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Ann Thorac Surg 2001;72:276-278
© 2001 The Society of Thoracic Surgeons

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Case report

The use of a Dumon stent for the treatment of a bronchopleural fistula

Accepted for publication June 7, 2000.

Address reprint requests to Dr Watanabe, Second Department of Surgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
e-mail: shun{at}khosp2.kufm.kagoshimau.ac.jp

	Abstract

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We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.

	Introduction

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The treatment of a bronchopleural fistula (BPF) after pulmonary resection remains a major therapeutic challenge for thoracic surgeons. We report the successful management of a BPF with bronchial stent placement accompanied with irrigation of the empyema cavity after failed closure of the bronchial stump by operative procedures.

A 67-year-old man underwent a right upper lobectomy and partial resection of the posterior parietal pleura with formal lymph node dissection for a 6-cm adenocarcinoma of the lung (pathological T3 N0 M0). A bullous change was noted in the remaining lung. The proper size of staple was used for bronchial closure. The postoperative course was uneventful.

Radiation therapy to the site of pleurectomy was initiated on postoperative day 14. On the following day, dyspnea developed, and a chest roentgenogram showed a mild pneumothorax on the right side. Therefore, radiation therapy was stopped. The bullous lesion was considered the cause of the pneumothorax. Because of increasing dyspnea and the development of fever and leukocytosis, an emergent thoracotomy was performed on postoperative day 20. The findings of bronchial stump dehiscence and empyema led to reamputation and resuture of the stump accompanied with omental wrapping.

Five days later, the BPF recurred. Closure of the open bronchus with a pedicled flap of intercostal muscle was carried out. A pneumonectomy could not be done because of preoperative pulmonary dysfunction. Next day, a tracheostomy was performed. These two operative procedures, however, failed to manage the BPF (Fig 1).

View larger version (137K): [in this window] [in a new window]   Fig 1. Chest roentgenogram before Dumon stent placement showing empyema of right hemithorax.

After continual irrigation of the right empyema cavity with a saline solution for approximately 3 months, a chest roentgenogram revealed almost normal findings in the right hemithorax (Fig 2). The patient was discharged 6 months after stent placement without any subsequent space problems or infection. No recurrence of the BPF and no complications relating to stent placement occurred. The patient died of brain metastasis 8 months after discharge.

View larger version (56K): [in this window] [in a new window]   Fig 2. (A) Chest roentgenogram made 3 months after stent placement revealing almost normal findings in right hemithorax. (B) Line drawing indicates stent position.

	Comment

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The vast majority of BPFs occur after pneumonectomy or bilobectomy. The development of such a fistula after right upper lobectomy alone, as in our patient, is an infrequent event. A stapled closure is contraindicated when the bronchus is thickened, inflamed, or insufficient in length [3]. These unfavorable findings were not present in our patient. He received radiation therapy postoperatively, but the total dose was only 2 Gy. Therefore, the cause of the BPF was unknown.

We performed two types of operation but failed to manage the BPF because of the fragility of the right upper lobe bronchus. The fragile state was due to the delayed diagnosis.

There are many types of tracheobronchial stents [4]. Most reports describe their use in airway stenoses and very few, for treatment of airway fistulas. Dumon stents have been used for the management of tracheobronchial stenosis [5]. In our patient, we decided to place a Dumon stent from the right main bronchus to the truncus intermedius to close the stump as the final step in the management of the BPF because the right upper lobe orifice comes off the right mainstem bronchus at a 90-degree angle. A Dumon stent is made of molded silicone and thus is flexible and compatible with living tissue. Also, it can be removed. The irritating cough expected as a result of a foreign body does not develop [5]. Our stent placement technique using a fiberoptic bronchoscope is simple and certain and does not require general anesthesia.

Most BPFs occur after pneumonectomy and right bilobectomy. In these situations, the fistula is situated at the distal side of the main bronchus and would not be amenable to management with an endobronchial stent. In recent years, wire mesh tubes that look like covered, walled, straight stents have been introduced, but long-term experience with their use is limited [6].

Miller and coworkers [7] emphasized the efficacy of daily irrigation of the empyema space with an antibiotic solution. Therefore, we continued daily irrigation of the empyema space until the dead space was obliterated after stent placement.

On the basis of this experience, we believe that placement of a Dumon stent along with adequate drainage can be useful to treat a BPF that cannot be managed by the usual operative procedures.

	References

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1. Watanabe S., Toyohira H., Yamaoka A., Yotsumoto G., Shiota K., Taira A. Usefulness of Dumon-type endotracheal stent for left main bronchial obstruction caused by thoracic aortic aneurysm: a case report. Nippon Kyobu Geka Gakkai Zasshi 1996;44:1776-1780.[Medline]
2. Asamura H., Naruke T., Tsuchiya R., Goya T., Kondo H., Suemasu K. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456-1464.[Abstract]
3. Vester S.R., Faber L.P., Kittle C.F., Warren W.H., Jensik R.J. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:1253-1258.[Abstract]
4. Gaissert H.A., Patterson G.A. Tracheobronchial stents. In: Pearson F.G., Hiebert C.A., Deslauriers J., McKneally M.F., Ginsberg R.J., Urschel H.C., Jr, eds. Thoracic surgery: endoscopy. New York: Churchill Livingstone, 1995:223-233.
5. Dumon J.F. A dedicated tracheobronchial stent. Chest 1990;97:328-332.[Abstract/Free Full Text]
6. Wassermann K., Koch A., Muller-Ehmsen J., Reuter M., Michel O., Eckel H.E. Clinical and laboratory evaluation of a new thin-walled self-expanding tracheobronchial silicone stent: progress and pitfalls. J Thorac Cardiovasc Surg 1997;114:527-534.[Abstract/Free Full Text]
7. Miller J.I., Fleming W.H., Hatcher C.R., Jr Balanced drainage of the contaminated pneumonectomy space. Ann Thorac Surg 1975;19:585-588.[Abstract]

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This Article Abstract Full Text (PDF) 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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Watanabe, S.-i. Articles by Sakasegawa, K.-i. Search for Related Content PubMed PubMed Citation Articles by Watanabe, S.-i. Articles by Sakasegawa, K.-i. Related Collections Trachea and bronchi