Interventional techniques and strategies for postoperative bronchopleural fistula treatment: a narrative review

Introduction

Background

Bronchopleural fistula (BPF) denotes a pathologic connection between the bronchial lumen (from the main bronchus to segmental branches) and the pleural cavity. In the postoperative setting, a central BPF most often reflects bronchial stump dehiscence or incomplete stump healing after anatomical lung resection. BPF should be distinguished from alveolar-pleural fistula (APF), which arises distal to the segmental bronchi; persistent/prolonged air leak (PAL) is most commonly defined as an air leak lasting more than 5 days, although thresholds between 5 and 7 days are used across studies. Postoperative BPF after anatomical lung resection remains one of the most consequential complications of lung resection given its direct association with pleural sepsis, aspiration risk, and respiratory failure. While early postoperative stump dehiscence often requires surgical re-exploration, advances in interventional pulmonology have expanded bronchoscopic options for localization and occlusion, particularly for patients at high surgical risk (1-4).

Rationale and knowledge gap

BPF and PAL are associated with high morbidity and mortality, prolonged hospitalization, and increased costs. Although multiple surgical, bronchoscopic, and pleural-directed strategies are available, the evidence is heterogeneous and often limited to retrospective series or case reports. A practical knowledge gap remains in matching each intervention to fistula phenotype, pleural space status, collateral ventilation, nutritional and inflammatory status, and patient physiological reserve.

Objective

This narrative review outlines interventional options for managing postoperative BPF, emphasizes practical considerations for each procedure, and offers an anatomy-based multidisciplinary framework to guide treatment selection. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1312/rc).

Methods

This narrative review summarizes interventional strategies for postoperative BPF and PAL/APF after anatomical lung resection and incorporates clinically relevant incidence, risk-factor, and outcome data that inform therapy selection. PubMed/MEDLINE was searched on March 1, 2026, using medical subject headings (MeSH) and free-text combinations for BPF, APF and PAL, lung resection, bronchoscopic or other interventional therapies. The electronic search was supplemented by screening reference lists of key reviews and primary studies. Publications from database inception to March 1, 2026 were considered. Eligible sources included reviews, observational cohorts, case series, and case reports that described interventional closure or occlusion strategies after lobectomy, bilobectomy, pneumonectomy, or other anatomical lung resection, or that provided actionable data on localization, pleural drainage, collateral ventilation, chest-tube management, procedure-specific risk, or outcomes. Non-postoperative reports were included only when they informed device technique or patient selection for postoperative BPF/PAL. Because definitions, anatomic descriptors, and endpoints varied substantially, findings were synthesized narratively rather than by meta-analysis.

Study-selection summary: Electronic search results and hand-searched records were de-duplicated in a reference manager. Titles and abstracts were screened for relevance, followed by full-text review. All authors participated in selection. Emphasis was placed on clinically actionable reports with clear anatomic localization, intervention details, and outcome reporting. Contemporary multicenter studies, systematic reviews/meta-analyses, and recent interventional reports were prioritized when available (Table 1).

Definitions and classification

A BPF is a pathologic communication between the bronchial lumen and the pleural space. A central postoperative BPF, used in this review to mean mainstem, lobar, bronchoplasty/anastomotic, or bronchial stump dehiscence, differs from APF, where the leak arises from distal parenchyma beyond the segmental bronchi. Peripheral APF/PAL may behave differently and is often approached with segmental bronchoscopic occlusion or pleural-directed strategies. Postoperative fistulas are commonly categorized by timing (early versus late after resection), anatomic level (central, mainstem/lobar versus peripheral, segmental/subsegmental), and estimated size. Large central defects, particularly after pneumonectomy, carry the greatest risk of aspiration and rapid contamination of the remaining lung (1-5).

Epidemiology, risk factors, and pathophysiology

In addition to true bronchial stump BPF, postoperative APF/PAL is common after pulmonary resection. Overall air-leak incidence after elective lung resection has been reported at approximately 28–60%, and most leaks resolve within the first several postoperative days. However, a prolonged course beyond 5 days is generally considered pathologic rather than a slowly healing event. Risk factors reported for PAL include reduced forced expiratory volume in 1 second, emphysema, prolonged steroid exposure, poor nutritional status (including low serum albumin and cholinesterase), pleural adhesions, male sex, and upper lobectomy/bilobectomy (6).

Reported incidence of postoperative stump BPF varies by procedure type and population, with higher risk after pneumonectomy than after lobectomy. Risk factors described across surgical series include residual tumor at the bronchial stump, right-sided pneumonectomy, perioperative infection or empyema, poor nutritional status, diabetes, immunosuppression (including steroid exposure), and neoadjuvant therapy. Mechanistically, stump ischemia or breakdown, devascularization, tension, and infection contribute to dehiscence; once a pleural space becomes contaminated, the resulting inflammation and necrosis can perpetuate a persistent communication (4,7-15).

In a recent large single-institution risk-factor analysis, Matsunaga et al. reported that among 4,794 consecutive patients undergoing anatomical pulmonary resection, BPF occurred in 32 patients (0.67%), with rates of 0.18% after segmentectomy, 0.54% after lobectomy, 2.56% after bilobectomy, and 4.19% after pneumonectomy. Multivariable predictors included male sex [odds ratio (OR) 6.91], body mass index (BMI) <22 kg/m² (OR 2.40), vital capacity (VC) <80% (OR 2.93), right lower lobectomy (OR 10.92), right middle and lower lobectomy (OR 6.97), right pneumonectomy (OR 16.68), and additional resection of surrounding organs (OR 3.47). The 90-day mortality after BPF was 15.6% and 5-year overall survival was 28.1%. These data support risk-stratified prevention and heightened attention to bronchial stump reinforcement in high-risk procedures (16).

Large database work from the French Epithor project also provides a risk-prediction perspective. In 34,000 major pulmonary resections, Pforr et al. reported 30-day BPF in 318 patients (0.94%) and developed a predictive score using sex, BMI, dyspnea score, comorbidity burden, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and side of resection, with internal discrimination (C-index) of 0.80 (17).

Diagnosis and localization

Clinical manifestations range from persistent air leak and failure of lung re-expansion to expectoration of pleural contents, recurrent pneumonia, and sepsis. Evaluation typically begins with pleural space assessment (e.g., chest tube output and air leak) and imaging. Computed tomography (CT) can demonstrate pneumothorax, pleural collections, stump abnormalities, and occasionally the fistulous tract. Rarely, CT bronchography has been described to improve visualization of the communicating airway. Nuclear medicine techniques (e.g., scintigraphy) have also been reported to detect post-pneumonectomy fistulae. Bronchoscopy allows for direct visualization, targeted dye/balloon occlusion maneuvers to localize the culprit airway, and delivery of endoscopic therapies (2,18-24).

Notably, a sudden decrease in pleural fluid on chest radiography is not always synonymous with bronchial stump dehiscence. Gunji et al. reported a benign emptying phenomenon after right lower lobectomy that radiographically mimicked BPF. However, further exploration showed that the bronchial stump was intact and there was no air leak on testing. The pleural fluid later reaccumulated on its own, without any fistula-directed intervention (25).

General multidisciplinary management principles

Immediate priorities include airway protection, adequate pleural drainage, prevention of contralateral aspiration, reduction of airway pressures when feasible, and control of pleural infection through drainage and targeted antimicrobial therapy. Recent real-world data support early nutritional and hematologic optimization during staged care (1,2,4,15,26-32).

Interventional therapy should be framed as definitive or bridge therapy. Definitive therapy is most plausible for small, accessible defects and for peripheral APF/PAL when airflow can be durably reduced. Bridge therapy is more common for large central stump BPF, infected pleural spaces, ongoing sepsis, malignant disease, or high operative risk. In these scenarios, endobronchial occlusion with valves, spigots, stents, coils, sealants may reduce airflow and aspiration while pleural source control, nutritional rehabilitation, and surgical planning proceed (1,2,4,15,29-32).

Open-window thoracostomy, negative-pressure wound therapy, and muscle or omental flap reinforcement are not competing alternatives to bronchoscopy; they are often complementary stages. A typical sequence for an infected central BPF is infection source control, reduction of airflow and aspiration risk, open-window thoracostomy or other pleural-space control when empyema or a fixed residual space persists, and later definitive closure or obliteration with vascularized tissue after further optimization (4,8,9,11,12,15,33-35).

Surgical management

Surgery remains the standard for many early or large central stump BPFs, especially in cases of acute post-resection dehiscence, failure of bronchoscopic measures, or pleural space infection that cannot be controlled with drainage alone. Surgical strategies include stump revision and re-closure, completion resection in selected cases, reinforcement with vascularized tissue (e.g., intercostal, serratus anterior, latissimus dorsi, or omental flaps), and procedures aimed at pleural space sterilization and obliteration. In chronic infected spaces, open-window thoracostomy (including the modified Eloesser flap) and staged closure techniques have been used (4,8,9,11,12,15,33,34).

Timing is crucial. Early postoperative stump dehiscence in an operable patient usually warrants urgent surgical evaluation because mechanical dehiscence and contamination may progress quickly. Late or chronic BPF often requires staged management, especially when empyema and severe malnutrition are present. Alternative surgical corridors (e.g., transsternal bronchial closure) have also been described for selected late or complex post-pneumonectomy fistulae where repeat thoracotomy is high risk (4,8,9,11,12,15,33,34).

In a 25-year, single-center experience of lobectomy for lung cancer, Mazzella et al. reported postoperative BPF in 44 of 5,150 patients (0.85%). Management was individualized and staged: 11 cases resolved with non-invasive treatment, direct stump repair achieved resolution in 9, completion intervention was performed in 14, and open-window thoracostomy was used in 6; two patients underwent injection of an n-butyl cyanoacrylate glue via percutaneous CT-guided approach. Thirty-day and 90-day mortality from fistula onset were 18.2% and 22.7%, respectively. This underscores the severity of post-lobectomy BPF and the need for flexible algorithms combining surgical and other interventional options (35).

In selected patients with delayed but large stump dehiscence in the absence of active pleural sepsis, innovative flap fixation techniques may expand operative options. Nakamura et al. described elective repair of complete bronchial stump dehiscence (~10 mm) after lobectomy with a pedicled latissimus dorsi flap and a “retrograde intrabronchial” suturing technique under bronchoscopic guidance to secure the flap to the stump from within the airway. Although this combined bronchoscopic and surgical approach seems promising for improving flap apposition when external exposure is limited, the available evidence remains limited to isolated case reports (36).

Yang et al. further emphasized that physiologic status at repair influences surgical success. In their 39-patient surgical repair series, overall repair success was 59% and mortality was 56.4%. Mechanical ventilation at the time of repair was associated with markedly lower success than repair without mechanical ventilation (15.4% vs. 80.8%) and remained significant on multivariable analysis, supporting ventilatory optimization and vascularized tissue coverage when feasible (37).

Bronchoscopic and other interventional therapies

Bronchoscopic interventions are important for patients who are poor surgical candidates, for peripheral APF/PAL after resection, and as bridge therapy that reduces airflow and pleural contamination while infection, nutrition, and surgical planning proceed. The choice of intervention should be guided by fistula phenotype, defect size, pleural space status, collateral ventilation, and the patient’s physiologic reserve. The strength of evidence varies substantially across modalities and should not be interpreted uniformly: valves have pooled observational data for PAL, whereas sealants, stents, occluders, spigots, coils, and biologic strategies often rely on retrospective series or case reports (1,31,38-40).

Sealants, glues, and chemical sclerosis

For small-to-moderate fistulae, particularly when the tract is accessible bronchoscopically and the pleural space is clean or controlled, clinicians have reported closure using topical sealants or chemical sclerosis of the mucosa around the fistula. Techniques include placement of absorbable materials (e.g., oxidized regenerated cellulose), application of tissue adhesives (including cyanoacrylates), and use of adjunctive balloon catheters for localization and temporary occlusion. Chemical ablation/sclerosis with agents such as polidocanol, tetracycline, or absolute ethanol has also been described; these methods aim to induce local inflammation, granulation, and fibrosis that progressively seal the defect. Because over-injection can enlarge the defect or cause necrosis, careful dosing and delivery are crucial (40-47).

The evidence supporting sealants and sclerosing agents consists mainly of case reports and small series. These techniques may be definitive in selected small, clean defects, but in infected spaces or larger central stump dehiscence they should generally be viewed as adjunctive or bridge measures rather than stand-alone definitive therapy.

In practice, sealant-based approaches may be less durable in central bronchi than in peripheral airways because the proximal airway wall is relatively rigid and high airflow and secretions can dislodge material. Even when immediate sealing is achieved, late migration and the need for repeat instillation have been reported, limiting applicability to a subset of small, accessible defects (28).

Fibrin glue is comprised of two main components, fibrinogen and thrombin, which form a fibrin clot when mixed. It can be delivered through the bronchoscope working channel using a catheter (preferably a dual-lumen system that injects both components simultaneously). Once instilled, the sealant typically solidifies within minutes to form an occlusive plug. It may expand over the following 24 hours, helping to further seal the airway, and is then gradually resorbed (28).

Several technical precautions are emphasized in published experience. Suctioning should be avoided while liquid sealant is present, because aspirating glue or sealant into the bronchoscope working channel can lead to hardening and irreversible damage. The injection catheter tip should be advanced far enough beyond the bronchoscope to prevent contact of sealant with the scope, it is important to avoid catheter kinking or forceful injection to minimize the risk of catheter tearing and leakage into the working channel (28).

A wide variety of other sealants and adhesives have been described, but prospective studies comparing efficacy and safety are lacking. Cyanoacrylate-based glues rapidly polymerize on contact with tissue/body fluids and have been used for endobronchial closure in selected postoperative cases. Albumin-derived surgical adhesives (e.g., BioGlue) have primarily been applied intraoperatively to reinforce or cover bronchial stump dehiscence or staple-line disruptions, with only isolated reports of endoscopic administration. Synthetic polyethylene glycol (PEG) sealants (e.g., FocalSeal-L) and photopolymerized sealants activated by visible light have also been reported for small bronchial stump defects. Absorbable materials such as oxidized regenerated cellulose (Surgicel) can be placed bronchoscopically to mechanically occlude the defect and promote fibrinogenesis; in one report, Surgicel was packed into a central BPF with temporary support from a Fogarty balloon, which was removed 48 hours later after successful closure (28,42,45).

Bronchoscopic autologous blood patching has also been reported for refractory APF/PAL. Wiaterek et al. described oxidized regenerated cellulose followed by 3 mL autologous blood via a modified Fogarty catheter, with immediate air-leak cessation and chest tube removal two days later, representing isolated feasibility evidence (48).

In reports of central BPFs visible by bronchoscopy, submucosal absolute ethanol injection has been used to close fistulas. One early report described successful closure of five consecutive BPFs without complications, and a more recent report similarly describes ethanol-based endoscopic closure while emphasizing the need for caution because of potential tissue injury (41,46).

Endobronchial chemical cauterization has also been used as part of conservative-endoscopic protocols. In one postoperative series, sequential bronchoscopic silver nitrate application was associated with closure in most patients, suggesting a potential option for selected postoperative BPFs when the fistulous opening can be directly treated endoscopically (49).

Other endoscopic occlusion materials have been reported, including bronchoscopic placement of polyglycolic acid mesh as part of postoperative fistula closure strategies (50).

Recently, Duong and colleagues described a bronchoscopic technique using a customized bone plug as an occlusive scaffold for postoperative BPF following lung resection. In their case series of six patients who underwent resection for non-small cell lung cancer, initial air-leak resolution occurred in all patients; however, recurrence within two months was reported in two cases and two patients ultimately required additional surgical repair, suggesting a potential role as a bridge or adjunct in selected high-risk patients, particularly when pleural infection is present (51).

Kooranifar and colleagues reported six adults with intubation-related BPF treated bronchoscopically using argon plasma coagulation (APC) to prepare the tract, followed by fibrin glue instillation. Five patients achieved complete closure; in most responders the air leak ceased within 1–3 days and no recurrence was noted during 3-month follow-up. One death occurred which was not related to the intervention. This combined “thermal preparation + sealant” strategy may be a practical option for selected tracts when surgery is not feasible (52).

One-way endobronchial valves (EBVs)

EBVs have been studied in postoperative patients, particularly for PAL after lung resection, but the strongest pooled efficacy data come from heterogeneous PAL cohorts. Accordingly, valve outcomes are most directly applicable to postoperative PAL from peripheral APF-type leaks, whereas evidence for true central postoperative stump BPF remains limited.

In pooled observational cohorts (2,472 patients), EBV therapy achieved closure in approximately 82% of cases (95% confidence interval 75–88%; prediction interval 64–92%). However, these outcomes largely reflect peripheral air leaks rather than true central bronchial stump fistulae. Complication reporting was inconsistent among studies, although the available data suggested a complication rate of approximately 9%. The most common complications were granulation tissue formation, valve migration or expectoration, and hypoxemia (53).

Target selection and assessment of collateral ventilation can influence valve outcomes. Omballi et al. described Chartis-guided collateral ventilation assessment as an adjunct to balloon occlusion for identifying the target lobe or segment, but the small sample size limits generalizability. Practical planning therefore combines CT-based fissure assessment, bronchoscopic balloon occlusion, and physiologic judgment rather than relying on a single test (54,55).

Commercial systems commonly discussed for PAL include the Spiration and Zephyr valves (Figure 1). Valves are placed through a flexible bronchoscope via a working-channel delivery system and can be removed after leak resolution (56,57). These one-way valves were initially designed for bronchoscopic lung volume reduction in severe emphysema (58). They were later adopted for PAL, where they allow egress of air and secretions from distal lung units while limiting inspiratory flow into the treated segment, thereby reducing flow through the fistula and allowing closure over time (59,60).

Figure 1 Representative bronchoscopic and chest CT appearances of two commercial endobronchial one-way valve systems used for persistent air leak. (A) Bronchoscopic view of a Spiration valve. (B) Corresponding chest CT image demonstrating the Spiration valve in situ. (C) Bronchoscopic view of a Zephyr valve. (D) Corresponding chest CT image demonstrating the Zephyr valve in situ. CT, computed tomography.

A nationwide database analysis has examined national trends and outcomes of intrabronchial valve implantation for PAL. More recently, a literature review and expert panel recommendations summarized multiple studies with resolution reported within days to weeks in many cases and emphasized patient selection and procedural technique (59,61).

Case series from different regions continue to add real-world outcomes, including reported success in high-risk populations and in patients with emphysema-associated PAL. These series reinforce that valve therapy is often used in patients with poor surgical candidacy (39,56,57,60).

In a single-center cohort from Shanghai Pulmonary Hospital involving 26 patients treated with endobronchial one-way valves (14 postoperative BPF; others due to pneumothorax or mycobacterial disease), Song et al. reported an overall effectiveness rate of 73.1%. Among patients with chest tubes, the median time to chest tube removal was 7 days (range, 2–90 days) after valve placement, following a prolonged pre-valve drainage duration in many cases. There were no reports of complications in patients who did not have their valves removed at follow-up (62).

In a brief report from a resource-limited county hospital, Liang et al. described six consecutive Spiration EBV placements for PAL, predominantly patients with chronic lung disease complicated by secondary spontaneous pneumothorax. Chest tube drainage had been present for a mean of 29.4 days before EBV placement; after valve deployment, the mean time to chest tube removal was 4.5 days (range, 1–7 days) and the mean time to hospital discharge was 8.2 days. Five of six patients had chest tubes removed before discharge, and the remaining patient was discharged with a Heimlich valve followed by outpatient follow up and removal. While limited by small sample size and single-operator experience, this series highlights the potential for earlier bronchoscopic referral to shorten prolonged drainage courses in high-risk patients (63).

Larger institutional experience is also emerging. Tung et al. reported a retrospective cohort of 67 bronchial valve placements, including 49 cases after lung resection and 18 cases from other etiologies (spontaneous and iatrogenic pneumothorax, BPF, pleural malignancy and exploratory thoracotomy). Air-leak resolution was ≥95% in most indication groups (80% in spontaneous pneumothorax), only 7% of patients underwent pleurodesis after valve placement, and 61% were discharged with a chest tube. The 90-day all-cause mortality rate was 9%. In the post-resection cohort, the median time to bronchoscopic valve intervention was 7 days and chest tube discontinuation occurred approximately 9–10 days after valve placement depending on operative approach. These findings support valves as a well-tolerated adjunct that can facilitate discharge and outpatient leak management, while underscoring the need for prospective comparative studies and standardized endpoints (64).

Emerging procedural platforms may help deliver therapy to difficult-to-reach targets. In a lung transplant recipient with a postoperative BPF refractory to chest tube management, Wadiwala et al. reported robotic-assisted bronchoscopy to access the culprit bronchial segment followed by instillation of endobronchial sealant and EBV deployment with a conventional bronchoscope; the pneumothorax resolved within 12 days, and no recurrence was reported at follow-up (65).

Airway stents and customized occluding stents

Airway stenting can provide immediate mechanical occlusion of central airway defects and is most often a bridge strategy for large or complex central BPFs, particularly when infection control, nutritional optimization, or definitive reconstruction must be staged. In selected malignant or non-operative settings it may provide durable palliation or closure, but risks include mucus impaction, migration, granulation tissue formation, infection, and rare erosion or bleeding. Stents must be used cautiously in benign disease because prolonged dwell time increases complication risk and removal can be challenging, particularly for metallic devices (1,66-68).

Stents intended to bridge a BPF typically include an occlusive covering to prevent air and secretion seepage through the defect. Commonly used devices include silicone stents (e.g., Dumon), hybrid stents (e.g., Aero), and covered self-expanding metallic stents (e.g., Ultraflex or Silmet). More recently, anatomically contoured carinal devices such as the covered nitinol J-Carina stent (aerstent TBJ) have been developed to span defects involving the carina and can be delivered via a reloadable system with the option for repositioning. Uncovered metallic stents do not physically occlude a fistula because of the open mesh but may facilitate delayed closure through local inflammatory response; because these stents can embed quickly, early removal is generally recommended when feasible (28).

Specialized occluding stents with a ‘blind pouch’ distal end have been reported for large postoperative defects to eliminate direct airway-pleural communication, but these devices are often custom-made and not widely available. Advances in patient-specific design and three-dimensional (3D) manufacturing have enabled customized stent fabrication for complex airway disease and may have future applications in fistula management (68,69).

Stenting may be particularly useful as part of multimodal palliation in malignant settings or when multiple fistulous sites coexist. Jimu et al. reported a patient who developed multiple postoperative BPFs after right lower lobectomy for lung cancer with subsequent recurrence and metastasis. Management combined control of infection and targeted deployment of bronchial stents while undergoing oncologic treatments; the fistulas resolved and the patient achieved a complete oncologic response with progression-free survival exceeding three years. Although anecdotal, this case illustrates how airway stents can function as a bridge strategy that stabilizes the airway-pleural interface while definitive oncologic and supportive therapies take effect (70).

Cardiac occluder devices (e.g., Amplatzer)

Cardiac occluder devices (most commonly Amplatzer-derived designs) were developed for structural heart defect closure and have been used off-label to close BPFs. These devices consist of self-expanding nitinol discs connected by a waist that centers within the defect. Under bronchoscopic and/or fluoroscopic guidance, the device is deployed via a catheter; position can often be adjusted before release. Occluding devices are most appropriate for larger central defects where anchoring is feasible; successful outcomes depend on precise sizing, stable deployment, and adequate control of pleural infection (71-74).

Published Amplatzer/occluder series report successful closure in selected patients, including large or central defects, with follow-up extending beyond one year in some series. However, the available evidence consists largely of case reports and small retrospective series. These devices may function as definitive therapy in selected high-risk patients, but in infected or unstable patients they are often best considered a bridge to pleural-space control and later reconstruction (39,71,72,74,75).

In a single-center retrospective case series of 10 patients with postoperative BPF after lobectomy or pneumonectomy, Bai et al. reported flexible bronchoscopic deployment of a VSD occluder with technical success rate of 100% and a 70% complete closure rate over a median of 115 days, without device-related complications (76).

Motus et al. described a retrospective series of 13 patients with BPF after pneumonectomy treated with an Amplatzer atrial septal defect occluder. Three patients experienced device displacement: one required repositioning, another needed muscle coverage, and one died after the device became dislodged during a severe tuberculosis exacerbation. The remaining 10 patients had an uneventful recovery. Overall, these findings suggest the approach is feasible, while also underscoring the importance of controlling pleural infection and securing the device properly (77).

More recently, Rim et al. described a “precision” endoscopic approach for closing postsurgical BPFs in three patients. Using flexible bronchoscopy with fluoroscopic guidance, they placed Amplatzer vascular plugs (AVP), choosing AVP II for defects larger than 6 mm and AVP IV for defects smaller than 6 mm. This report again underscores the importance of precise sizing to avoid displacement (78).

Technical adaptations may broaden the feasibility of occluder deployment with flexible bronchoscopy. Goel et al. described closure of a large BPF using an Amplatzer ventricular septal defect (VSD) occluder, employing a snare passed through the bronchoscope working channel to grasp and align the device parallel to the scope for controlled delivery into the fistula. Such technique-focused reports provide pragmatic guidance for centers without routine rigid bronchoscopy, but underscore the need for meticulous sizing, secure anchoring, and close follow-up to minimize dislodgement and obstruction (79).

Based on the authors’ experience, selection between a VSD and an atrial septal defect (ASD) occluder is principally guided by the thickness of the fistula wall. In fistulas with a thicker wall, a VSD occluder is generally favored, owing to its original design specifications for the interventricular septum, which is anatomically thicker than the interatrial septum. This same structural attribute, however, renders the VSD device less effective at achieving a complete seal compared with the ASD occluder, which is engineered for the thinner interatrial septum and consequently conforms more closely to thin-walled defects. Device selection therefore reflects a trade-off between anchoring stability in thick-walled fistulas and the quality of mucosal apposition and seal in thinner ones.

Although much of the published literature describes deployment via flexible bronchoscopy, in the authors’ experience these devices may also be deployed under direct visualization using rigid bronchoscopy, which affords superior airway control and procedural precision (Figure 2). In this technique, the occluder is first unsheathed outside the airway. One disc of the device is subsequently engaged with rigid forceps and advanced into the fistula under direct visualization, such that one disc is positioned on either side of the defect. Following confirmation of satisfactory deployment, the engaged disc is released and the rigid forceps are withdrawn.

Figure 2 Endoscopic and radiologic appearance of a postpneumonectomy bronchopleural fistula before, during, and after closure with an ASD occluder. (A) Bronchoscopic view of the bronchial stump demonstrating dehiscence of the bronchial stump following pneumonectomy, with a well-demarcated bronchopleural fistula visible in the airway wall. (B) Bronchoscopic view immediately following deployment of an ASD occluder device across the fistula, demonstrating the nitinol mesh disc seated within the defect with apposition to the surrounding bronchial mucosa. (C) Intraprocedural view obtained through a rigid bronchoscope demonstrating deployment of the ASD occluder under direct visualization, providing enhanced airway control and accurate device positioning across the fistula. (D) Postprocedural axial CT image demonstrating the deployed ASD occluder in situ. ASD, atrial septal defect; CT, computed tomography.

Adjunctive 3D printing may assist with sizing and localization for peripheral fistula occlusion. In a retrospective series of 13 patients treated between 2023 and 2024, Li et al. used patient-specific 3D-printed models to plan occlusion of 19 peripheral fistulas, with Amplatzer II-type occluders used in 15 fistulas (78.9%) and coils in 4 fistulas (21.1%). Technical success was 100% and clinical success was 92.3%, with closure or effective drainage enabling chest tube removal in 12 of 13 patients and improvements in inflammatory and performance status measures in one month. Although single center, these data support a role for preprocedural anatomic modeling in complex peripheral BPFs where conventional bronchoscopic localization and sizing are challenging (80).

Endobronchial Watanabe spigots (EWSs)

EWS are silicone bronchial plugs designed for bronchial occlusion. They are most applicable to segmental or subsegmental PAL/APF sources and can be definitive in selected peripheral leaks or may serve as a bridge. Migration/dislocation and post-obstructive pneumonia remain important limitations.

The use of silicone spigots for intractable pneumothorax with ongoing air leak has shown good performance in small series, while highlighting the importance of adequate sizing and the risk of migration and post-obstructive pneumonia. In a retrospective study of cancer-related pneumothorax treated with EWSs, 26 cases were evaluated and chest tubes were successfully removed in 19 (73.1%), while 7 (26.9%) required surgical management. These findings suggest that spigots can work well for selected patients with refractory leaks, but they may be less effective in advanced disease, highlighting the need for careful patient selection and close follow-up (81).

Additional data from a Japanese single-center retrospective study of 20 patients undergoing endobronchial spigot placement (27 procedures) for refractory pneumothorax, postoperative fistula and hemoptysis showed clinical improvement in 75% of patients, including 1 of 2 patients with postoperative fistula. Procedure-related complications included spigot migration (3 patients) and mediastinal/intra-abdominal emphysema (1 patient) (82).

EWS has also been deployed early in infected pleural space disease when controlling the air leak is necessary for source control. In a small case series of three frail patients with acute empyema and PAL due to BPF, Yokota et al. placed Watanabe spigots after pleural drainage and antimicrobial therapy alone did not stop bubbling. Following occlusion, there was complete resolution of air leak within approximately one to four weeks (6–26 days), without reported device migration or device-related infection (83).

Endobronchial embolization and coil-based occlusion

For peripheral fistulae, endobronchial embolization strategies have been used to occlude the responsible airway and reduce airflow through the pleural defect. Approaches include deployment of vascular occlusion coils (e.g., Gianturco-type) sometimes combined with cyanoacrylate sealant to promote closure. A 2024 systematic review of postoperative BPF treated with embolization coils found an overall closure rate of about 80%. The best outcomes were seen in smaller defects, often less than 3 mm in the included cases, and coil migration was among the reported complications (42,44,84).

Recent experience suggests that detailed anatomic planning may also support coil-based occlusion in selected peripheral leaks. In the 3D printing-assisted series by Li et al., coils were used in 4 of 19 occluded fistulas (21.1%), and all targeted fistulas were managed in a single session as part of an overall clinical success rate of 92.3% (80).

Pleural-directed interventional negative pressure drainage

Some patients with peripheral postoperative BPF have been treated using pleural-directed interventional techniques. CT-guided or fluoroscopy-guided placement of specialized drainage catheters with controlled negative pressure to promote closure has been described in retrospective series. This approach may be considered when a peripheral fistula is difficult to access endobronchially or when bronchoscopic occlusion is ineffective (85).

Experimental and emerging approaches

Mesenchymal stem cell (MSC) delivery has been proposed to promote fibroblast proliferation and collagen deposition; Petrella et al. published an early proof-of-concept case in which stem-cell infusion was followed by closure of an airway fistula. Beyond biologics, several groups anticipate a growing role for customized devices, particularly with 3D modeling and printing, to support pre-procedural sizing, positioning, and design of patient-specific stents or occluders in challenging cases (40,69,80,86).

Beyond MSC strategies, autologous biologic products have been proposed to augment healing. Liu et al. reported bronchoscopic-assisted instillation of autologous frozen platelet-rich plasma combined with digital chest drainage to treat a large postoperative BPF (20 mm × 10 mm) after lobectomy, achieving fistula healing and reduction of the residual pleural cavity in a case report. This approach is promising, but the evidence is still limited to a small number of isolated reports (87).

Comparative outcomes, real-world evidence, and evidence hierarchy

For PAL/APF, bronchial valves have the strongest pooled interventional evidence, but the data still come from heterogeneous observational studies rather than randomized trials. For coils, a postoperative systematic review suggests useful closure rates in small peripheral fistulas. For sealants, chemical sclerosis, customized stents, occluders, spigots, and biologics, the literature is dominated by retrospective cohorts, small series, and case reports (53,84).

Contemporary multicenter real-world studies provide important context beyond device-specific reports. In the ESSG-01 retrospective multi-institutional study of 81 postoperative BPF patients, endoscopic interventions were performed in 29.6% of patients, and cure with endoscopic treatment alone was achieved in 20.8% of those treated endoscopically. Surgery for BPF was performed in 85.2% of patients; open-window thoracostomy was the most frequent procedure. Among patients undergoing open-window thoracostomy, window closure was achieved in 53.1% (26/49), with reported closure success of approximately 83% using muscle flaps and 100% using omental flap closure. Overall, BPF cure was 53.1%, non-cure was 46.9%, and mortality during follow-up was 58.0%; low albumin and low hemoglobin at BPF onset were significant non-cure factors (88).

A more recent multicenter post-pneumonectomy BPF analysis also reinforces the prognostic role of systemic condition at diagnosis: in 33 patients, mortality during follow-up was 27.3%, and inflammatory/nutritional indices such as neutrophil-to-lymphocyte ratio and C-reactive protein/albumin ratio were associated with mortality risk. These findings support additional attention to infection burden, inflammation, anemia, and nutrition when planning interventional or surgical treatment (89).

The literature on BPF management remains heterogeneous. Few studies directly compare interventions, and reporting of fistula size, pleural space status, and follow-up is inconsistent. Nonetheless, some comparative data exist. In a postoperative cohort (n=92), Wang et al. reported significantly higher 28-day and 90-day survival with interventional therapy compared with conservative management (76.9% vs. 43.4% and 66.7% vs. 35.9%, respectively), and conservative therapy was independently associated with 90-day mortality [hazard ratio (HR) 2.91]. Conversely, selected postoperative series demonstrate that conservative or minimally invasive approaches, including repeated endoscopic chemical cauterization, can achieve closure in many cases when defects are small and pleural sepsis is controlled (2,8,32,49,90).

Valve success rates reported in PAL cohorts should not be interpreted as equivalent evidence for complete post-pneumonectomy bronchial stump dehiscence. Similarly, successful occluder or sealant case reports demonstrate feasibility, but their generalizability depends on defect size, tissue-margin quality, pleural infection control, and operator expertise. Contemporary reviews consistently emphasize early identification, pleural space management, and matching the closure strategy to defect anatomy and patient operability (1,11,15,31,91).

Practical framework for selecting therapy

A practical framework for treatment selection is summarized in Table 2. The first decision is not the device, but the phenotype and physiologic context: central bronchial stump BPF versus peripheral APF/PAL, clean versus infected pleural space, stable versus unstable patient, and operable versus inoperable status. In central stump dehiscence with sepsis or a residual infected pleural space, early thoracic surgical involvement and pleural source control are critical; bronchoscopic techniques may reduce airflow and aspiration while the patient is optimized. In peripheral APF/PAL, target localization and collateral ventilation assessment guide valve, spigot, coil, sealant, pleurodesis, or pleural-directed intervention selection (1,2,11,15,31,35,55,88,90,91). The major intervention categories, typical roles, and evidence considerations are summarized in Table 3.

Strengths and limitations

Strengths of this review include a practical, anatomy-driven description of established and emerging interventional options, integration of bronchoscopic, surgical, and pleural-space management considerations, and inclusion of recent case series, systematic reviews, and multicenter real-world studies. Limitations include the narrative design, reliance on heterogeneous retrospective studies and case reports, lack of formal risk-of-bias assessment, and absence of quantitative pooling across interventions; therefore, conclusions should be interpreted as a practical framework rather than as comparative efficacy guidance.

Conclusions

Postoperative BPF remains an infrequent but serious complication after anatomical lung resection that carries high morbidity and mortality. Early recognition, pleural space drainage and infection control, nutritional optimization, ventilatory strategies to reduce flow across the defect, and accurate localization are essential prerequisites for durable closure. Risk stratification should also incorporate procedure- and patient-level factors such as right lower lobectomy, right middle-lower bilobectomy, right pneumonectomy, additional organ resection, male sex, low BMI, and reduced VC. Surgery is often required for early stump dehiscence or large central defects, while bronchoscopic/interventional approaches provide effective alternatives or bridges in selected high-risk patients. Growing pooled evidence supports bronchial valve therapy for PAL in APF, whereas stents, sealants, spigots, coils, and other occluders remain more anatomy-dependent and are supported by lower-level evidence. Contemporary multicenter data highlight the importance of multimodal management and systemic optimization. Standardized reporting, prospective registries, and multidisciplinary algorithms are needed to refine patient selection and optimize durable closure.

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-2026-1312/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1312/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1312/coif). The series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” was commissioned by the editorial office without any funding or sponsorship. E.E.F.V. reports grants from Zidan, Cook, Intuitive Surgical, and Medtronic; consulting fees and honoraria from Intuitive Surgical; payment for expert testimony from Expert Witness; participation on a Data Safety Monitoring Board or Advisory Board for Johnson & Johnson; and leadership or fiduciary role in World Robotic Bronchoscopy. 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. Written informed consent for publication of the clinical images could not be obtained despite all possible attempts. The images are original, fully de-identified, and contain no patient-identifying information. The authors confirm that applicable requirements for patient privacy and confidentiality were met.

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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