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Ann Thorac Surg 2005;79:2128-2130
© 2005 The Society of Thoracic Surgeons

Case report

A Novel Approach to the Management of Persistent Postpneumonectomy Bronchopleural Fistula

Brendan P. Madden, MD, FRCP*, Abhijat Sheth, FRCS, Timothy B.L. Ho, PhD, MRCP, Gregory R. McAnulty, FRCA, Richard E. Sayer, FRCS

Department of Cardiothoracic Surgery, St. George’s Hospital, London, United Kingdom

Accepted for publication December 10, 2003.

* Address reprint requests to Dr Madden, St. George’s Hospital, Blackshaw Rd, London SW17 0QT, UK (E-mail: brendan.madden{at}stgeorges.nhs.uk).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
A 69-year-old man who had a left pneumonectomy for nonsmall cell lung cancer had a bronchopulmonary fistula develop that recurred after surgical closure. He had multiple organ failure develop precluding further operative intervention. Successful resolution of the fistula was achieved using a novel application of a covered expandable metallic stent.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Bronchopleural fistula is a well-recognized complication after pneumonectomy associated with significant morbidity and mortality. Ischemia and infection and the requirement for mechanical ventilation are known precipitating factors. Surgical repair remains the treatment of choice for most patients. For selected patients expandable metallic stent deployment may be an alternative.

A 69-year-old man with nonsmall cell lung carcinoma was referred to our unit for a left upper lobectomy. During the operation a central tumor (stage 2A) invading the pulmonary artery was identified, and the operation was extended to a left pneumonectomy. The resection margins were free of tumor. The bronchial stump was approximately 1 cm long and was closed with a stapling device. On postoperative day 3, the patient had left-sided chest pain, dyspnea, and pyrexia of 39°C develop. A chest roentgenogram was consistent with aspiration pneumonitis. No pathogens were cultured from sputum, blood, or the pneumonectomy space fluid. Bronchoscopy revealed a small hole (2 mm) in the bronchial stump. A left-sided intercostal drain was inserted.

Then the patient underwent re-thoracotomy. The stump was re-resected, sutured, and reinforced with an intercostal muscle flap. Air tightness was confirmed intraoperatively. At this stage, gram-negative rods were detected in the pleural space fluid and intravenous ceftazidime was commenced. On the third day after re-thoracotomy, the patient had a right-sided pleural effusion develop, and a chest drain was inserted. His sputum cultured revealed methicillin resistant Staphylococcus aureus. The patient had respiratory failure develop and methicillin resistant S. aureus septicemia. He was transferred to the intensive care unit for inotropic and mechanical ventilatory support. Antibiotic treatment was broadened to include vancomycin.

After reintubation, ventilatory support was provided by a single lumen tracheal tube and a SensorMedics 3100B high frequency oscillator ventilator (SensorMedics, Yorba Linda, CA). Bronchoscopy at this time revealed complete breakdown of the bronchial stump, and he subsequently had multiple organ failure develop. We believed that there was no prospect of weaning from mechanical ventilatory support. As his comorbidity was considered a contraindication to further surgery, we elected to deploy an 8-cm (6.5-cm covered) expandable metallic stent (Ultraflex, Boston Scientific, Watertown, MA) through a rigid bronchoscopy into the lower trachea extending into the right main bronchus ending 0.5 cm proximal to the right upper lobe bronchus. A tracheostomy tube was positioned within the stent.

Two weeks after stent deployment, the patient was successfully weaned from mechanical ventilation. The left pneumonectomy space was subsequently drained by creating a Clagett’s window. Follow-up bronchoscopy confirmed satisfactory stent position. He had no problems with sputum retention. Four weeks after stent deployment, the patient was discharged from the intensive care unit (Fig 1) and convalesced for 2 months in the thoracic ward.



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  		Fig 1. Chest roentgenogram after creation of a Clagett’s window and discharge from the intensive care unit. The tracheal stent is visible extending into the right main bronchus. A tracheostomy tube has been deployed within the stent.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Bronchopleural fistula is a well-recognized complication after pneumonectomy with a reported incidence of 1% to 4% and a mortality ranging from 16% to 70% [1]. Causative factors include ischemia and infection and the requirement for mechanical ventilation [1]. A small or occult bronchopleural fistula sometimes remains unrecognized with minimal symptoms, although a fall in fluid level on chest roentgenogram should arouse suspicion [2]. A large bronchopleural fistula presents a danger of flooding of the remaining lung, and therefore prompt drainage of the pleural space and urgent surgical intervention are mandatory. Mechanical ventilatory support, if required, may best be achieved by high frequency jet or oscillator ventilation or with selective bronchial intubation. Surgical closure with reinforcement of the bronchial stump with vascularized tissue in the form of transposed muscle or omental flap remains the procedure of choice for most patients [3]. Recurrence of bronchopleural fistula after surgical repair carries a mortality in excess of 50%, largely due to respiratory insufficiency and uncontrolled sepsis [4].

The introduction of the newer generation of expandable metallic stents has led to a significant improvement in the management of patients with large airway compromise in whom formal surgical repair is inappropriate or contraindicated [5]. A recent development has been the manufacture of covered stents in which a single layer of translucent polyvinyl chloride envelops the midsection of the stent. We have successfully employed covered stents to seal tracheal tears after percutaneous tracheostomy and tracheoesophageal fistula [6]. In this case we applied the technique to our patient in an attempt to isolate the right lung and reduce contamination from the pneumonectomy space fluid. We also wished to reduce the air leak, promote healing of the bronchial stump, and potentially wean the patient from mechanical ventilation. Our patient was considered unfit for further surgical intervention. Although a silicon stent has been used to help seal a bronchopleural fistula [7], we believe this is the first successful use of a covered expandable metallic stent in the management of complete dehiscence after surgical repair of a bronchopleural fistula postpneumonectomy. We suggest considering this approach for patients with similar clinical presentations.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Shields TW, Ponn RB. Complications of pulmonary resectionIn: Shields TW, LoCicero III J, Ponn RB, editors. General thoracic surgery. Philidelphia: Lippincott Williams and Wilkins; 1999.
  2. O’Meara JB, Slade PR. Disappearance of fluid from the postpneumonectomy space J Thorac Cardiovasc Surg 1974;67:621-628.[Medline]
  3. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomya review of 96 cases. Ann Thorac Surg 1997;63:1391-1396.[Abstract/Free Full Text]
  4. de la Riviere AB, Defauw JJ, Knaepen PJ, van Swieten HA, Vanderschueren RC, van den Bosch JM. Transsternal closure of bronchopleural fistula after pneumonectomy Ann Thorac Surg 1997;64:954-957.[Abstract/Free Full Text]
  5. Madden BP, Datta S, Charokopos N. Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology Ann Thorac Surg 2002;73:938-944.[Abstract/Free Full Text]
  6. Madden B, Datta S, Hussain I, McAnulty G. Tracheal stenting for rupture of the posterior wall of the trachea following percutaneous tracheostomy Monaldi Arch Chest Dis 2001;56:320-321.[Medline]
  7. Tayama K, Eriguchi N, Futamata Y, et al. Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy Ann Thorac Surg 2003;75:290-292.[Abstract/Free Full Text]



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This Article
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