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Ann Thorac Surg 1997;64:230-233
© 1997 The Society of Thoracic Surgeons

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Case Report

Closure of a Bronchopleural Fistula Using Decalcified Human Spongiosa and a Fibrin Sealant

Feather River Hospital, Paradise, California

Accepted for publication February 10, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Bronchopleural fistulas associated with empyema can occur as a life-threatening sequelae after pulmonary resection, most frequently occurring after pneumonectomy. With the use of the flexible bronchoscope, the bronchopleural fistula of a 62-year-old critically ill woman was permanently sealed with a fibrin sealant and a small section of demineralized human spongiosa. Closure of bronchopleural fistulas with the application of fibrin sealant plus human spongiosa may offer a valuable addition to the armament of therapeutic alternatives.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Bronchopleural fistulas may result as a severe postoperative complication after pulmonary resection [1–3]. Although rare after lobectomy (1% to 5%), the incidence of fistula formation after pneumonectomy is 5% to 15% [4]. Complicated by empyema, bronchopleural fistulas are deleterious because they are often life threatening [5, 6]. Although bronchopleural fistulas may seal with tube thoracostomy and antibiotic pleural irrigation, or operative closure, bronchoscopy using a fibrin sealant is possible and therefore has been recommended as first-line therapy [7].

Over the past decade, the use of a two-component fibrin sealant has been investigated through various means of application for closure of bronchopleural fistulas [1, 7, 8]. Although found to be useful in fistulas smaller than 3 mm, fibrin sealant alone has not been effective in occluding larger fistulas [9]. This report describes the successful closure of a 5-mm bronchopleural fistula with empyema using demineralized human donor spongiosa and a fibrin sealant applied through a flexible bronchoscope.

A 62-year-old woman was diagnosed with bronchogenic adenocarcinoma after a transthoracic needle aspirate biopsy. On an emergent basis, the patient underwent a right pneumonectomy that required a second operation because of bleeding at the surgical stump 4 days after the initial operation. Bronchoscopy at this time did not reveal any endobronchial lesions. Progressive weakness, cachexia, and syncopal episodes developed, which led to readmission approximately 3 months after surgical stump repair. On the eve of admission, the patient underwent immediate thoracentesis and exploratory bronchoscopy. These procedures identified a 5-mm bronchopleural fistula (Fig 1) associated with a gross purulent empyema infecting the right pleural space. The surgical stump was located approximately 1 cm from the main carina.

View larger version (82K): [in this window] [in a new window]   Fig 1. . Five-millimeter bronchopleural fistula.

One month later, the patient was discharged home at her request with intrapleural antibiotic irrigation continued on an outpatient basis. The patient was readmitted 2 weeks later due to anorexia, deterioration of physical state, and aspiration of the antibiotic irrigant into the left lung. Repeat bronchoscopy did not reveal any further signs of healing and the fistula persisted at 5 mm in diameter. Intrapleural antibiotic irrigation solutions in addition to the intravenous antibiotics were maintained. Consent was acquired from the patient, the hospital's Institutional Review Board, and the Food and Drug Administration to proceed with the bronchoscopic application of a two-component fibrin sealant, which we had acquired from Immuno Clinical Research. The fibrin glue was applied directly to the fistula using a modified French Edwards Swan-Ganz catheter, the distal end of which was cut at the 30-cm reference mark, providing a "two-catheter system." After several attempts, the fibrin plug was consistently expectorated within 24 hours after the procedure. The addition of various carriers did not prove beneficial in maintaining the plug within the fistula, which was confirmed by bronchoscopy after each occurrence.

Consent was subsequently obtained from the patient, and the procedure approved by the Institutional Review Board, Food and Drug Administration, and the hospital's Ethics Committee, to use demineralized human donor spongiosa in conjunction with fibrin sealant. The demineralized bone was prepared from a commercially available cortical cancellous strut of bone measuring 12 mm by 10 cm. The strut of bone was placed into a 10% hydrochloric acid and ethylenediaminetetraacetic acid solution for 36 hours until the desired flexibility was obtained. The preparation was then washed in bacteriostatic normal saline solution and transferred to a sterilizing solution of 0.05% glutaraldehyde for cross-linking and stabilization of the spongiosa. After several washings in bacteriostatic normal saline solution, the spongiosa separated from the cancellous bone. The spongiosa was easily cut into sections slightly larger then the size of the fistula opening. As the spongiosa dried, it was compressed into a "spindle-fiber" type formation for easy insertion into the lumen of the fistula. When wetted, the compressed bone returned to its original configuration (memory effect), lodging itself snugly within the fistula. The fibrin sealant was applied to the fistula before and after the bone fragment was inserted. Placement of the bone material was achieved with the use of 20C forceps. One end of the bone fragment was grasped with the forceps positioned beyond the end of the fiberoptic bronchoscope, and the fragment was then dragged through the endotracheal tube to the site of the bronchopleural fistula. Under direct visualization, the bone fragment was packed within the fistula and released (Fig 2). Rapid application was necessary so the compressed bone did not prematurely return to its original configuration before proper placement.

View larger version (90K): [in this window] [in a new window]   Fig 2. . Spongiosa and fibrin plug.

	Comment

Top Footnotes Abstract Introduction Comment References

 
The applicability of rigid and flexible bronchoscopes in the abatement of bronchopleural fistulas has been well documented in the medical literature [1, 2, 5, 7, 8, 10, 11]. The flexible bronchoscope is more advantageous, providing superior and precise access to a greater portion of the bronchial tree than does the rigid scope [1]. Fistulas measuring less than 3 mm have been closed using fibrin sealant alone [9]. Fistulas more than 3 mm are difficult to treat owing to the patient's expectoration of the fibrin plug.

Redl and colleagues [3] have described successful closure of bronchopleural fistulas using fibrin sealant to secure sections of decalcified calf spongiosa within the fistula. Using fibrin sealant to coat, seal, and secure the spongiosa results in complete occlusion of the fistula site, whereas the spongiosa fragment reduces the chance of the plug becoming dislodged. It is important to note that the two fibrin components should be applied directly to the fistula site and allowed to mix at the desired location as the clot will begin to develop within seconds. Tissue granulation generally covers the spongiosa in 2 to 3 weeks [9]. This procedure has been reported to successfully close fistulas up to 5 mm, as was experienced in our case. Pridun and associates [12] claim this procedure to be more than 60% successful in patients with bronchopleural fistulas.

At present, fibrin glue is not available in the United States, but is available in Europe under the names of Beriplast, Tisseel, and Tissucol [13]. We obtained Tisseel from a site in Michigan where it was being released for use in a cardiovascular research protocol. On-site preparation of fibrin glue is possible. The fibrinogen component may be prepared from cryoprecipitate, fresh frozen plasma, or single-donor human plasma [13].

Healing of the stump is allowed to occur by the mechanical occlusion of the bronchopleural fistulas with the decalcified bone plug [10]. Reports of healing in animal models after a similar procedure are as follows: Increased redness at 3 days indicating an increase of tissue blood supply, also a disintegration of the fibrin and granulation tissue growing into the plug. By day 11, there is complete incorporation of the plug. At 2 months, without complication, spongiosa and fibrin are completely covered over with epithelial tissue [12].

In conclusion, closing large bronchopleural fistulas with fibrin sealant and decalcified spongiosa appears to be advantageous for several reasons. Fibrin sealant can be easily produced in the pharmacy and cortical spongiosa is readily available. Bronchoscopy offers specific access directly to the surgical stump. These procedures may be accomplished through the use of topical and light anesthesia, averting the risks associated with general anesthesia. Bronchoscopic attempts at fistula closure also remove the obvious risks and trauma associated with thoracotomy and other thoracic surgical options. Finally, decreased costs and length of hospital stay using nonsurgical procedures are truly advantageous. This technique could potentially be used in both stable and critically ill patients; therefore, patient condition may not be a significant determining factor. Closure of bronchopleural fistula with the application of a fibrin sealant in combination with human spongiosa may offer a valuable addition to the armament of therapeutic alternatives for this high-risk complication of postsurgical pulmonary resection.

	Footnotes

Top Footnotes Abstract Introduction Comment References

 
Address reprint requests to Dr Ulmer, Pharmacy Services, Feather River Hospital, 5974 Pentz Rd, Paradise, CA 95969.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Glover W, Chavis TV, Daniel TM, Kron IL, Spotnitz WD. Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas. J Thorac Cardiovasc Surg 1987;93:470–2.[Abstract]
2. Torre M, Chiesa G, Ravini M, Vercelloni M, Belloni PA. Endoscopic gluing of bronchopleural fistula. Ann Thorac Surg 1987;43:295–7.[Abstract]
3. Redl G, Schlag G, Pridun N. Decalcified cancellous bone for treatment of bronchopleural fistulas. In: Update and future trends in fibrin sealing in surgical and non-surgical fields: Round Table: Bronchopleural fistula; 1992 November 15–18; Am. Stadtpark.
4. Wertzel H, Bonnet R, Swoboda L, Hasse J. Postoperative bronchial stump fistula-treatment with fibrin glue and spongy bone graft. In: Update and future trends in fibrin sealing in surgical and non-surgical fields: Round Table:Bronchopleural fistula; 1992 November 15–18; Am. Stadtpark.
5. Regel G, Sturm A, Neumann C, Schueler S, Tscherne H. Occlusion of bronchopleural fistula after lung injury-a new treatment by bronchoscopy. J Trauma 1989;29:223–6.[Medline]
6. Becker HD. Treatment of postoperative bronchial fistulae by endoscopic fibrin application. In: Update and future trends in fibrin sealing in surgical and non-surgical fields: Round Table: Bronchopleural fistula; 1992 November 15–18; Am. Stadtpark.
7. York EL, Lewall DB, Hirji M, Gelfand ET, Modry DL. Endoscopic diagnosis and treatment of a postoperative bronchopleural fistula. Ann Radiol 1985;28:560–2.
8. Onotera R, Unruh HW. Closure of a post-pneumonectomy bronchopleural fistula with fibrin sealant (Tisseel). Thorax 1988;43:1015–6.[Abstract/Free Full Text]
9. Stamatis G, Fechner S, Freitag L, Greschuchna D. Autologous spongiosa graft and fibrin sealant for endoscopic treatment of bronchopleural stump fistulas. In: Update and future trends in fibrin sealing in surgical and non-surgical fields. Round Table: Bronchopleural fistula; 1992 November 15–18; Am. Stadtpark.
10. Roksvaag H, Skallberg L, Nordberg C, Solheim K, Hoivik B. Endoscopic closure of bronchial fistula. Thorax 1983;38:696–7.Thorax1983;38:696–7.[Free Full Text]
11. Baumann M, Sahn S. Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient. Chest 1990;97:721–8.[Abstract/Free Full Text]
12. Pridun N, Hauck H, Hollus P. Bronchopleural fistulas-management of fistulas with specially prepared spongiosa in a combination with fibrin sealant. In: Update and future trends in fibrin sealing in surgical and non-surgical fields: Round Table: Bronchopleural Fistula, 1992 November 15–18; Am. Stadtpark.
13. Thompson D, Letassy N, Thompson G. Fibrin glue: a review of its preparation, efficacy, and adverse effects as a topical hemostat. Drug Intell Clin Pharm 1988;22:946–51.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David T. Jones Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baumann, W. R. Articles by Jones, D. T. Search for Related Content PubMed PubMed Citation Articles by Baumann, W. R. Articles by Jones, D. T.