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Ann Thorac Surg 2002;74:2174-2176
© 2002 The Society of Thoracic Surgeons

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Case report

Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate

^a Department of Respirology, Kishiwada City Hospital, Kishiwada City, Japan
^b Department of Radiology, Kishiwada City Hospital, Kishiwada City, Osaka, Japan

Accepted for publication August 1, 2002.

* Address reprint requests to Dr Hirata, Department of Respirology, Kishiwada City Hospital, Kishiwada City, Osaka 596-8501, Japan.
e-mail: kch-16{at}kch.city.kishiwada.osaka.jp

	Abstract

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We report herein 2 patients with intractable postoperative bronchopleural fistula with empyema after lobectomy or subsegmentectomy. The patients underwent several treatments including thoracotomy, but the fistula closure was not successful. Finally, the bronchopleural fistula was successfully treated by endobronchial closureusing vascular occluding coils and n-butyl-2-cyanoacrylate (Histoacryl).

	Introduction

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Bronchopleural fistula is one of the most serious complications after pulmonary resection. The incidence of bronchopleural fistula after pneumonectomy is as high as 4.5% to 20% [1], whereas its incidence after lobectomy is less than 1%, but it is not uncommon to be fatal once a bronchopleural fistula occurs [2]. In patients with complications of pyothorax, which can be particularly difficult to treat, frequently require surgical management. However, because the general status of the patient is usually poor in these circumstances, effective but less invasive therapeutic procedures are needed.

Recently, various endobronchial approaches have been reportedly used for the treatment of bronchopleural fistula [3–6]. However, there are no clear indications regarding these procedures. We report herein 2 patients with intractable postoperative bronchopleural fistula that could not be managed by various therapeutic procedures including thoracotomy but were successfully treated by endobronchial closure using vascular occluding coils and n-butyl-2-cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Germany).

	Case reports

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Patient 1
A 73-year-old man was admitted to the hospital because of high fever and productive cough. Five months before admission, he underwent lobectomies of the middle and lower lobes of his right lung in our hospital (squamous cell carcinoma, pT3 N0 M0). On the first hospital day, he was diagnosed as having right pneumonia and pyothorax with bronchopleural fistula. Because daily intrathoracic irrigation through the chest tube and systemic administration of antibiotics could not effectively cure the empyema, thoracotomy was performed on the 26th hospital day. Intraoperative observation revealed bronchopleural fistula (rtB3c) in the upper lobe where the lung was previously dissected with stapled closure. Surgical debridement and limited thoracoplasty were performed, and the bronchopleural fistula was closed with a pedicle intercostal muscle flap. Although air leakage was not observed after operation, it recurred on postoperative day 7. Fibrin glue was endobronchially injected into rtB3 after confirming that the air leakage was localized to rtB3 by performing serial occlusion with balloon inflation using a balloon-tipped catheter. Because air leakage recurred, pleural irrigation was performed twice through the chest tubes, but to no avail. The patient’s status deteriorated due to aspiration pneumonia. Endobronchial attempt of closure of the bronchopleural fistula was performed with vascular occluding coils (three 6-mm long coils and one 5-mm long; Platinum Coil Vascular Occlusion System, Boston Scientific Co, Fremont,) and fibrin glue as filling. These measures, however, proved to yield only temporary effect. Three days after this procedure, a chest roentgenogram revealed that one of the vascular occluding coils had fallen into the thoracic cavity. Hence, bigger vascular occluding coils (two coils 30-mm long and two 50-mm long) and Histoacryl + Lipiodol were used to fill the bronchopleural fistula. Histoacryl was mixed with Lipiodol at a 1:1 ratio, and 2 mL of the mixture was injected through a catheter. Air leakage was not noted after this procedure, and the thoracic cavity was irrigated daily through the chest tubes. Although the inflammation seemed to be ameliorated, air leakage recurred 37 days later, and as a result an open-window thoracotomy was performed. Intraoperative observation revealed that another bronchopleural fistula existed in other segment of the lung (S2) and that the original fistula for which endobronchial embolization had been performed remained closed. The postoperative course was uneventful, but the patient died of respiratory failure 10 months after discharge.

Patient 2
A 64-year-old woman with a history of diabetes mellitus and bronchial asthma was admitted to the hospital because of fever and dyspnea. Four years before admission, a mastectomy had been performed for left breast cancer. Sixteen months before admission, a solitary pulmonary metastasis was discovered, for which partial resection of the left lung (S6) was performed. Four months before admission, multiple pulmonary metastases were discovered in the bilateral lungs, for which partial resection of the left lung (S10) and right S2a subsegmentectomy were performed in two stages. One month before admission, systemic administration of anticancer drugs began. On admission, chest roentgenogram and chest computed tomographic scan revealed dissociation at the subsegmentectomy surface (rtS2a) that had been sutured, leading to the diagnosis of postoperative bronchopleural fistula. Because air leakage was severe, and it did not improve despite chest tube drainage and pleurodesis (performed twice), closure of the bronchopleural fistula with pedicle intercostal muscle flap by thoracotomy was performed on the 20th hospital day. However, air leakage recurred on postoperative day 4, for which pleurodesis was performed again but to no avail. By postoperative day 14, an empyema developed. Hence, endobronchial closure of the fistula was attempted with vascular occluding coils (seven coils 4-mm long) after confirming that the air leakage was localized to rtB2a using a balloon-tipped catheter. Concurrent filling of the fistula with Histoacryl had been planned, but it was canceled because air leakage stopped during the endobronchial procedure only after the use of coils. Air leakage recurred and endobronchial closure of bronchopleural fistula with coils (two coils 10-mm long and one 4-mm long) and Histoacryl (2 mL) was performed 2 days later. Air leakage stopped immediately after the procedure. Intrathoracic irrigation was performed daily, and the patient was discharged 5 weeks later. Follow-up examination at 6 months after discharge, bronchoscopy revealed that Histoacryl was still occluding the bronchus.

	Comment

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Because both patients would have been died if the endobronchial procedure failed, the present report emphasized that postoperative bronchopleural fistulas, which could not be treated by even surgical measures, were cured immediately by minimally invasive procedures that used vascular occluding coils and Histoacryl.

Conventionally, thoracotomy is required when the postoperative bronchopleural fistula cannot be cured by a nonsurgical procedure [6]. Although patient 1 seemed to require more extended thoracoplasty or open-window thoracotomy and patient 2 seemed to require completion lobectomy of the upper lobe of the right lung, instead of closure of the fistula using a pedicle intercostal muscle flap, these procedures were too invasive to be given high priority. Therefore, this endobronchial procedure was performed when all else had failed to cure the bronchopleural fistula.

In our report, the use of coils alone or in combination with absorbable fibrin glue failed to close permanently the bronchopleural fistula. The effect of the combination of vascular occluding coils and Histoacryl was immediate after injection of Histoacryl. Therefore, the coils seemed to act as a matrix for Histoacryl to be fixed at the filling site, and Histoacryl seemed to be a major factor in achieving long-lasting closure. Jain and colleagues [7] reported that a bronchopleural fistula could not be closed by Histoacryl alone, but it was successfully treated by a combination of coils and this material. Thus, we consider the combination of vascular occlusion coils and Histoacryl to be better than that of coil alone or Histoacryl alone in the management of bronchopleural fistula as shown in our patients.

On the other hand, the shortcomings of this procedure includes the introduction of a foreign matter in the body and the possibility that the bronchial mucosa might be stimulated resulting in persistent cough. However, in our patients, symptoms of bronchial irritation such as cough did not persist after the procedure.

In conclusion, endobronchial closure with vascular occluding coils and Histoacryl may be an option for the treatment of intractable postoperative bronchopleural fistula.

	References

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1. Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Sem Thorac Cardiovasc Surg 2001;13:3-7.[Medline]
2. Cooper W.A., Miller J.I., Jr Management of bronchopleural fistula after lobectomy. Sem Thorac Cardiovasc Surg 2001;13:8-12.[Medline]
3. Watanabe S., Shimokawa S., Yotsumoto G., Sakasegawa K. The use of a Dumon stent for the treatment of a bronchopleural fistula. Ann Thorac Surg 2001;72:276-278.[Abstract/Free Full Text]
4. Hartmann W., Rausch V. A new therapeutic application of the fiberoptic bronchoscope. Chest 1977;71:237.
5. Martin W.R., Siefkin A.D., Allen R. Closure of a bronchopleural fistula with bronchoscopic instillation of tetracycline. Chest 1991;99:1040-1042.[Abstract/Free Full Text]
6. Memis A, Organ I, Paridar M. Use of Histoacryl and covered Nitinol stent to treat a bronchobiliar fistula. JVIR 2000;11:1337–40
7. Jain R., Baijal S.S., Phadke R.V., Pandey C.K., Saraswat V.A. Endobronchial closure of a bronchopleural cutaneous fistula using angiography catheters. AJR 2000;175:1646-1648.[Free Full Text]

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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 Hirata, T. Articles by Fujisawa, I. Search for Related Content PubMed PubMed Citation Articles by Hirata, T. Articles by Fujisawa, I. Related Collections Trachea and bronchi