| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2003;75:290-292
© 2003 The Society of Thoracic Surgeons
a Department of Surgery, Sasebo Kyohsai Hospital, Sasebo, Japan
b Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Accepted for publication August 9, 2002.
* Address reprint requests to Dr Tayama, Department of Surgery, Sasebo Kyohsai Hospital, 10-17 Shimaji, Sasebo 857-8575, Japan
e-mail: ktayama{at}kkr.sasebo.nagasaki.jp
 |
Abstract |
|---|
 Top Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
A 72-year-old man underwent right pneumonectomy after induction chemotherapy for an adenocarcinoma located in the right lower lobe and associated with subcarinal and pretracheal lymphadenopathy (p-T2N2 mol/L0). The main bronchus was closed with staples (Ethicon Endo-Surgery, Cincinnati, OH) and covered with a Tacho-comb sheet (Nycomed Pharma Ag, Linz, Austria) to prevent the development of a bronchopleural fistula. The postoperative course was satisfactory and the patient was discharged in good condition after 30 days. The next day he was admitted again because of serous sputum and massively productive cough; the chest roentgenogram taken on readmission revealed a radiolucent area indicative of an air space on the right side. Bronchoscopic findings of the right main bronchus were apparently normal. We suspected the air space was due to a bronchopleural fistula and therefore we performed an emergency thoracotomy on readmission day 1 (postpneumonectomy day 31), because he had no aspiration pneumonia or empyema. Intraoperatively the bronchial stump was found to be covered with the Tacho-comb sheet but we detected air leakage from the center of the sheet; thus we sutured the stump again using 3-0 Prolene polyglactin 910 (Ethicon, Somerville, NJ) and placed a pedicardial fat pad over the suture. We closed the wound after confirming there was no air leakage at the bronchopleural fistula or at the Tacho-comb sheet.
On October 26, 2000, because of the patient’s high fever and leukocytosis we inserted a chest tube drain and found that he had an empyema but did not have a bronchopleural fistula. On November 8, 2000, a new bronchopleural fistula developed at the same site and an open thoracotomy was carried out. The diameter of the bronchopleural fistula was 3 mm and we treated it endoscopically. The procedure consisted of three sessions (carried out once every week) of multiple submucosal injections of polidocanol (Aethoxysklerol Kreussler) on the edges of the fistula. Seven days after the first injection, reactive tissue was observed proliferating from the edge toward the center of the fistula. The procedure was repeated every 3 weeks but the fistula did not close. During this time we continued disinfection in the open thoracic cavity. On March 9, 2001, the infection in the thoracic cavity had disappeared and we performed thoracoplasty and repaired the fistula using the latissimus dorsi muscle flap. However, on March 19, 2001, the chest roentgenogram revealed aspiration pneumonia and a chest computed tomography (CT) scan showed the fistula had recurred (Fig 1); therefore, the patient was intubated and mechanically ventilated. We tried to block the air current of the central airway to close the right main bronchial stump fistula. On March 23, 2001, we cut the right arm of a Y-shaped Dumon stent 12 mm in diameter and 40 mm long (model BD 400; Novatech, Plan de Grasse, France), folded it, and closed the stump of the stent using Aron Alpha (Fig 2). This modified Dumon stent was inserted through a rigid bronchoscope under intravenous anesthesia from the trachea into the left main bronchus after extubation. On May 26, 2001, the chest roentgenogram and the chest CT scan revealed the air lucent area in the right thorax had disappeared (Fig 3). The patient’s respiratory function improved; he died as a consequence of brain metastases 3 months after the disappearance of the bronchopleural fistula.
|
|
|
|
Comment |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
Conservative treatment consists of early insertion of a chest tube for drainage and thereby for prevention of aspiration pneumonia. Sometimes this procedure is not effective for empyema associated with bronchopleural fistula because of washing is almost impossible. Washing of pleural cavity would cause aspiration pneumonia through the BPF. In our patient the fistula was detected 31 days after pneumonectomy. According to the classification of Varoli and colleagues this was an intermediate bronchopleural fistula. We think the cause of bronchopleural fistula in our patient was impaired healing of the bronchial stump due to bulky dissection subcarinal lymphnodes. We chose emergency thoracotomy instead of tube drainage because the patient did not present with aspiration pneumonia or empyema but we suspected a fistula had developed and we considered it was an improvement to close it as soon as possible. After conservative therapy endoscopic treatment aimed at closing the bronchial fistula is usually attempted. The use of gluing material ensures an immediate closure that stops air leakage but it involves remarkable technical difficulties because of the rapidity with which these materials solidify and the impossibility of applying this technique to all bronchi or to every kind of bronchopleural fistula. Recently polidocanol submucosal injections have been reported to pose no serious technical difficulties and they can be used on any bronchus, even the superior ones [6]. Varoli and colleagues [6] described this treatment as simple, safe, scarcely traumatic, and inexpensive. Even more interesting is the 100% healing rate of partial fistulas as wide as 10 mm and those occurring after pneumonectomy [6]. We used this technique in our patient after the repair of the bronchial stump in the remnant right thorax was not effective. We administered numerous submucosal injections of polidocanol on the edges of the fistula but this procedure also was unsuccessful.
The last treatment possibility is a surgical approach such as transternal mediastinal approach, thoracoplasty, omentopexy, or intrathoracic muscle transposition that should be reserved for those patients showing impaired healing. We performed thoracoplasty and repaired the bronchopleural fistula using a latissimus dorsi muscle flap because the patient had previously undergone a gastrectomy and we could not use the omentum. Furthermore after thoracoplasty the right thoracic cavity was almost closed; however the fluid in the cavity increased owing to the new fistula that developed in the right main bronchus on postoperative day 11. Thus the fluid flowed into the left main bronchus causing aspiration pneumonia and the patient was intubated and mechanically ventilated. Continuous flow from ventilation did not close the fistula. Therefore we considered one-lung ventilation by placing the tip of the bronchial tube in the left main bronchus to block the orifice of the fistula but this procedure would have been a burden for the patient. Consequently we used the modified Dumon stent.
Since Dumon [7] first described his tracheobronchial stent in 1990 the use of these silicone endoprostheses has gained increasing acceptation especially for patients with central airway stenoses. Recently Watanabe and colleagues [8] reported they had successfully managed a patient with a bronchopleural fistula after lobectomy using a Dumon stent. We modified the Dumon stent by cutting and folding the right arm of the stent using Aron Alpha for the carina. We put only a flap to fasten the stent at the right main bronchus. That is to say, the Aron Alpha was not in direct contact with the bronchial mucosa and we believed that this modified Dumon stent with Aron Alpha was harmless for the body. Furthermore the viscosity of Aron Alpha is the strongest among other bonds. Placement of this stent was easy and safe. This procedure has two advantages: one is the blockade of the bronchopleural fistula; the other is that a chest tube drainage could be used in the thoracic cavity and granulation tissue developed. This modified Dumon stent was useful for bronchopleural fistula after pneumonectomy. We did not remove this stent while the patient was alive but after his death, we confirmed complete closure of the fistula at the postmortem examination.
It would be reasonable to intubate the patient from the trachea to the left main bronchus to prevent the air current from the central airway to the bronchial stump fistula in the right main bronchus. In our patient continuous drainage of the right thoracic cavity performed concomitantly with blockade of the airway with the bronchopleural fistula might have induced intrathoracic development of granulation tissue, which might have resulted in closure of the stump.
|
References |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  C. A. Kutlu, S. Patlakoglu, A. E. Tasci, and O. Kapicibasi A novel technique for bronchopleural fistula closure: an hourglass-shaped stent. J. Thorac. Cardiovasc. Surg., January 1, 2009; 137(1): e46 - e47. [Full Text] [PDF]
|
|
|
|
 |
|
 L. A. Clemson, E. Walser, A. Gill, J. E. Lynch, and J. B. Zwischenberger Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate Ann. Thorac. Surg., November 1, 2006; 82(5): 1924 - 1926. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Feller-Kopman, R. Bechara, R. Garland, A. Ernst, and S. Ashiku Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest, July 1, 2006; 130(1): 273 - 275. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. T. Bolliger, T. G. Sutedja, J. Strausz, and L. Freitag Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents. Eur. Respir. J., June 1, 2006; 27(6): 1258 - 1271. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
X. Han, G. Wu, Y. Li, and M. Li A novel approach: treatment of bronchial stump fistula with a plugged, bullet-shaped, angled stent. Ann. Thorac. Surg., May 1, 2006; 81(5): 1867 - 1871. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Tsukada and H. Osada Use of a Modified Dumon Stent for Postoperative Bronchopleural Fistula Ann. Thorac. Surg., November 1, 2005; 80(5): 1928 - 1930. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. P. Madden, A. Sheth, T. B.L. Ho, G. R. McAnulty, and R. E. Sayer A Novel Approach to the Management of Persistent Postpneumonectomy Bronchopleural Fistula Ann. Thorac. Surg., June 1, 2005; 79(6): 2128 - 2130. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. S. Koh, A. A. Ling Hsu, and A. Thirugnanam Novel management of a large chronic bronchocutaneous fistula after lobectomy Interactive CardioVascular and Thoracic Surgery, June 1, 2005; 4(3): 248 - 249. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. E. Garcia Franco, J. F. Aldeyturriaga, and J. Z. Gaviria Ultraflex Expandable Metallic Stent for the Treatment of a Bronchopleural Fistula After Pneumonectomy Ann. Thorac. Surg., January 1, 2005; 79(1): 386 - 386. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
