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Ann Thorac Surg 2004;77:326-328
© 2004 The Society of Thoracic Surgeons

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Case report

Closure of bronchopleural fistulas using Albumin-Glutaraldehyde tissue adhesive

^a Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA

Accepted for publication April 29, 2003.

^* Address reprint requests to Dr Shiraishi, Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan 602-8566.
e-mail: isao{at}koto.kpu-m.ac.jp

	Abstract

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Bronchopleural fistulas are a life-threatening complication of pulmonary resection. A 21-year-old woman developed a large bronchopleural fistula after undergoing a pneumonectomy for carcinoid tumor. Despite bronchial stump revision and omental coverage, the fistula recurred. The second patient is a 42-year-old woman with a history of multiple thoracotomies who developed a bronchopleural fistula following aortic root replacement. Using either rigid bronchoscopy or thoracoscopy, these fistulas were evaluated and sealed with an albumin-glutaraldehyde tissue adhesive that may have improved strength and biocompatibility compared with other tissue sealants. This approach may be an effective alternative in the treatment of bronchopleural fistulas.

	Introduction

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Bronchopleural fistulas can be a severe complication of pulmonary resection with a mortality between 29% and 71% [1] and occur in 0.8% to 15% of pneumonectomies according to a recent series [2]. Large, refractory fistulas may require operative interventions including bronchial stump revision with omental or muscular reinforcement, thoracoplasty, or open window thoracostomy. However, minimally-invasive techniques using tissue sealants, including fibrin, have been recommended for initial therapy [3]. In this report the application of a bovine albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc., Kennesaw, GA) is described as an alternative agent that may be effective in the closure of bronchopleural fistulas.

	Case reports

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Patient 1
A 21-year-old woman underwent a right pneumonectomy for a carcinoid tumor involving the right mainstem bronchus, which was transected just above the origin of the upper lobe. One-month later, she developed an empyema and underwent tube thoracostomy. Bronchoscopy revealed a large fistula at the medial aspect of the bronchial stump. Although the air leak initially subsided with the application of fibrin, it recurred the following day. On final pathology, the pneumonectomy margin was positive for focal carcinoid.

After transfer to the University of Michigan for further treatment, she was found on bronchoscopy to have a 1-cm opening at the bronchial stump. She underwent reexcision of the bronchial cuff, with negative frozen sections, using a stapled closure reinforced with Vicryl sutures and an omental flap. One-week later, a Clagett procedure was performed, filling the pleural cavity with polymyxin, neomycin, and bacitracin.

However, 4-months later she developed fevers with a right hydropneumothorax consistent with a recurrent bronchopleural fistula. She was started on intravenous antibiotics and underwent tube thoracostomy. Bronchoscopy demonstrated a small necrotic area in the central portion of the bronchial stump, although no frank hole was seen. Two 4 Fr Fogarty catheters were attached to the double-barreled BioGlue applicator. Using rigid bronchoscopy, the catheters were positioned over the weakened area, which was then completely covered with BioGlue. The patient was placed in the right lateral decubitus position for 1 minute to allow the adhesive to dry and to prevent occlusion of the left bronchial airways.

Postoperatively, no air leak was found, and antibiotics were stopped after she defervesced. On postoperative day 3 the right hemithorax was filled with double antibiotic (DAB) solution, composed of doxycycline and polymyxin B, and the chest tube was removed. At 5-month follow-up she was much improved with complete filling of her right hemithorax on chest radiograph.

Patient 2
The second patient is a 42-year-old woman with a history of bicuspid aortic valve who had undergone multiple thoracotomies. She recently underwent an ascending aortic root replacement for coarctation and was found to have dense pleural adhesions. Postoperatively she developed a persistent bronchopleural fistula and was started on intravenous antibiotics. With her history of multiple thoracotomies, she was treated conservatively with tube thoracostomy and long-term oral antibiotics due to her recent aortic prosthetic graft. However, a computed tomography chest scan 3-months later continued to reveal a residual posterior apical pleural space.

With a history of severe pleural adhesions, a left thoracotomy and exploration were considered inappropriate due to the potential for further lung injury and bronchopleural fistulas. An empyema tube was also considered, but due to her young age and prosthetic aortic graft, the decision was made to attempt to either resect or seal the fistula using a thoracoscopic approach. After irrigation with chlorpactin, a ureteroscope was introduced through the chest tube (Fig 1). A small, posterior apical bronchopleural fistula was identified with dense pleural adhesions making any mobilization difficult. A single 4 Fr Fogarty catheter was introduced through the working port of the scope and attached to the BioGlue applicator. The adhesive was quickly applied to prevent occlusion of the catheter as the two components of the BioGlue mixed. The small, posterior apical space was completely filled with 20 mL of BioGlue sealing the bronchopleural fistula. Ventilation to the right lung was then withheld for 1 minute to allow the adhesive to dry, and a new 20 Fr chest tube was placed through the residual tract.

View larger version (33K): [in this window] [in a new window]   Fig 1. Application of albumin-glutaraldehyde tissue adhesive using a ureteroscope introduced through the chest tube.

	Comment

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Bronchopleural fistulas occur in 0.8% to 15% of patients after pneumonectomy [2] and can have devastating consequences including aspiration pneumonia and empyema with a mortality between 29% and 71% [1]. Factors that predispose to fistula formation include chemotherapy or radiation therapy, positive margins, a long bronchial stump, right pneumonectomy, and postoperative mechanical ventilation [1, 2]. Excessive dissection, resulting in tissue ischemia, and tension on the bronchial suture line can also lead to dehiscence. Treatment options include revision of the bronchial stump with omental or muscular coverage, thoracoplasty, open window thoracostomy, and more recently, bronchoscopic closure with various sealants.

Fibrin has been used in the closure of bronchopleural fistulas with varying success [3, 4] and is often recommended as the initial therapy. However, some have questioned its adhesive strength and reliability in sealing tissues [5]. Acrylic glues and other adhesives have also been used, but have not been widely accepted due to issues with histocompatibility [5].

BioGlue is derived from bovine albumin cross-linked by glutaraldehyde and has been approved as an adhesive for vascular anastomoses and aortic root repair. The components are mixed in a double helix syringe, and polymerization begins immediately after application, reaching full strength within 2 minutes. Herget and coworkers [6] described using an albumin-glutaraldehyde adhesive as a sealant for bronchial anastomoses in sheep. They found no signs of healing disturbances or pneumothorax. Tight closure of all defects was found, and at 12 weeks, few remnants of adhesive were present. They found BioGlue to be an effective adjunct in sealing bronchial anastomoses and parenchymal defects with minimal disruption in healing [6].

Tissue adhesives can be applied using minimally-invasive techniques and may be ideal in patients who would not tolerate a thoracotomy. Patients with dense adhesions may also benefit from a thoracoscopic approach through the chest tube as demonstrated here. Albumin-glutaraldehyde tissue adhesives may provide improved strength and biocompatibility and is a valuable alternative in the closure of bronchopleural fistulas.

	References

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1. Wright C.D., Wain J.C., Mathisen D.J., Grillo H.C. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management. J Thorac Cardiovasc Surg 1996;112:1367-1371.[Abstract/Free Full Text]
2. Deschamps C., Bernard A., Nichols F.C., 3rd, et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence. Ann Thorac Surg 2001;72:243-247.[Abstract/Free Full Text]
3. York E.L., Lewall D.B., Hirji M., Gelfand E.T., Modry D.L. Endoscopic diagnosis and treatment of postoperative bronchopleural fistula. Chest 1990;97:1390-1392.[Abstract/Free Full Text]
4. Glover W., Chavis T.V., Daniel T.M., Kron I.L., Spotnitz W.D. Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas. J Thorac Cardiovasc Surg 1987;93:470-472.[Abstract]
5. Fleisher A.G., Evans K.G., Nelems B., Finley R.J. Effect of routine fibrin glue use on the duration of air leaks after lobectomy. Ann Thorac Surg 1990;49:133-134.[Abstract]
6. Herget G.W., Kassa M., Riede U.N., Lu Y., Brethner L., Hasse J. Experimental use of an albumin-glutaraldehyde tissue adhesive for sealing pulmonary parenchyma and bronchial anastomoses. Eur J Cardiothorac Surg 2001;19:4-9.[Abstract/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 Author home page(s): Mark D. Iannettoni Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lin, J. Articles by Iannettoni, M. D. Search for Related Content PubMed PubMed Citation Articles by Lin, J. Articles by Iannettoni, M. D. Related Collections Congenital - cyanotic