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Ann Thorac Surg 2005;80:1930-1932
© 2005 The Society of Thoracic Surgeons

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Case report

Occlusion of a Broncho-Cutaneous Fistula With Endobronchial One-Way Valves

^a Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, and Monash University, Melbourne, Australia
^b Department of Cardiothoracic Surgery, Austin and Repatriation Medical Centre, Heidelberg, Australia

Accepted for publication June 7, 2004.

^_* Address correspondence to Dr Snell, Department of Allergy, Immunology and Respiratory Medicine, 5th Floor, Alfred Hospital, Melbourne 3004, Australia (Email: g.snell{at}alfred.org.au).

	Abstract

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Bronchopleural and broncho-cutaneous fistulas can be problematic after lobectomy for tumors or aspergillomas. Closure of the air leak and treatment of infection are essential to allow the fistula to heal. The initial treatment can usually proceed along standard lines, but if the fistula persists, then treatment can be problematic. This report is the first description of the use of multiple Emphasys Medical endobronchial valve prostheses (Emphasys Medical, Inc, CA) to control a previously intractable broncho-cutaneous fistula. The valves have been specifically designed for airway placement as part of a therapeutic approach to severe emphysema. The advantages of using valves in this situation are discussed.

	Introduction

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Mr Williams discloses a financial relationship with Emphasys Medical, Inc.

 

Broncho-cutaneous fistulas are a rare, late complication of lobectomy. They are known to occur after the resection of tumors and aspergilloma. Closure of the air leak and treatment of infection are essential to effect healing of the fistula. Endobronchial occlusion of fistulas has been used in recent years for its simplicity and success in otherwise intractable cases. This report describes the endoscopic closure of a large, longstanding broncho-cutaneous fistula by placing a newly designed airway prostheses with one-way valves.

A 53-year-old man with a history of aspergillosis was referred for consideration of endobronchial treatment of a 6-year broncho-cutaneous fistula. The fistula had complicated a right upper lobectomy with right apical segmentectomy and thoracoplasty performed in 1997. Surgery was undertaken for significant hemoptysis in the setting of an extensive upper lobe cavitation and associated Aspergillus fungal balls. Relevant past medical history included bilateral talc pleurodesis for spontaneous pneumothoraxes and rheumatoid arthritis treated with Prednisolone.

Despite the thoracoplasty, there was a large residual subscapular space and constant air leak. Repeated unsuccessful attempts were made to obliterate the post lobectomy apical space by muscle transpositions of the right serratus anterior and left latissimus dorsi muscles. A small posterior space was managed with tube drainage. All of these procedures failed to obliterate the space completely, and in 2003 the patient was left with a long broncho-cutaneous fistula, opening into a posterior chest wall sinus (Fig 1). The patient was able to breathe in and out through the fistula, even with a closed nose and mouth. This translated to recurrent pulmonary sepsis and social difficulties. An assessment fiberoptic bronchoscopy revealed intact right upper lobe and superior segment right lower lobe stumps. The air leak was determined to be from specific basal segments of the right lower lobe. This was achieved by occluding segment-by-segment with the fiberoptic bronchoscope and monitoring the effect on air leak, and subsequently by injecting colored dye and observing its appearance at the fistula skin opening.

View larger version (148K): [in this window] [in a new window]   Fig 1. The preoperative chest roentgenogram shows the extent of the prior right chest wall surgical attempts at fistula control.

View larger version (129K): [in this window] [in a new window]   Fig 2. An example of the Emphasys Medical valve (Emphasys Medical, Inc, CA). The proximal end is seen with the silicon valve facing forward. A Nitinol frame supports and anchors the valve in the airway.

View larger version (179K): [in this window] [in a new window]   Fig 3. The prosthesis in situ in a basal segmental airway.

On review in December 2003, the air leak appeared to be completely controlled with increasing epithelization of the raw surface where the air leak had previously been located. Although there was some residual discharge from the chest wall sinus, sputum production had dramatically decreased and there had not been any other significant pulmonary sepsis problems.

	Comment

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Aspergillosis in nonimmunocompromised patients is uncommon, but it is more likely to occur in patients with prior pulmonary disease or mild immune dysfunction with corticosteroid use [2]. Surgery remains a primary therapy for symptomatic aspergilloma, but it is acknowledged that major postoperative complications still occur, including bronchopleural fistula and resistant air space problems. In a recent series of 18 patients by Denning and colleagues [2], 4 patients underwent repeat surgical resection, with 1 patient who had further complications of an ongoing bronchopleuro and broncho-cutaneous fistula.

Historically, closures of bronchopleural and broncho-cutaneous fistulas have been attempted using pedicle muscle flaps with or without further resection of the bronchus [3, 4]. Persistent infection and air leak reduced the likelihood of healing. More recently, bronchopleural fistulas have been successfully treated endoscopically using a number of techniques to occlude the bronchial stump. These include the use of vascular occluding coils in conjunction with fibrin glue [5] and the use of a Dumon stent (Novatech, France) [6]. However, these techniques are only best suited for small fistulas and are prone to movement, which does not allow for local decompression if infected secretions build up [5].

The Emphasys prosthesis (Emphasys Medical, Inc, Redwood City, CA) was chosen because of its unique features, including the one-way valve that prevents the passage of air distally through the fistula, but allows the passage of infected secretions [1]. It is known that these valves do not cause irritation of the airway or chronic cough and can be removed if necessary. Multiple valves can be placed in a simple procedure to occlude a large air leak. Different sized prostheses can be chosen depending on the proposed target airway size.

The successful occlusion of the airway was essential in this case to control the recurrent pulmonary sepsis and allow the chest wall sinus to heal. Although further reconstructive surgery may yet to be used to completely fill the residual sinus, this report describes a simple endoscopic procedure that enabled the healing of a large, long-term fistula that had defied conventional surgical approaches.

	Acknowledgments

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Emphasys Medical, Inc, provided financial and technical support to perform this study.

	References

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1. Snell GI, Holsworth L, Borrill ZL, et al. The potential for bronchoscopic lung volume reduction using bronchial prosthesesa pilot study. Chest 2003;124(3):1073-1080.[Abstract/Free Full Text]
2. Denning DW, Riniotis K, Dobrashian R, Sambatakou H. Chronic cavitary and fibrosing pulmonary and pleural aspergillosiscase series, proposed nomenclature change and review. Clin Infect Dis 2003;37(Suppl 3):S265-S280.
3. Jones Jr WF, Hughes FA, Campbell RE, Keisker HW. Management of bronchocutaneous fistula Am Surg 1961;27:798-802.[Medline]
4. Cooper WA, Miller Jr JI. Management of bronchopleural fistula after lobectomy Semin Thorac Cardiovasc Surg 2001;13(1):8-12.[Medline]
5. Watanabe S, Watanabe T, Urayama H. Endobronchial occlusion method of bronchopleural fistula with metallic coils and glue Thorac Cardiovasc Surg 2003;51(2):106-108.[Medline]
6. 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(1):276-278.[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): Leif Eriksson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Snell, G. I. Articles by Williams, T. J. Search for Related Content PubMed PubMed Citation Articles by Snell, G. I. Articles by Williams, T. J. Related Collections Lung - other