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Ann Thorac Surg 2006;81:364-366
© 2006 The Society of Thoracic Surgeons

Case report

Bronchopleural Fistula Treated With a Covered Wallstent

Nicola C. Jones, AFRCS(Ed) a , * , Alan J. B. Kirk, FRCS a , Richard D. Edwards, MRCP, FRCR b

a Department of Cardiothoracic Surgery, Western Infirmary, Glasgow, Scotland, United Kingdom
b Department of Radiology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom

Accepted for publication September 17, 2004.

* Address correspondence to Ms Jones, Department of Cardiothoracic Surgery, Western Infirmary, Glasgow, Scotland G11 6NT (Email: nc.jones{at}btinternet.com).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Bronchopleural fistula is a well-recognized complication of pneumonectomy, which presents a difficult challenge to the thoracic surgeon. We report the successful treatment of a bronchopleural fistula after right pneumonectomy for lung cancer, using a covered esophageal stent.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Bronchopleural fistula (BPF) is a well-recognized and potentially fatal complication of pneumonectomy [1]. Several strategies regarding its prevention and subsequent management have been described [1, 2]. We report the successful management of a large BPF after right pneumonectomy by placement of a covered esophageal stent.

A 64-year-old retired man was diagnosed with squamous cell carcinoma of the lung. At operation the tumor was close to the carina, as anticipated from the bronchoscopy findings; therefore, a right pneumonectomy was carried out. The bronchus was cleared of lymphadenopathy and was divided using an automatic stapling device, angled to include the right lower trachea. The bronchial stump was covered in tissue glue and further reinforced by mediastinal pleura and azygos vein. The initial postoperative course was uneventful, and he was discharged home on postoperative day 7.

The patient was readmitted 3 weeks later with severe breathlessness and expectoration of large amounts of bloodstained material when lying down. A chest roentgenogram showed a hydropneumothorax occupying the right pneumonectomy space. Rigid bronchoscopy revealed a 2-mm defect in the bronchial stump. The diagnosis of tracheo-bronchopleural fistula was made, with dehiscence of the bronchial stump. The fistula was cauterized using sodium hydroxide crystals and application of tissue glue. He made a good recovery and was discharged home.

He was readmitted 6 weeks postoperatively, in a moribund condition due to obvious sepsis. Despite rib resection, tube thoracostomy (40 French gauge) and 10-day antibiotic therapy, he remained breathless and pyrexial with a persistent leukocytosis. At bronchoscopy the fistula was now noted to be >1 cm. A repeat thoracotomy was carried out with right pleural toilet, direct bronchial closure, and omentopexy. The BPF unfortunately persisted, and although the sepsis was well-controlled, he remained severely dyspneic at rest due to a large percentage of his tidal volume escaping through the fistula.

After discussion with the interventional radiologists, it was agreed that the placement of a covered stent would be a reasonable treatment option. The diameters of the trachea and left main bronchus measured 22 mm and 14 mm, respectively, by computed tomography (Fig 1). As it was necessary to stent both trachea and left main bronchus, a covered, self-expanding esophageal Flamingo Wallstent (Boston Scientific Ltd, Natick, MA), tapering from 24 to 16 mm was selected. This stent is comprised of a covered self-expanding cobalt-based alloy. The proximal and distal 15 mm of the stent were uncovered to aid fixation. The distal 25 mm was trimmed from the 100 mm stent to minimize the risk of covering the orifice of the left upper lobe bronchus while maintaining adequate apposition in the distal trachea. The stent was introduced over a guidewire placed in the left lower lobe bronchus through a fiberoptic bronchoscope. The fistula was excluded by the stent with immediate improvement in the patient's dyspnea.



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  		Fig 1. Nonenhanced computed tomographic scan shows large defect at the level of the right bronchial stump.

 
The patient was discharged, but he was readmitted a week later with symptomatic deterioration. A chest roentgenogram revealed that the stent had migrated proximally; therefore it was necessary to insert a second covered Wallstent (Boston Scientific Ltd). On this occasion, the stent was not trimmed and the distal uncovered portion was deliberately placed across the orifice of the left upper lobe bronchus (Fig 2).



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  		Fig 2. Radiographic appearance after insertion of a second covered Wallstent (Boston Scientific, Ltd). Skin markers were placed at the positions of the carina and left main bronchus (arrows) origin using a combination of bronchoscopy and fluoroscopy.

 
He showed no further signs of empyema, and antibiotic therapy was stopped. He was treated with mucolytics and cough suppressants to minimize further stent migration. Chest roentgenograms showed progressive obliteration of the pneumonectomy space. There was no evidence of collapse or consolidation of the left upper lobe during follow-up. The patient died from an unrelated cerebrovascular accident 12 months after his final discharge.


   Comment
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 Abstract
 Introduction
 Comment
References
 
The incidence of bronchopleural fistula after major thoracic surgery is reported as 2% to 12%, with the associated mortality of 10% to 50% [1, 2]. The variation in incidence and mortality rates can be attributed to differences in definition, underlying pathology, surgical technique, postoperative management, and concomitant radiotherapy or chemotherapy. The use of new surgical materials and automatic stapling devices has reduced the incidence considerably, with Vester and colleagues [2] reporting a 1.6% incidence. The majority of BPFs occur after pneumonectomy or bilobectomy.

The diagnosis of BPF is made both on clinical grounds and radiologic evidence. The clinical signs are fever, haemopurulent or mucopurulent sputum, cough producing staples or sutures, surgical emphysema, and increasing breathlessness. The radiologic signs are increased pneumothorax, lessening or disappearance of intrapleural effusion after pneumonectomy and a positive fistulogram [1]. Diagnosis is confirmed by bronchoscopy. There are many factors attributed to the cause of BPFs including erosion of the suture line by an extrinsic or intrinsic lesion, intrinsic weakness of the bronchial stump, invasion of the bronchial stump by neoplasm, devitalization and devascularization of the bronchus, peribronchial infection, poor approximation of the mucosa, and length of the stump [1, 2].

The use of stents in airways has been reported for more than 40 years, ever since Montgomery [3] described the use of a silicone T-tube to stent the trachea in 1965. It is now a well-established technique for the management of tracheal stenosis [4, 5]. Silicone was the preferred material, as it is flexible, relatively inert, causes little tissue reaction, and is more malleable. Dumon [4] modified this stent in 1990 and redesigned the rigid bronchoscope and introducer system in order to improve stent insertion and reduce stent migration. Gianturco first described a self-expanding, metallic Z-stent and Wallace and colleagues reported its successful use in tracheal stenosis in 1986 [5].

Watanabe and colleagues [6] described the successful management of BPF after lobectomy, which involved placement of a short-segment silicone stent. However, covered metallic stents are now commercially available for use in the bronchial tree.

Tracheobronchial stents may cause problems due to a foreign body sensation resulting in irritable cough or impaired mucociliary clearance of secretions. It is important to prevent build-up of tenacious secretions within the stent, using inhaled mucolytics such as acetylcysteine. Appropriate sizing is crucial in order to minimize migration. In this case, removal of the uncovered distal portion of the original stent may have contributed to its subsequent migration.

We conclude that covered stents may be an effective treatment in patients with a large inoperable bronchopleural fistula when other treatment options have failed.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Pacheco CR, Gongora E, Rivero O, Green L. Conservative treatment of bronchopleural fistula after pulmonary resection J Thoracic Surg 1957;14(2):196-205.
  2. Vester SR, Faber P, Kittle CF, Warren WH, Jensik RJ. Bronchopleural fistula after stapled closure of bronchus Ann Thorac Surg 1991;52:1254-1258.
  3. Montgomery WW. T-tube tracheal stent Arch Otolaryng 1965;82:320-321.
  4. Dumon JF. A dedicated tracheobronchial stent Chest 1990;97:328-332.[Abstract/Free Full Text]
  5. Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial treeexpandable metallic stents used in experimental and clinical applications. Radiology 1986;158:309-312.[Abstract/Free Full Text]
  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;72:276-278.[Abstract/Free Full Text]



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