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Ann Thorac Surg 2002;73:945-948
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Endobronchial neodymium:yttrium-aluminum garnet laser for noninvasive closure of small proximal bronchopleural fistula after lung resection

^a Department of Surgery II, Nagoya City University Medical School, Nagoya City, Japan

Accepted for publication October 18, 2001.

* Address reprint requests to Dr Kiriyama, Department of Surgery II, Nagoya City University Medical School, 1, Kawasumi, Mizuho, Nagoya, 467-8601, Japan
e-mail: m.kiri{at}med.nagoya-cu.ac.jp

	Abstract

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Background. Bronchopleural fistula (BPF) is a serious complication of lung resection. The management of persistent BPF is one of the most complex challenges encountered by thoracic surgeons.

Methods. We used neodymium:yttrium-aluminum garnet (Nd:YAG) laser in 8 patients with BPF who were treated at our hospital, between January 1991 and December 1997. Through the flexible fiberoptic bronchoscope, Nd:YAG laser beam was directed to the bronchial mucosa surrounding the BPF. One-half–second energy pulses of 8 to 20 W were used. Close follow-up of successful patients showed complete closure of the BPF without further treatment.

Results. The procedure was successful in 4 of 5 patients who had no infection or tumor at the bronchial stump. However, the procedure failed in 3 other patients, who had residual tumor or infection by aspergillus at the stump.

Conclusions. Closure of small BPF by laser seems to be due to edema and to an inflammatory reaction of the bronchial mucosa surrounding the BPF. If the diagnosis of small proximal BPF is made in the absence of tumor or infection, Nd:YAG laser offers an option for endobronchial treatment of small (<2 mm) BPF. If this technique is successful, it avoids the morbidity associated with more invasive surgical procedures.

	Introduction

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Bronchopleural fistula (BPF) is a serious complication of lung resection. It causes significant morbidity, prolonged hospitalization, and even mortality. The management of persistent BPF is one of the most complex challenges encountered by the thoracic surgeon. Its incident has been reported to be 0% to 28% after pulmonary surgery [1–3]. Preoperative treatment (chemotherapy or radiotherapy) was found to increase the risk of BPF [4]. Regardless of the origin, the overall mortality of patients with BPF remains high, varying from 20% to 70% in the literature; the most common cause of death is aspiration pneumonia, with subsequent adult respiratory distress syndrome [5]. If a major bronchial stump dehiscence occurs during the first week after pulmonary resection, immediate resuture and reinforcement of the bronchial stump is the procedure of choice [2,6]. Minor fistulas can be managed initially with tube thoracotomy and suction, and some fistulas will close spontaneously with this treatment. However, most BPFs present as subacute or chronic air leak. Patients with these BPFs initially receive conservative management with dependent drainage and reduction of pleural space, antibiotics, optimal ventilation management [7], and nutritional supplementation. If these conservative measures fail to close the fistula in 1 to 3 weeks, surgical intervention is usually considered as the next step in management. However, the bronchoscopist can now use several nonoperative techniques to attempt endobronchial closure of BPF. Bronchoscopic application of a sealing agent to occlude the fistula can be used, particularly in poor surgical candidates [2, 7]. In this article, we report successful use of neodymium:yttrium-aluminum garnet (Nd:YAG) laser for endobronchial management of small proximal BPF.

	Material and methods

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We used Nd:YAG laser in 8 patients with small proximal BPF who were treated at Nagoya City University Hospital between February 1991 and December 1997. There were 7 men and 1 woman. The mean age of the patients was 53.1 years (range 37 to 68 years). The distribution of the tumors by location, operative procedure, and the histology are shown in Table 1. These BPFs occurred between 1 month and 2.5 years and were confirmed by flexible bronchoscopy. A BPF was diagnosed by either continued air leakage, or observation by bronchoscopy of the pleural exudate at the bronchial stump. In all cases BPF was at the stump and was less than 2 mm. Closed tube drainage was the first step in the treatment in 5 patients (cases 1, 2, 3, 4, and 7). On the bronchial stump, 1 patient (case 7) had infection of aspergilloma and 2 patients (cases 2 and 4) had invasion of malignant tumor (Table 2).

View larger version (67K): [in this window] [in a new window]   Fig 1. Bronchoscopic findings in stump of right main bronchus (case 1). (A) Before irradiation, bronchoscopy showed small bronchopleural fistula (arrow) of the stump after right pneumonectomy. (B) Several minutes after laser irradiation, bronchopleural fistula (arrow) seems to be closed.

	Results

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Permanent closure of BPF was achieved in 4 patients (cases 1, 5, 6, and 8). These patients had no inflammation or tumor cell at the bronchial stump. Compared with patients in whom the procedure failed, all patients in whom it was successful were treated with a relatively high power of 15 to 20 W. Three of these patients (cases 5, 6, and 8) were treated with 300 to 400 J. Three patients (case 1, 5, and 8) were alive between 3 and 9 years after the therapy. One patient (case 6) died due to recurrence of lung cancer at 2 months after the therapy, but his BPF had healed. The air leaks in the successfully treated patients stopped immediately after the treatment. These patients were discharged from the hospital between 7 and 12 days after the Nd:YAG laser therapy.

The procedure failed in 4 other patients (cases 2, 3, 4, and 7). The BPF recurred immediately or as late as 36 days after the laser therapy. Two patients required reoperation (omentopexy) for the management of the BPF. Two patients (cases 2 and 4) had residual tumor, and 1 patient (case 7) had aspergillus infection at the stump. In another patient (case 3), the cause of failure may be the relatively weak power of irradiation at 5 to 8 W (74 to 130 J). Three patients (cases 2, 4, and 7) died between 36 days and 5 months after the therapy. In 2 of them, BPF had caused quality of life to deteriorate. One patient (case 3) received omentopexy after the recurrence of the BPF and is still alive 9 years after the last operation.

	Comment

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For a postoperative BPF, the patient is usually treated conservatively with a pleural drainage or with operative closure of the bronchial stump. The choice depends on the state of the patient, the interval between the lung resection and BPF, and whether the pleural space is already infected [1, 8–12]. To avoid empyema, early operation is recommended [8, 13]. However, this is not always possible, and a less invasive method to close the BPF is needed.

The role of bronchoscopy in the management of BPF is expanding because of advances in bronchoscopic techniques and sealants. Bronchoscopy facilitates diagnosis of BPF in many cases by direct visualization of the fistula [7, 14]. Proximal fistulas such as those associated with lobectomy or pneumonectomy are often directly visualized through a bronchoscope. Nonsurgical alternatives have been attempted, including endobronchial occlusion with cyanoacrylate tissue glue, fibrin glue, and chemical cautery with topical tetracycline or doxycycline, or silver nitrate. The most widely used sealants for proximal BPF are cyanoacrylate-based and fibrin glue [2, 14]. Reports on these procedures in a small series have been published, with variable success rates.

All of these agents appear to work in two phases: initially by acting as a plug and mechanically sealing the leak, and subsequently by inducing an inflammatory reaction with mucosal proliferation and fibrosis in the area, creating a permanent seal [13–15].

The Nd:YAG laser has been useful as palliative treatment for tracheobronchial disease. Most often, it has been used to coagulate and evaporate endobronchial lesions [16]. Cavaliere and colleagues [17] have treated 1,000 patients with Nd:YAG laser in 1,396 applications in 5 years. They reported treating 9 patients with BPF; four small fistulas closed spontaneously, four medium fistulas closed after repeated silver nitrate treatment, and one remained open. These investigators suggested that the laser was used to clean the fistulized zone of suture threads and necrotic tissue. Wang and colleagues [18] reported a patient with BPF after a right lower lobectomy, which was treated successfully with flexible bronchoscopy and coagulation with Nd:YAG laser by producing slight erosion and bleeding around the fistula.

The effect of the laser depends on the type of laser, wavelength, power density, duration of the application, and nature of the target tissue. Laser energy absorbed by the tissue is converted into heat. According to the temperature reached, various effects are observed: coagulation (blanching of the lesion), protein denaturation (gray coloring of the lesion), carbonidazation (black coloring of the lesion), and vaporization [16]. In our limited experience, we noted blanching of the bronchial mucosa in cases that were successful; in comparison, in cases in which the procedure failed, the mucosa retained a pinkish color, suggesting that the coagulation was insufficient. We suggest that energy of Nd:YAG laser irradiation should be 15 to 20 W (total 300 to 400 J) for closure of minor BPF. We presume that the successful closure of minor BPF by the laser was due to edema and to protein denaturation of the tissue surrounding the BPF by the thermal effect of the laser. Subsequent exudate of fibrin serves to maintain the closure of the fistula. If sealing of the BPF is maintained for 3 or 4 weeks, epithelial proliferation and fibrosis make the sealing permanent.

This treatment was successful in 4 of 5 patients without local infection or tumor. We think that the cause of failure in 1 of the 5 patients without local infection or tumor was insufficient cauterization power. The failure in the other 3 patients was probably due to infection and residual tumor at the BPF site. In our experience, repeated trials in unsuccessful patients did not seem to improve the success rate. We suggest that surgical treatment should not be delayed in patients with local infection or tumor if initial attempts with laser have failed.

In conclusion, whenever bronchial stump insufficiency is suspected after lung resection, bronchoscopy should be performed. If the diagnosis of small proximal BPF has been made in the absence of infection in the thoracic cavity or residual tumor at the stump, Nd:YAG laser offers an option for noninvasive endobronchial closure of small (ie, <2 mm) BPF.

	References

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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 Kiriyama, M. Articles by Sasaki, H. Search for Related Content PubMed PubMed Citation Articles by Kiriyama, M. Articles by Sasaki, H. Related Collections Related Article