Ann Thorac Surg 2006;82:1924-1926
© 2006 The Society of Thoracic Surgeons
How To Do It
Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate
Lindsey A. Clemson, BSa,
Eric Walser, MDb,
Amanjit Gill, MDb,
James E. Lynch, BS, RRTc,
Joseph B. Zwischenberger, MDc,*
a School of Medicine, The University of Texas Medical Branch, Galveston, Texas
b Department of Radiology, The University of Texas Medical Branch, Galveston, Texas
c Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
Accepted for publication January 18, 2006.
* Address correspondence to Dr Zwischenberger, Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555. (Email: jzwische{at}utmb.edu).
 |
Abstract
|
|---|
Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.
|
Introduction
|
|---|
The treatment most often recommended for persistent, complex, symptomatic bronchopleural fistulas (BPFs) involves a thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. However, this major operation can be ineffective or medically contraindicated. We report an innovative approach with transthoracic injection of coils into and adjacent to the BPF of a postpneumonectomy bronchial stump. Both coils and glue were introduced through transthoracic needles placed under guidance or thoracoscopic visualization to achieve closure in 2 consecutive patients. The postpneumonectomy space could then be irrigated, sterilized, and filled with antibiotics, and the chest tubes could be removed.
|
Technique
|
|---|
Institutional review board approval was obtained for a retrospective chart review. Patient number 1, a 57-year-old man, underwent a right pneumonectomy for stage IIB adenocarcinoma. The right bronchial stump was stapled and covered with parietal pleura. Four months after pneumonectomy he was treated for pulmonary embolus. One week later he complained of recurrent chest pain. A chest computed tomographic scan showed a fluid level change in the postpneumonectomy space with a BPF at the right main stem bronchial stump (Fig 1A). The BPF was confirmed by bronchoscopy and two large bore chest tubes were placed to evacuate air and fluid. No signs of empyema were present. A pathologic fracture of the right pelvis from metastatic lung cancer was confirmed. Therefore, he was judged a poor candidate for major surgery.
View larger version (79K):
[in this window]
[in a new window]
|
Fig 1. (A) Postpneumonectomy bronchopleural fistula (BPF) of right mainstem bronchus. (B) Postoperative computed tomographic-guided coil and glue injection at right mainstem bronchopleural fistula.
|
|
Under computed tomographic guidance, two 18-gauge needles were inserted percutaneously to transfix the BPF by puncturing the adjacent perihilar soft tissue. Endovascular coils (8 mm x 4 cm) (Cook, Inc, Bloomington, IN) were inserted through the needle and across the BPF. Then 1 cc of cyanoacrylic glue was injected through both needles into the fistula and adjacent soft tissues (Fig 1B). Chest tubes were placed to balanced suction. A small air leak was detected by inhalation xenon scanning 14 days later. Fistula closure was repeated by visualization of the air leak site using video-assisted thoracic surgery. Two more coils were inserted across the fistula, followed by glue injection into the adjacent tissues (Fig 2). The postpneumonectomy space was irrigated and filled with Dakin's antibiotic solution (sodium hypochlorite, 0.45% to 0.5%; and boric acid, 4%) and the chest tubes were removed.
View larger version (43K):
[in this window]
[in a new window]
|
Fig 2. Computed tomographic guided transthoracic coil and glue injection. (A) Set-up of procedure. (B) Detail of image-guided coil insertion into bronchopleural fistula (BPF) and adjacent tissues. (C) Detail of needle injecting cyanoacrylate glue into coils and surrounding tissues.
|
|
A week later the patient became short of breath; chest roentgenogram showed air and fluid levels with subcutaneous emphysema. The coil and glue procedure was repeated under computed tomographic guidance with successful closure. A fine needle aspiration of a lymph node adjacent to the bronchial stump was positive for metastasis. The BPF remained closed until death 1 month later due to systemic progression of cancer.
Patient number 2, a 47-year-old woman, had a right pneumonectomy for stage IIB nonsmall cell lung cancer followed by four cycles of chemotherapy postoperatively. Six months later she presented with cough, dyspnea, and a feeling of fluid in her chest, confirmed by an increased air and fluid level on chest roentgenogram. She was afebrile with a normal white blood cell count. Bronchoscopy showed a small air leak at the stump. Thoracentesis yielded gram negative organisms and she was started on vancomycin and pipperacillin–tazobactam (Zosyn, Wyeth Pharmaceuticals, Madison, NJ) with tube thoracostomy. This patient was unwilling to undergo a major surgical procedure and opted for our less invasive approach for treatment. A percutaneous coil and glue closure of the right BPF was performed under computed tomographic guidance using the technique previously described. Five days later the right thoracic cavity was irrigated with tissue plasminogen activator (due to septations) and antiseptic solution (cefipime). A xenon ventilation scan showed no leaks. She was discharged the next day after Dakin's solution irrigation and chest tube removal. Oral linezolid and levofloxacin were prescribed for 2 weeks. One month later the patient is asymptomatic with no change in air and fluid levels.
|
Comment
|
|---|
A bronchopleural fistula is defined as "communication between lobar or segmental pulmonary bronchi and the pleural space" with an incidence of 0.5% after lobectomy and 4.5% to 20% after pneumonectomy [1]. Darling and colleagues [2] reported an incidence of BPF formation after right pneumonectomy of 13.2% and after left pneumonectomy of 5%. Perioperative risk factors for BPF include radiation, chemotherapy, or immunocompromised states. Intraoperative risk factors are surgical inexperience, right pneumonectomy, long stump, stump devascularization, residual cancer, and tension on the bronchial closure. Prolonged ventilation, systemic steroids, and reintubation are postoperative risk factors.
A thoracotomy with transposition of muscle flaps or mobilization of omentum to cover the defect, vascularize the tissue, and occupy the empty postpneumonectomy space is recommended for primary closure of a BPF. These open BPF closure techniques have reported a recurrence rate of 25% to 72% [3–5]. Recently, isolated reports of successful management of BPF with placement of stents, both Dumon Bronchial Stent (Bryan Corp, Woburn, MA) and Ultraflex (Boston Scientific, Watertown, MA) have emerged [6–10]. The majority of successful BPF closures with intrameatal stents are left-sided postpneumonectomy BPF, with tracheobronchial right-sided size similarity, allowing a seal with a long covered stent. However, we wanted to avoid placing a foreign body into the normal trachea and left main bronchus due to the inherent problems of granulation tissue formation at the stent edges, inefficient clearance of secretions across the stented segment, and the lumen differential. Use of endobronchial closure techniques has gained popularity as a minimally invasive option for small BPFs or in poor surgical candidates [11]. Hollaus and colleagues [12] have reported use of endobronchial closure using submucosal injected fibrin glue with a closure rate of 51%, although some still required a chronic drainage system. Ponn and colleagues [13] have reported the use of vascular occlusion coils placed endobronchially using fluoroscopic guidance to successfully close parenchymal BPFs after failed surgical and sealant management. The endobronchial approach requires several repeat procedures in most patients to achieve adequate closure.
In this report, we describe the evolution of an image-guided technique utilizing transthoracic placement of coils and cyanoacrylate glue. In contrast to endobronchial techniques, our technique combines vascular occlusion coils as scaffolding and a sealant that potentially decreases the number of procedures and even successfully closes a major bronchial stump leak. Transthoracic needle biopsy of mediastinal and hilar lesions is a well-established technique with a low incidence of serious complications (ie, namely, a 0% to 34% reported incidence of pneumothorax and a hemoptysis rate of 0% to 10%) [14]. However, due to the presence of a postpneumonectomy space in our patients, the chance of either of these complications was low to nonexistent. The hilar vessels can be avoided with careful technique, computed tomographic fluoroscopy imaging, and a tangential approach.
Our technique successfully managed two recalcitrant postpneumonectomy BPFs. Image guidance allows insertion of coils transversely through the BPF into the tissues adjacent to the fistula tract while avoiding major vessels. The coils serve as scaffolding to which the injected cyanoacrylate glue adheres, providing anchorage to aid fistula closure. This is superior to prior reports in which glue plugs were placed directly into the lumen of a BPF and were then subsequently dislodged [15]. Although further experience is needed to validate this approach, our image-guided technique for BPF closure provides a sound basis for less invasive management of postpneumonectomy BPF.
|
References
|
|---|
- Cerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula Semin Thorac Cardiovasc Surg 2001;13:3-7.[Medline]
- Darling GE, Abdurahman A, Yi QL, et al. Risk of a right pneumonectomy: role of bronchopleural fistula Ann Thorac Surg 2005;79:433-437.[Abstract/Free Full Text]
- Asamura H, Kondo H, Goya T, Tsuchiya R, Naruke T, Suemasu K. [Bronchopleural fistulas developing after pulmonary resections for lung cancer predisposing factors, management, and prognosis] Nippon Kyobu Geka Gakkai Zasshi 1991;39:1894-1901.[Medline]
- Chichevatov D, Gorshenev A. Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy Asian Cardiovasc Thorac Ann 2005;13:211-216.[Abstract/Free Full Text]
- Michaels BM, Orgill DP, Decamp MM, Pribaz JJ, Eriksson E, Swanson S. Flap closure of postpneumonectomy empyema Plast Reconstr Surg 1997;99:437-442.[Medline]
- Garcia Franco CE, Flandes Aldeyturriaga J, Zapatero Gaviria J. Ultraflex expandable metallic stent for the treatment of a bronchopleural fistula after pneumonectomy Ann Thorac Surg 2005;79:386.[Free Full Text]
- Madden BP, Sheth A, Ho TB, McAnulty GR, Sayer RE. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula Ann Thorac Surg 2005;79:2128-2130.[Abstract/Free Full Text]
- 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]
- Tsukada H, Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula Ann Thorac Surg 2005;80:1928-1930.[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]
- Salmon CJ, Ponn RB, Westcott JL. Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula Chest 1990;98:233-234.[Medline]
- Hollaus PH, Lax F, Janakiev D, et al. Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases Ann Thorac Surg 1998;66:923-927.[Abstract/Free Full Text]
- Ponn RB, D'Agostino RS, Stern H, Westcott JL. Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils Ann Thorac Surg 1993;56:1343-1347.[Medline]
- Protopapas Z, Westcott JL. Transthoracic hilar and mediastinal biopsy Radiol Clin North Am 2000;38:281-291.[Medline]
- Walser EM, Gomez G, Zwischenberger JB, et al. Combined transthoracic and transtracheal closure of large bronchopleural fistulae J Laparoendosc Adv Surg Tech A 2004;14:97-101.[Medline]
This article has been cited by other articles:
|
|
|
|
 
S. Yata, T. Kaminou, M. Hashimoto, Y. Ohuchi, K. Sugiura, A. Adachi, T. Kawai, M. Endo, S. Takasugi, S. Yamamoto, et al.
Successful closure of intractable tracheoesophageal fistula using a combination of a modified silicon stent and metallic stents
Acta Radiologica Short Reports,
March 1, 2012;
1(2):
9 - 9.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Y. Chae, J. H. Shin, H.-Y. Song, J.-H. Kim, T. S. Shim, and D. K. Kim
Bronchopleural Fistula Treated With a Silicone-Covered Bronchial Occlusion Stent
Ann. Thorac. Surg.,
January 1, 2010;
89(1):
293 - 296.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. F. Molnar
Current surgical treatment of thoracic empyema in adults
Eur J Cardiothorac Surg,
September 1, 2007;
32(3):
422 - 430.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
