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Ann Thorac Surg 1995;60:1812-1814
© 1995 The Society of Thoracic Surgeons

Case Report

Diagnosis of Postpneumonectomy Bronchopleural Fistula Using Ventilation Scintigraphy

Frank A. Pigula, MD, Robert J. Keenan, MD, Keith S. Naunheim, MD, Peter F. Ferson, MD, Rodney J. Landreneau, MD

Section of Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

Accepted for publication June 20, 1995.


   Abstract
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Occult bronchopleural fistulas are frequently present when empyemas develop in a postpneumonectomy space. Recognition of the bronchial stump disruption can be difficult, which may lead to delays or errors in the management of these difficult problems. We report the use of xenon ventilation nuclear scintigraphy as an effective noninvasive means of confirming the diagnosis of occult postpneumonectomy bronchopleural fistulas.


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The postoperative development of a bronchopleural fistula is a serious complication of pneumonectomy. The diagnosis of an early postpneumonectomy bronchopleural fistula can be obvious with the development of acute cough, aspiration of the serosanguineous contents of the pleural space into the contralateral lung, progressive subcutaneous emphysema, and respiratory distress.

On the other hand, delayed or less extensive bronchial disruptions after pneumonectomy can present diagnostic problems. These conditions frequently manifest as a postpneumonectomy space infection with an associated fall in the fluid level in the pleural cavity or a new fluid ``meniscus sign'' at the level of the bronchial stump on chest roentgenography.

Unfortunately, the diagnosis often remains in question despite the use of invasive endoscopic studies. We report the successful use of noninvasive xenon-133 ventilation scintigraphy to unequivocally demonstrate an occult bronchopleural fistula in a patient in whom an empyema developed 1 month after right pneumonectomy.

A 48-year-old man underwent right pneumonectomy for stage II squamous cell cancer of the right lung. His early postoperative course was unremarkable. One month after discharge the patient was readmitted to evaluate a complex right pleural space process, consistent with postpneumonectomy empyema. Thoracentesis demonstrated an exudative process from which Peptostreptococcus was cultured. Fiberoptic bronchoscopy and thoracoscopic exploration revealed an apparently well healed bronchial stump. Continuous inflow-outflow irrigation with penicillin (modified Clagett procedure) of the pleural cavity was established. Two weeks of irrigation cleared the organism, but cultures now showed Klebsiella. The antibiotic regimen was adjusted, and the irrigation treatment was continued for an additional 2 weeks. Repeat cultures (x2) after 1 month of irrigation therapy were sterile. The chest was filled with antibiotic solution and the tube thoracostomy wounds were closed. The patient returned 1 week after discharge with complaints of persistent cough. Chest roentgenography revealed the persistence of an apical pleural space (Fig 1Go). Repeat bronchoscopy was again unrewarding. At this point, ventilation scintigraphy was performed as a means ofidentifying any occult bronchial communication with the right pleural space. This study revealed the presence of radioactivity in the right pleural space, confirming the presence of a bronchopleural fistula (Figs 2, 3GoGo). With this information, the patient underwent an open drainage procedure (``Clagett window''). He did well postoperatively and was discharged home 5 days later.



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  		Fig 1. . Chest roentgenogram demonstrating air fluid level in right postpneumonectomy space.

 


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  		Fig 2. . Ventilation scan demonstrating equilibration of radioactive xenon gas in the postpneumonectomy space through an endoscopically occult bronchopleural fistula (posterior view).

 


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  		Fig 3. . Perfusion scan demonstrating the expected absence of radioactivity in the right postpneumonectomy space.

 

   Comment
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Various techniques can be used to demonstrate the presence of a postpneumonectomy bronchopleural fistula. Bronchoscopic examination of the airway should be considered early and usually reveals any significant bronchial dehiscence. Instillation of methylene blue into the pleural cavity and appearance in the sputum can also be diagnostic, as is the appearance of the dye in pleural fluid after endobronchial injection. This, however, necessitates violation of the pleural cavity and the potential contamination of an innocent, sterile space. Bronchography has been used, but this intervention carries the risk of contrast pneumonitis in the remaining lung.

Postpneumonectomy empyema occurs in 2% to 12% of patients. Approximately 40% of patients have an associated bronchopleural fistula, and only about 20% of these fistulas can be expected to close spontaneously [1]. The initial management of a postpneumonectomy empyema space is chest tube drainage and antibiotic therapy until stabilization of the mediastinum is documented. The treatment options diverge from this point depending on the presence or absence of an associated bronchopleural fistula. Empyema patients without bronchopleural fistula are candidates for an attempt at sterilization of the pleural space and wound closure using the modified Clagett procedure [2]. Success with this procedure has been reported in the range of 50% of patients without bronchopleural fistula. If the modified Clagett procedure fails, conversion to a chronic open drainage situation (Eloesser flap) with or without subsequent delayed muscle flap coverage of the fistula and obliteration of the postpneumonectomy space is indicated [3]. If a bronchopleural fistula is documented, open management of the empyema space is indicated once the mediastinum is stable.

There have been few reports in the literature advocating the use of ventilation scintigraphy for the diagnosis of postpneumonectomy bronchopleural fistula. Neilsen and associates [4] have suggested this method to localize the site of persistent air leak in postthoracotomy patients. Moote and colleagues [5] used ventilation lung scanning to image a postpneumonectomy bronchopleural fistula. We believe it is also important to report this diagnostic maneuver in the surgical literature. Because of the safety and convenience of ventilation scintigraphy, thoracic surgeons should consider this diagnostic modality early in the work-up of pneumonectomy patients in whom they fear the presence of a bronchopleural fistula.


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Address reprint requests to Dr Landreneau, General Thoracic Surgery, University of Pittsburgh, Suite 300, Liliane Kaufmann Building, 3459 Fifth Ave, Pittsburgh, PA 15213.


   References
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 References
 

  1. Shields TW, ed. General thoracic surgery. 4th ed. Baltimore: Williams and Wilkins, 1994:694--700.
  2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963;45:141–5.[Medline]
  3. Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher CR Jr. Single-stage complete muscle flap closure of the post pneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31.[Abstract]
  4. Neilsen K, Blake LM, Mark J. Localization of bronchopleural fistula using ventilation scintigraphy. J Nucl Med 1994;35:867–9.[Abstract/Free Full Text]
  5. Moote D, Ehrlich L, Martin RH. Postpneumonectomy bronchopleural fistula imaged by ventilation lung scanning. Clin Nucl Med 1987;12:337–8.[Medline]



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This Article
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Right arrow Author home page(s):
Frank A. Pigula
Robert J. Keenan
Keith S. Naunheim
Peter F. Ferson
Rodney J. Landreneau
Right arrow Permission Requests
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Right arrow PubMed Citation
Right arrow Articles by Pigula, F. A.
Right arrow Articles by Landreneau, R. J.

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