Ann Thorac Surg 2005;80:1928-1930
© 2005 The Society of Thoracic Surgeons
Case report
Use of a Modified Dumon Stent for Postoperative Bronchopleural Fistula
Hisashi Tsukada, MD
*
,
Hiroaki Osada, MD
Department of Surgery, Division of Chest Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
Accepted for publication June 4, 2004.
* Address correspondence to Dr Tsukada, Department of Surgery, Division of Chest Surgery, Kyorin University School of Medicine, 6–20–2 Shinkawa Mitaka, Tokyo 181–8611, Japan (Email: tsukada{at}tf6.so-net.ne.jp).
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Abstract
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This report describes a case of a postoperative bronchopleural fistula successfully managed with a modified Dumon stent. Surgical interventions for the bronchopleural fistula with empyema were subsequently avoided. Dumon stent is an acceptable option for the treatment of postoperative bronchopleural fistulas.
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Introduction
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Bronchopleural fistula following lung resection continues to be a therapeutic challenge for chest surgeons. We here report a patient with bronchopleural fistula and empyema, who was successfully managed by applying a Dumon stent without surgical intervention.
A 54-year-old male underwent right extrapleural pnemonectomy with combined resection of a hemidiaphragm and hemipericardium for an epithelial type of diffuse malignant mesothelioma. The right main bronchus was closed with staples and an additional five interrupted sutures were placed fistully for reinforcement. A reversed combined latissimus dorsi and serratus anterior muscle flap was utilized to reconstruct the hemidiaphragm and hemipericardium without prosthetic materials and also to reinforce the right main bronchial stump. The muscle flap was anchored by the additional sutures mentioned above.
Massive serous sputum and cough started suddenly early the morning of postoperative day 8. We immediately placed a chest tube to drain the right thoracic cavity but could not prevent severe aspiration pneumonia and respiratory failure. The patient was then intubated down to the left main bronchus and received mechanical ventilation for one month to treat the aspiration pneumonia (Fig 1A). Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa were positive cultures from the right chest tube drainage fluids. The empyema was treated by the closed suction drainage and intravenous administration of imipenem and vancomycin. Bronchoscopy was performed following extubation. Figure 1B shows the bronchoscopic view of the fistula. Our strategy was to cover the fistula from the inside using an endobronchial procedure and fistula heal spontaneously. We specially ordered a modified Y-shaped Dumon stent (Novatech, Plan de Grasse, France). The stent size and shape was designed by computed tomographic images (Fig 2)A. This stent was fabricated to our specifications such that the right arm of the Y was shortened and made with a sealed end (Fig 2B). The modified stent was implanted two months after the original surgery through a rigid bronchoscope. The air leakage from the chest tube disappeared one week after the stent insertion. The residual isolated empyema cavity was replaced by the thickness of the granulation tissue rapidly (Fig 3A). The chest tube management was changed to an open drainage manner four weeks after the stent insertion and it was removed inch by inch every day. The empyema was treated conservatively. We required the flexible bronchoscopy for the intraluminal stent toileting at 2 months and 6 months after insertion. We observed granulation tissue in the left main bronchus at the end of the stent 6 months after the stenting. We removed the granulation by yttrium-aluminum-garnet laser irradiation. The stent was removed one year after insertion. Figure 3B shows the bronchoscopic view of the resolved fistulas. Three years after the initial surgery the patient was well and without tumor relapse.
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Fig 1. (A) Chest roentgenogram revealed a chest tube in the right thoracic cavity and intubated tube placed in the left main bronchus. (B) Bronchoscopic view revealed a large bronchopleural fistula and necrotic tissue at the right main bronchial stump.
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Fig 2. (A) The length of the right arm and the diameter of each part of the stent were calculated by the computed tomographic image. (B) Specially ordered modified Dumon stent. The right arm of the Y was shortened and the open end of the right arm sealed tight with silicon material from which the stent is fabricated.
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Fig 3. (A) The residual empyema cavity was decreased by the thickness of peel and the modified Dumon Y stent is placed in the tracheal tree just before removal. (B) View after removing stent. Bronchial stump is restored after treatment with a modified Dumon stent.
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Comment
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Reportedly, the incidence of bronchopleural fistula after pulmonary resection is in the range of 1% to 4% [1, 2]. A total of 523 lobectomies or pneumonectomies have been performed at our institution over the last decade. Fifteen of these cases (2.9%) involved bronchopleural fistulas following resection. Our standard course of action has been surgery, such as closure of the fistula with extrathoracic muscle flaps or omentum with obliteration of the usually coexisting empyema cavity. Thoracoplasty with obliteration of the postpneumonectomy hemithorax cavity required huge amounts of tissue for reconstruction. The case reported here did not meet conditions required for our standard procedure. This patient already had major muscle flaps consumed by the initial surgery. For this reason we decided to cover a fistula with a Dumon stent placed endobronchially and avoid further surgical interventions. Takayama and colleagues [3] reported modified Dumon stent for the treatment of a bronchopleural fistula following a right pneumonectomy. In the Takayama study the right arm of a Y-shaped Dumon stent was cut, folded, and inserted, covering the stump using a sealant (Aron Alpha; Toagosei Co, Ltd, Japan). Cutting an arm of an imported device like a Dumon stent might not, however, be covered by Japanese law pertaining to "product liability." Considering this, we ordered the special Dumon stent from the manufacturer. For a similar report please see Okabayashi and colleagues [4].
Dumon stents were originally intended for the management of tracheobronchial stenoses [5]. To our knowledge, only 4 cases in which a Dumon stent was utilized for the treatment of postoperative bronchopleural fistula have been reported [3, 4, 6, 7]. In these reports, as with our own experience, the methods of treatment for a right upper bronchial fistula utilizing a Dumon stent after right upper and middle bilobectomy case, were tried. We also successfully treated this case conservatively and avoided additional surgical intervention. We suggest that a Dumon stent is an acceptable option for the treatment of postoperative bronchopleural fistulas.
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References
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- Deschamps C, Bernard A, Nichols III FC, et al. Empyema and bronchopleural fistula after pneumonectomyfactors affecting incidence. Ann Thorac Surg 2001;72:243-248.[Abstract/Free Full Text]
- Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations J Thorac Cardiovasc Surg 1992;104:1456-1464.[Abstract]
- Takayama 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]
- Okabayashi T, Hamada M, Shibuya Y, Miyazawa T, Makihata K. A case of recovery from postextrapleural pneumonectomy respiratory failure and bronchopleural fistula by differential lung ventilation and stenting using a customized Dumon Y stent Kikanshigaku 2001;23:550-555.
- Dumon FJ. A dedicated tracheobronchial stent Chest 1990;97:328-332.[Abstract/Free Full Text]
- 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]
- Pospisil R, Sumutny S, Marel M. Occulusion of a post-pneumonectomy fistula using the Dumon stent Rozhl Chir 2001;80:339-342.[Medline]
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Abstract
Introduction
