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Ann Thorac Surg 2000;69:1629-1630
© 2000 The Society of Thoracic Surgeons
a Department of Respiratory Diseases, St. Giovanni Battista Hospital, Torino, Italy
b Department of Thoracic Surgery, University of Torino, Torino, Italy
c Department of Thoracic Surgery, St. Luigi Gonzaga Hospital, Orbassano, Italy
As originally published in 1994:
Ermanno Scappaticci, MD, Francesco Ardissone, MD, Enrico Ruffini, MD, Sergio Baldi, MD, and Maruizio Mancuso, MD
Department of Respiratory Disease, Hospital Molinette, and Department of Thoracic Surgery, University of Torino, Torino, Italy
Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (methyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopic gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (< 15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopic treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistulas occurred later after the operation (> 15 days) and all had associate empyema. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.
Updated in 2000 by Ermanno Scappaticci, MD, Francesco Ardissone, MD, Enrico Ruffini, MD, Sergio Baldi, MD, Flavio Revello, MD, and Francesco Coni, MD
The management of postoperative bronchopleural fistula (BPF) remains a subject of controversy because none of the wide variety of therapeutic approaches has been found to be successful or suitable for all patients. Endoscopic gluing has been proposed for the direct closure of BPF in view of its safety and noninvasiveness. Our original work [1] in 1994 focused on the feasibility of endoscopic closure of postoperative BPF with tissue glue adhesive (methyl-2-cyanoacrylate) and its efficacy in facilitating subsequent treatment of residual pleural space.
At present, our series includes 20 patients with BPF treated by endoscopic gluing from 1986 to 1999. Eighteen patients were operated on for lung carcinoma (pneumonectomy in 10 patients, bilobectomy in 3, lobectomy in 5); 2 patients underwent pneumonectomy for malignant pleural mesothelioma and inflammatory disease. There were 13 early (
15 days) and seven late (
15 days) fistulas.
Of the 13 early fistulas, six developed after pneumonectomy and seven after lobectomy or bilobectomy. Of the six postpneumonectomy BPF, three were small (< 5 mm) and were all closed by endoscopic gluing. One patient had associated empyema, which resolved after BPF closure. Three patients had large ( 5 mm) BPF with empyema, and in all cases, endoscopic gluing failed to close BPF. Of these, 2 died and 1 was successfully treated by surgical correction of BPF with resolution of empyema.
Of the seven postlobectomy BPF, three were small and were all closed by endoscopic gluing. All had resolution of the associated empyema. Four patients had large BPF (with two associated empyemas); endoscopic gluing failed in 2 patients (who both died) and was successful in 2 with resolution of the associated empyema.
Of the seven late fistulas, six developed after pneumonectomy and one after lobectomy. All had associated empyema and all were small fistulas.
Of the six postpneumonectomy late BPF, endoscopic gluing was successful in 5 patients but the associated empyema persisted; the patient in whom endoscopic gluing failed required subsequent surgical correction of the fistula with success. All patients had persistence of the empyema despite successful BPF closure.
The postlobectomy late BPF was successfully closed by endoscopic gluing with resolution of the empyema.
Overall, endoscopic gluing resulted in permanent closure of BPF in 14 of 20 patients (70% success rate). The highest success rate occurred in small fistulas (12/13 [92%]). A low success rate was observed in large fistulas (2/7 [28%]), with an associated high mortality (4/7 [57%]). Resolution of associated empyema was achieved in all early, small fistulas, either postpneumonectomy or postlobectomy. Conversely, only one out of seven empyemas associated with late BPF resolved after closure of the fistula.
A review of the recent literature on the subject indicates that endoscopic treatment of BPF is still a valuable therapeutic option in selected patients. Hollaus and associates [2] reported 45 patients with postresectional BPF, of whom, 29 were treated endoscopically with fibrin glue or spongy calf bone. The success rate was 35%, although only 9 patients had resolution of associated empyema. The authors concluded that the best results are expected in small, early fistulas. Varoli and associates [3], in a recent series of 35 patients endoscopically treated with multiple submucosal injections of a sclerosing agent (polidocanol), reported a success rate of 65% with permanent closure of fistulas up to 10 mm. All associated empyemas recovered. The technique only failed in patients with total dehiscence of the bronchial stump.
In conclusion, our present experience, as compared with our 1994 work, still confirms the validity of endoscopic gluing in the treatment of postresectional BPF in selected patients. Optimal indications are small, early fistulas, in which permanent closure is almost always followed by resolution of the associated empyema. Late fistulas are usually coexistent with chronic empyemas, and endoscopic gluing, although effective, rarely results in resolution of the empyema. Large fistulas ( 5 mm) are only occasionally closed by endoscopic gluing either with methyl-2-cyanoacrylate or fibrin glue [2]. Preliminary experience with sclerosing agents seems encouraging [3], without the serious complications reported using these agents in esophageal veins [4]. Finally, total dehiscence of the bronchial stump is not amenable to endoscopic treatment.
References
This article has been cited by other articles:
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  G. Stratakos, L. Zuccatosta, I. Porfyridis, M. Sediari, C. Zisis, V. Mariatou, E. Kostopoulos, A. Psevdi, S. Zakynthinos, and S. Gasparini Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae J. Thorac. Cardiovasc. Surg., September 1, 2009; 138(3): 603 - 607. [Abstract] [Full Text] [PDF]
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 D. West, A. Togo, and A. J. B. Kirk Are bronchoscopic approaches to post-pneumonectomy bronchopleural fistula an effective alternative to repeat thoracotomy? Interact CardioVasc Thorac Surg, August 1, 2007; 6(4): 547 - 550. [Abstract] [Full Text] [PDF]
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 E. Scappaticci, F. Ardissone, S. Baldi, F. Coni, F. Revello, P. L. Filosso, and E. Ruffini Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient Ann. Thorac. Surg., January 1, 2004; 77(1): 328 - 329. [Abstract] [Full Text] [PDF]
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