Ann Thorac Surg 1999;68:1088-1089
© 1999 The Society of Thoracic Surgeons
How To Do It
A new instrument for endoscopic gluing for bronchopleural fistulae
Yoshio Tsunezuka, MD, PhDa,
Hideo Sato, MD, PhDa,
Toshihide Tsukioka, MDa,
Chikashi Hiranuma, MDa
a Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
Address reprint requests to Dr Tsunezuka, Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, 920-8530, Japan
e-mail: tsune{at}ipch.kanazawa.ishikawa.jp
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Abstract
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Fibrin glue was developed as a biologic adhesive and is frequently used in thoracic surgery, but no endoscopic instrument is available to spray fibrin glue. We developed an instrument, a new tube system, to aerosolize fibrin glue endoscopically to treat bronchopleural fistulae. This instrument was made of polypropylene, 2 mm diameter, and consisted of three microtubes, 0.3 mm diameter. Fibrinogen and thrombin glue were applied at the same time and aerosolized by burst pressure. The use of this instrument during bronchoscopy was found to increase the effectiveness of endoscopic treatment for bronchopleural fistulae.
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Introduction
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Postoperative bronchopleural fistula (BPF) is a serious complication in thoracic surgery. Various endoscopic closure techniques have been performed to minimize the invasiveness for high-risk patients [1, 2]. Fibrin glue is a biologic adhesive that is widely used through a fiber-optic bronchoscope, but the success rate is low, especially for a big fistula [3]. One of the causes of this poor success rate is that two kinds of glue cannot be mixed sufficiently on the affected area using the former instrument through a fiber-optic bronchoscope. We developed, and describe here, a new instrument to spray two kinds of glue to close BPF endoscopically.
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Technique
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This new instrument was developed to aerosolize fibrin glue endoscopically. The material employed to construct this instrument was polypropylene. The diameter of the top tube was 2 mm and the variable length was 120 cm (total length 150 cm) in a fiber-optic bronchofiber. The top consisted of three small tubes: one for fibrinogen injection (A-line), one for thrombin (B-line), and the other used as a compressed air line (P-line) (Ishikawa factory, Tochigi, Japan). A sterilization filter (Millipore) was attached to the tail of the P-line to aerosolize fibrin glue. The peripheral areas of A and B lines were connected to each syringe with fibrinogen and thrombin glue (Fig 1). The aerosolizing fibrin glues were applied through the instrument in the operative channel of the fiber-optic bronchofiber at the same time. The relationship among burst pressure, the distance from the top of the instrument to the sprayed site, and the diameter of spray were examined (Fig 2). A spray pressure of 1.0–3.0 kg/cm2 was suitable for management in the airway. A burst pressure higher than 3.0 kg/cm2 enlarged the diffusible range of fibrin glue excessively and the efficiency of treatment was poor. Small fistulae, less than 2 mm, were treated exclusively with fibrin glue (Beriplast, Centeon Ltd, King of Prussia, PA). The top of the instrument was inserted into the fistula, and sprayed. Fistulae larger than 2 mm and smaller than 5 mm were treated with a microcoil and fibrin glue. A 2–5 mm platinum embolization coil (Fig 3) (Fibered Platinum coil, Boston Scientific Japan Co, Tokyo, Japan) was introduced through the catheter into the fistula, employing the techniques used in standard vascular embolization [4]. Next, the fistulae embolized with the microcoils were sprayed with aerosolized fibrin glue endoscopically. The intervention was considered successful when air leakage from a pleural drainage tube stopped. After spraying, the instrument was not pulled through the bronchofiber, avoiding blockage of the operative channel by dry fibrin material. Instead, the instrument, together with the bronchofiber, was pulled from the airway, and the top of the instrument was then cleaned or cut.
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Fig 1. Photograph of the new instrument for endoscopic gluing. A = fibrinogen injection port (A-line); B = thrombin injection port (B-line); P = compressed air line (P-line); M = Millipore (sterilization filter); T = top of instrument (consisting of three small tubes, diameter 0.3 mm, made of polypropylene; D = 2 mm; d = 0.3 mm).
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Between April 1988 and March 1999, 18 bronchopleural fistulae patients were treated. The closure of bronchial fistulae using fibrin glue has been performed on 8 patients endoscopically, the new instruments were used on 3 patients. Pleural drainage was performed in all patients. All patients without new instruments failed to close fistulas at the first trial. The average number of endoscopic interventions irrespective of outcome was 2.75 (range 2–4). Two patients were treated with fibrin glue only and 2 were treated with microcoils and fibrin glue. The fistula sizes ranged from 1 to 5 mm. Bronchopleural fistula developed after pneumonectomy in 1 patient, and after lobectomy in 2 patients. Main stem fistula developed due to damage by an expandable metallic stent in 1 patient. One patient died of aspiration pneumonia and progression to systemic sepsis without operative intervention. Three patients had open window drainage and direct closure of fistula. However, 2 patients died due to systemic sepsis. All treatment involving patients using the instruments was successful. One patient was treated with microcoils and fibrin glue. The fistula sizes were 2, 2, and 4 mm. The fistulae occurred after pneumonectomy in 2 patients and after lobectomy in 1. There was no fistula recurrence after the treatment (18, 14, and 2 months).
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Comment
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Endoscopic treatment of BPF is minimally invasive, tolerated, and may play a significant role in the treatment of this complication, especially in high risk patients. However, few successful results of endoscopic closure of BPF with fibrin glue have been reported to date [2]. One reason for these findings is that applied fibrin may come off during coughing. Fibrin glue is made with highly concentrated human fibrinogen and clotting factors by mixing fibrinogen (A-glue) with thrombin glue (B-glue). Three methods exist for fibrin glue application: the layer method, in which A and B glues are applied separately; the mixture method, in which the glues are applied at the same time; and the spray aerosolized method, in which the glues are aerosolized by burst pressure. The spray aerosolized method is more effective than the layer or mixture methods concerning fixed power and fibrin clot formation [5]. The former bronchoscopic gluing procedures used the layer method; A-glue and B-glue were applied separately because the former endoscopic instruments were one-canal type. The fixed and adhesive ability of this procedure is low. Our instrument consisted of three microtubes, so A- and B-glues were applied at the same time and aerosolized by burst pressure.
The high spray pressure increased diffusing volume of fibrin glue from the applying point. We considered a pressure greater than 3.0 kg/cm2 to be unsuitable. Visible fistulae smaller than 2 mm, are indications of fibrin treatment, but fistulae larger than 2 mm are difficult to treat with fibrin glue only. Hollaus and associates [3] used spongy calf bone with fibrin glue for large fistulae. We placed microcoils into the fistula and sprayed fibrin after insertion to make a small defect and to increase the fixation of the fibrin clot. This procedure successfully closed BPF smaller than 4 mm. This instrument has wide applications, not only for fibrin glue, but also for gelatin-resorcine-formol (GRF) glue and other materials through a fiber-optic bronchofiber.
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References
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Torre M., Quaini E., Ravini M., Nerli F.P., Maioli M. Endoscopic gluing of bronchopleural fistula. Ann Thorac Surg 1994;58:901-902.[Medline]
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Jessen C., Sharma P. Use of fibrin glue in thoracic surgery. Ann Thorac Surg 1985;39:521-524.[Abstract]
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Hollaus P.H., Lax F., Janakiev D., et al. Endoscopic treatment of postoperative bronchopleural fistula. Ann Thorac Surg 1998;66:923-927.[Abstract/Free Full Text]
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Greenfield J.A. Transcatheter vessel occlusion. Interventional radiology. Philadelphia: WB Saunders, 1982:46-47.
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Sawamura Y., Asaoka K., Terasaka S., Tada M., Uchida T. Evaluation of application techniques of fibrin sealant to prevent cerebrospinal fluid leakage. Neurosurgery 1999;44:332-337.[Medline]
Accepted for publication May 14, 1999.
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Abstract
Introduction
