fistula”, “transsternal approach”, “transpericardial approach”, “transsternal transpericardial approach”, “Abruzzini technique”, “bronchial stump closure”, “bronchial stump reinforcement”, and “endoscopic management”. Additional relevant articles were identified by manually reviewing the reference lists of selected publications.

Two authors (J.P. and F.I) independently performed literature screening and study selection. Priority was given to high-level evidence including randomized clinical trials and retrospective or prospective cohort studies. Case reports, conference abstracts, editorials, and studies that provided relevant data on surgical technique and postoperative morbidity were also included. Systematic reviews and meta-analyses were screened for additional relevant references. Only studies published in English were considered.

Studies focused on postpneumonectomy BPF, recalcitrant central BPFs, bronchial stump reclosure, stump reinforcement, and adjunctive endoscopic or minimally invasive procedures were prioritized. Articles not directly related to central BPF, postpneumonectomy fistula, or transsternal/transpericardial bronchial closure were excluded. The studies were then prioritized according to methodological quality, sample size and clinical relevance. Given the narrative nature of the review, no formal quality assessment or quantitative meta-analysis was performed.

Table 1 summarizes the search strategy used for this narrative review.

Surgical technique

• Positioning: the patient is placed in the supine position, with a small roll or pillow beneath the shoulders to facilitate neck extension and anterior mediastinal exposure. The head is positioned at the upper end of the operating table, supported on a ring cushion, and gently extended. Both arms are secured alongside the body, as for a standard median sternotomy.
• Anesthesia considerations: preoperative discussion with the anesthesia team is essential, as airway management must be individualized according to fistula location, side of pneumonectomy, residual lung function, and the planned operative strategy. Several ventilation options have been described: double-lumen tube, long single lumen tube, endobronchial blocker and jet ventilation. It is the authors preference intubation with a long single-lumen endotracheal tube which is positioned in healthy bronchus. If necessary, the tube can be withdrawn temporarily during bronchial stump closure to facilitate exposure and suture placement. Frequent suctioning is recommended throughout the procedure to avoid contamination of the remaining airway with secretions from the fistula or infected pleural cavity (8).
• Median sternotomy, dissection and mobilization of great vessels, opening of posterior pericardium: the patient is prepared and draped as for a standard median sternotomy. A full median sternotomy is performed to access the anterior mediastinum. The great vessels are then carefully mobilized to expose the central airway. The superior vena cava and ascending aorta are dissected and gently retracted as needed. The lower trachea is approached above the pericardial reflection, taking particular care to avoid injury to the left recurrent laryngeal nerve (9). The anterior pericardium is opened to expose the intrapericardial structures. On the right side, the right pulmonary artery stump is usually located anterior to the posterior pericardium and slightly inferior to the carina. When necessary, the pulmonary artery stump can be carefully dissected and retracted inferiorly to improve exposure of the posterior pericardium and the tracheobronchial bifurcation (4,9,10) (Figure 1). The posterior pericardium is then incised, creating a transpericardial window that provides access to the distal trachea, carina, and main bronchial stump.
  

  Figure 1 Intraoperative overview of the transsternal approach with exposure of the main large vessels. L, left; SVC, superior vena cava.
• Exposure of the tracheobronchial tree and bronchial stump closure: after opening the posterior pericardium, gentle dissection of the tracheobronchial tree and/or stump is performed. Although this route is often described as an approach through a relatively unexplored operative field, adhesions and inflammatory changes may still be encountered, particularly in delayed or recurrent fistulas. When dense adhesions surround the bronchial stump, dissection should proceed carefully, and the stump may be divided progressively from anterior to posterior until it is safely mobilized (4). Anatomical considerations need to be kept in mind during this step: on both sides, the posterior membranous wall of the trachea lies adjacent to the esophagus. On the left side, the aortic arch is located anterolateral to the distal trachea, while the left recurrent laryngeal nerve runs in the tracheoesophageal groove. On the right side, the azygos vein lies adjacent to the lateral aspect of the distal trachea, near the tracheobronchial angle. These relationships may be distorted by traction, inflammation, previous surgery, or chronic pleural infection; therefore, careful dissection and continuous reassessment of the anatomy are mandatory. Once the tracheobronchial tree has been exposed and the bronchial stump adequately dissected, the devitalized portion of the stump should be resected whenever feasible. The objective is to obtain fresh, viable bronchial edges that allow a tension-free and airtight closure. Depending on stump length, tissue quality, and available working space, closure may be performed using interrupted sutures or a stapling device. These technical steps have been well illustrated by Ginsberg et al. using images, and by Gritsiuta et al. with a surgical video (7,11).

Ethical statement

All clinical procedures described in this study were in accordance with ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Surgical indications

Patient selection for the transsternal transpericardial approach depends on the location of the fistula, its time of appearance from the original surgery, the condition of the bronchial stump, the status of the pleural cavity, and the feasibility of obtaining safe exposure through a conventional transthoracic route. This approach is mainly indicated for selected central BPFs, particularly after pneumonectomy which are typically central and retracted behind great vessels, when direct access to the bronchial stump through the previous thoracotomy is unsafe, technically difficult, or has already failed (12,13).

The most relevant indications include recurrent or persistent central BPF after previous repair attempts, a short or necrotic bronchial stump, a stump partially or completely covered by the pulmonary artery, and fistulas located close to the carina or distal trachea (3,14). In these situations, the transsternal transpericardial route provides controlled exposure of the central airway and mediastinal vascular structures, allowing bronchial stump reamputation and closure on viable tissue when technically feasible. The length and quality of the bronchial stump are important determinants of suitability (15). A necrotic or very short stump may require proximal control and resection close to the tracheobronchial bifurcation, whereas a longer stump may allow re-resection of devitalized tissue and closure under less tension. Therefore, stump length should be interpreted together with tissue viability, fistula location, previous surgical attempts, and the degree of pleural contamination.

Contraindications and limitations should be clearly recognized when considering the transsternal transpericardial approach. This technique is generally not indicated for peripheral BPFs, small fistulas amenable to conservative or endoscopic management, or early fistulas that can be safely repaired through the previous thoracotomy (9). Prior cardiac surgery may represent a relative contraindication, as mediastinal adhesions can make safe access to the transpericardial plane more difficult. However, previous reports have shown that the approach can still be performed in selected patients with a history of coronary artery bypass grafting (CABG) (7,9).

Uncontrolled sepsis, undrained empyema, severe malnutrition, and poor general condition should be considered reasons to delay definitive bronchial closure until adequate pleural drainage, infection control, and nutritional optimization have been achieved (4). One important limitation of the transsternal transpericardial approach is that it does not directly address the pleural empyema during the same procedure. Therefore, adequate management of the pleural space, either before or after bronchial closure, remains essential.

Severe mediastinal distortion, extensive vascular involvement, or anatomical conditions that prevent safe transpericardial dissection may also limit the feasibility of the procedure. Finally, patients who are unable to tolerate major surgery or median sternotomy should be considered poor candidates for this approach.

Technical aspects for stump closure

Bronchial stump closure may be performed using either a stapled or hand-sewn technique, and the optimal method remains debated. During the primary pneumonectomy, stapled closure is currently preferred by many surgeons because it is reproducible, reduces operative time, provides simultaneous closure of the proximal and distal bronchial ends, and may decrease contamination of the operative field (16). However, hand-sewn closure remains useful in selected situations, particularly when the tumor is close to the bronchial division line, when the bronchial wall is thick, calcified, or fragile, or when local anatomy does not allow safe stapler placement (17).

In the setting of postpneumonectomy BPF repair through a transsternal transpericardial approach, the choice of closure technique depends mainly on bronchial stump length, tissue quality, fistula location, and available working space (18). The exposure obtained through this approach allows central control of the airway, but the operative field is narrow and the introduction of a stapling device may be technically difficult, especially when the stump is short, inflamed, or adherent to adjacent mediastinal structures (19,20). For this reason, many reported series have favored bronchial reamputation followed by hand-sewn closure with interrupted sutures (17,21).

Regardless of the closure method, the main technical principles are the same: devitalized tissue should be resected whenever feasible, closure should be performed on viable bronchial tissue, and excessive tension should be avoided. Intraoperative bronchoscopy or airway inflation may be useful to assess the integrity of the closure and exclude residual air leak or airway narrowing. In our practice, we prefer closure with interrupted non-absorbable sutures, particularly when stapler placement is limited by the central location of the fistula or by the reduced working space of the transsternal approach (Figure 2).

Figure 2 Closure of the bronchial stump with non-absorbable interrupted sutures.

Methods to reinforce the bronchial stump

Reinforcement of the bronchial stump closure is frequently considered in BPF repair, particularly in patients with poor tissue quality, chronic infection, previous radiation, malnutrition, or prior failed repair attempts. Several tissue options have been described, including omentum, intercostal muscle flap, parietal pleura, pericardium, pericardial fat, and mediastinal fat. However, no specific flap has consistently demonstrated superiority over another, mainly because the available studies include small and heterogeneous populations that are not directly comparable (22,23). Consequently, the choice of reinforcement should be individualized on a case-by-case basis according to fistula location, surgical access, local tissue availability, previous operations, degree of contamination, and surgeon experience. The omentum provides abundant, highly vascularized tissue with immunologic and angiogenic properties, making it particularly useful in chronically infected fields or recurrent fistulas. However, its use requires transposition from the abdomen, which may increase operative time and morbidity (24). Intercostal muscle flaps are readily available during transthoracic procedures and provide vascularized local coverage, but their use may be limited in patients with previous thoracotomy, devascularized chest wall tissue, or when the transsternal route is used without lateral thoracic access (25). Pericardium, pericardial fat, and mediastinal fat are particularly attractive during transsternal transpericardial repair because they are directly available within the operative field and avoid additional donor-site morbidity. Their main limitation is that they may provide less bulk than omentum or muscle flaps, especially in large defects or severely infected cavities (4,26).

Puskas et al., in a series of 42 patients treated for major postoperative BPF, reported an overall success rate of 80% after the initial repair and 86% after primary and secondary procedures in patients with recurrent fistula. In 35 of 42 cases, the bronchial stump was closed and buttressed with vascularized pedicle flaps, including omentum in 19 cases, muscle in 13, and pleura in 2 (13). Similarly, Ginsberg et al. reported 13 patients with postpneumonectomy BPF treated through the transsternal transpericardial approach, in whom the bronchial suture line was reinforced with vascularized pericardium. Three failures were observed, although they were not attributed to failure of the stump coverage itself (7).

Taken together, these reports suggest that bronchial stump reinforcement is a useful adjunct in selected patients undergoing repair of BPF, particularly when tissue quality is poor or the risk of recurrence is high. Nevertheless, the available evidence does not allow a definitive recommendation regarding the optimal flap. Therefore, the reinforcement strategy should be individualized according to fistula anatomy, surgical access, local tissue availability, degree of contamination, and surgeon experience.

Morbidity and mortality

Several retrospective series have reported the outcomes of transsternal transpericardial repair for postpneumonectomy BPF, although the available evidence remains limited and heterogeneous. A large collective series including six studies from North American and European centers between 1985 and 2000 reported 116 transsternal transpericardial repairs of BPF (9) (Table 2). Most patients were men (91%), had right-sided fistulas (81%), and had undergone pneumonectomy for lung cancer (84%). In most series, this approach was used for recalcitrant BPF or after failed attempts at repair through a previous thoracotomy. Only one study, which was also the largest series and included 55 patients, used the transsternal transpericardial approach as the first attempt for BPF repair (4).

Overall, postoperative morbidity was acceptable across most published series. Intraoperative and postoperative complication rates were generally low, ranging from 0% to 5%, while recurrence rates ranged from 0% to 30%. Mortality varied substantially among series. The largest study reported the highest mortality rate, reaching 24%, whereas mortality in the remaining five series ranged between 0% and 10% (4). This difference may reflect patient selection, as many patients included in the largest series were malnourished, debilitated, or had chronic pleural sepsis.

The first series published by Ginsberg et al. included 13 patients with chronic postpneumonectomy BPF treated through the transsternal transpericardial approach. Successful closure was achieved in 10 patients. Three recurrences were reported, although only one was attributed to staple-line failure, while the remaining fistulas closed spontaneously. No operative mortality or significant major morbidity was reported in this series (7).

Misthos et al. described their experience with eleven patients with BPF after right pneumonectomy with a median of 37 months postoperatively (10). All patients underwent transsternal transpericardial approach with reclosure of the stump with a staple line and reinforcement with an omentum flap. Only one patient had a recurrence with dehiscence of the staple line and died 3 months postoperatively. There were no major morbidities, despite the death of one patient, and only one patient (7.6%) had a recurrence in the late postoperative follow up.

Beltrami et al. reported 15 postpneumonectomy BPFs treated using Abruzzini’s technique, including ten left-sided and five right-sided fistulas. In all cases, the affected bronchus was divided and closed with interrupted sutures. The authors reported no fistula recurrence, and only one patient died due to myocardial infarction (21). Similarly, Topçuoglu et al. reported favorable long-term outcomes in 16 patients with postpneumonectomy BPF treated with complete bronchial dissection, hand-sewn closure, and reinforcement with a pericardial fat pad. At five years of follow-up, no recurrences were observed, and one patient died within 30 days postoperatively due to renal insufficiency (17).

Other series have also shown acceptable outcomes with Abruzzini’s technique, with reported overall morbidity of approximately 15% and mortality ranging from 10% to 15% (16,28). Taken together, these findings suggest that the transsternal transpericardial approach can achieve durable closure with acceptable morbidity and mortality in selected patients. However, outcomes are strongly influenced by baseline clinical condition, nutritional status, chronic empyema, previous failed repair attempts, and the timing of definitive surgical treatment.

Endoscopic adjuncts to the transsternal transpericardial approach

Endoscopy has increasingly emerged as a valuable adjunct to the transsternal transpericardial approach, it plays two different roles in the management of BPF. First, bronchoscopy is essential for diagnosis, localization, and characterization of the fistula, particularly in delayed or complex presentations (29). Second, endoscopic techniques may be used as definitive therapy in selected patients, as a bridge to surgery, or as an adjunct to open repair (22,30).

As a diagnostic and intraoperative adjunct, bronchoscopy helps define fistula size, location, bronchial stump length, and the relationship of the defect to the carina or main bronchus (31,32). This information is critical for determining whether the patient is suitable for endoscopic treatment alone or requires surgical repair. In selected cases, bronchoscopy may also assist the transsternal procedure by improving fistula localization. Gritsiuta et al. reported a delayed BPF diagnosed 14 years after pneumonectomy, in which bronchoscopy with contrast injection through a bronchial blocker allowed clear identification of the fistula before transsternal closure (11). Similarly, Spaggiari et al. described a video-assisted Abruzzini technique combining anterior mediastinotomy, cervical video-mediastinoscopy, and a parasternal thoracic port (33).

From a therapeutic standpoint, the success of endoscopic treatment is strongly influenced by fistula size. Small fistulas may be amenable to bronchoscopic treatment with fibrin glue, cyanoacrylate, biological sealants, or other adhesive substances (34,35). Intermediate defects may require combined occlusive methods, such as plugs, patches, coils, or sealants. In contrast, larger central postpneumonectomy fistulas are less likely to be definitively treated with sealants alone and frequently require surgical closure when the patient is fit for surgery (36). In these cases, endoscopic therapy should be viewed mainly as a bridge, adjunct, or palliative alternative in high-risk patients rather than as a substitute for transsternal transpericardial repair.

Therefore, endoscopic techniques should be interpreted according to the clinical scenario. In small fistulas, they may provide definitive closure in selected patients. In larger or central BPFs, particularly after pneumonectomy, their main value lies in diagnosis, anatomical characterization, intraoperative guidance, and temporary control of air leak or contamination before definitive repair. When pleural sepsis or chronic empyema is present, endoscopic closure alone is unlikely to be sufficient unless adequate drainage and infection control have been achieved. Thus, in the setting of transsternal transpericardial repair, endoscopy is best understood as a complementary tool that can improve planning and execution of the procedure rather than as an alternative that replaces the surgical approach.

Strengths and limitations

This review summarizes the role of the transsternal transpericardial approach in the management of selected patients with BPF. Several authors have reported favorable outcomes, suggesting that, although technically demanding, this approach may achieve definitive closure with acceptable morbidity and mortality in appropriately selected cases. However, the main limitation of the available literature is its low evidential weight. Most published data come from retrospective series, small cohorts, case reports, and technical descriptions, with substantial heterogeneity in patient selection, fistula characteristics, timing of repair, presence of empyema, previous treatment attempts, reinforcement methods, and outcome reporting.

The limited number of contemporary publications likely reflects the highly selected indication for this approach, the continued use of conventional transthoracic repair in many centers, and the increasing availability of endoscopic, video-assisted, and combined strategies in selected patients. For this reason, the transsternal transpericardial approach should be considered a valuable but selectively applied technique, supported mainly by retrospective evidence and expert surgical experience rather than by robust comparative data.

Conclusions

The transsternal transpericardial approach may be considered a valuable option in carefully selected patients with central or postpneumonectomy BPF, particularly when conventional transthoracic access is unsafe, technically difficult, or has failed. However, the available evidence is limited to small retrospective series, case reports, and technical descriptions. Therefore, its role should be interpreted with caution, and definitive conclusions regarding superiority over other approaches cannot be drawn.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Roman V. Petrov and Andrei I. Gritsiuta) for the series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” published in Journal of Thoracic Disease. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1084/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1084/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1084/coif). The series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were in accordance with ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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