Ann Thorac Surg 2007;83:1519-1521
© 2007 The Society of Thoracic Surgeons
Case Reports
Bronchopleural Fistula Repair During Clagett Closure Utilizing a Collagen Matrix Plug
Subroto Paul, MDa,
Simon G. Talbot, MDb,
Matthew Carty, MDb,
Dennis P. Orgill, MD, PhDb,
Lambros Zellos, MD, MPHa,*
a Division of Thoracic Surgery, Boston, Massachusetts
b Division of Plastic Surgery, Department of Surgery, Brigham & Women’s Hospital, Boston, Massachusetts
Accepted for publication October 3, 2006.
* Address correspondence to Dr Zellos, Brigham and Women’s Hospital, Division of Thoracic Surgery, 75 Francis St, Boston, MA 02115 (Email: lzellos{at}partners.org).
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Abstract
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We describe a 65-year-old man who was treated for an empyema after a right middle and lower lobectomy for adenocarcinoma with a Clagett procedure who subsequently had a bronchopleural fistula develop. After adequate debridement of the cavity through dressing changes, the right bronchus intermedius bronchopleural fistula was closed using a collagen porcine plug (Surgisis anal fistula plug [Cook Medical Inc, Bloomington, IN]) placed through the cavity into the fistula along with the placement of omentum into the cavity. This case report illustrates the utility of collagen plugs to close bronchopleural fistulas.
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Introduction
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The management of bronchopleural fistulas remains controversial as a myriad of therapeutic strategies have been implemented with varying degrees of success. Bronchopleural closure through re-suturing, re-stapling, or using the Clagett procedure is well described, but have considerable morbidity. Recent technologic advancements have placed an emphasis on minimally invasive techniques for bronchopleural fistula closure. These have included fibrin glue application, stent placement, or endobronchial one-way valve placement. We describe another technique with the use of a porcine collagen plug.
We describe a 65-year-old man who underwent a right thoracotomy with a right middle and lower lobectomy with a parathymic pericardial fat pad buttress to the bronchial stump for T2N1 lung adenocarcinoma. The patient’s medical history was notable for hypertension, his prostate cancer was treated with a radical prostatectomy, and his recently diagnosed left-sided renal cell cancer was to be treated by radiofrequency ablation after recovery from his thoracotomy. He began a planned four-cycle course of carboplatin and paclitaxel 6 weeks after his surgery. After completion of his second cycle of chemotherapy, the patient had a persistent cough develop with episodes of night sweats and leukocytosis (white blood cell count, 37.5). Subsequent chest computed tomography revealed a large right-sided pleural effusion with suggestion of fibrinous debris. The patient was taken to the operating room 9 weeks after the original bilobectomy and underwent a Clagett procedure. Bronchoscopy and visual inspection from within the chest did not reveal a bronchopleural fistula at this time. Intraoperative cultures from the thoracic cavity did not reveal any offending organisms. The patient was subsequently discharged home with dressing changes to debride the cavity and intravenous antibiotics despite negative cultures with plans to close the cavity after sufficient debridement with a muscle or omental flap. During the course of dressing changes in the following 4 weeks, the patient had a bronchopleural fistula develop as noted by the flow of air in the cavity during exhalation though an aperture in the apex of the cavity. Repeat chest computed tomography prior to closure confirmed the presence of the bronchopleural fistula (Fig 1A), as well as confirming that there was no evidence of metastatic disease in the chest at the time of closure.
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Fig 1. (A) Chest computed tomographic scan demonstrating bronchopleural fistula (asterisk). (B) Operative photograph demonstrating collagen plug (arrow) placed into bronchopleural fistula.
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The patient was taken to the operating room 10 weeks after the Clagett procedure. Bronchoscopy confirmed the presence of the bronchopleural fistula from his bronchus intermedius stump. During positive pressure ventilation, a continuous current of air was noted from the Clagett window apex. No clear bronchial stump was seen as granulation tissue had formed around the stump. There was no discrete tissue into which sutures could be placed for fistula closure. As no sutures could be placed, a porcine collagen plug (Surgisis anal fistula plug [Cook Medical Inc, Bloomington, IN]) previously described for use in anal fistula repair was placed into the fistula tract and trimmed to fit (Fig 1B). After placement of the plug, the air leak through the fistula resolved. Omentum was mobilized from the stomach and the colon through a midline laparotomy and was placed into the Clagett cavity through a small defect created in the diaphragm. Skin flaps were raised and both the thoracic cavity and midline laparotomy were closed in layers. A chest tube was placed near the bronchopleural fistula to water seal drainage and two Jackson-Pratt drains were placed under the skin flaps. The chest tube had no evidence of an air leak. Thereafter the patient had an uneventful postoperative course and was discharged home on postoperative day 4 with a chest tube and drains. The drains and chest tube were subsequently removed on an outpatient basis.
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Comment
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Successful management of bronchopleural fistulas after pulmonary resections remains a challenging problem in thoracic surgery. Multiple techniques have been developed to address this difficult problem including re-suturing and re-stapling techniques by redo thoracotomy or sternotomy and the Claggett procedure, all of which entail considerable morbidity [1–3]. Recent interest has been focused on minimally invasive procedures such as fibrin glue application and placement of endobronchial stent valves. We describe another technique with the use of a porcine collagen plug.
Collagen plug closure has been described for anal fistulas and the Surgisis product is marketed for this use [4]. Experimental canine models of bronchopleural fistula closure using a collagen screw has been described but not in human beings [5]. The Surgisis plug is ideal for fistula closure as it is biodegradable. Surgisis is derived from the collagenous mucosal layer of the wall of the porcine small intestine. It is processed and fixed by treatment with glutaraldehyde and other agents and then freeze-dried to cross-link proteins and reduce the immunogenicity of material [6]. Hence, Surgisis provides a matrix for native tissue in-growth and healing. It is also tapered and allows for easy modification to fit into fistulas of varying sizes. Application is simple as after it is sized to fit; it just needs to be snugly placed into the fistula and sealed. The collagen plug swells with hydration to further seal the fistula. In addition, it is Food and Drug Administration approved, readily available, and has been proven successful in the repair of anal fistulas.
In our case it was not possible to place sutures to primarily close the bronchopleural fistula as is often the case when fistulae develop early after resectional surgery. Hence, the fistula had to be sealed by other means. Options included placement of fibrin glue into the bronchopleural fistula, oxidized cellulose (Surgicel [Johnson & Johnson, Somerville, NJ]) followed by fibrin glue, or placement of a pedicled omentum or intercostal muscle on top of the fistula with the hopes that a seal would eventually form. Instead, a collagen plug was used to seal the fistula. This then enabled us to place vascularized omentum to fill the space as well as seal the fistula with tissue. Without sealing the fistula initially, a continuous air leak would have been present with persistent contamination of the cavity necessitating prolonged use of drainage catheters with a greater chance for subsequent infection and omental graft failure. The air leak could also cause graft failure by not allowing graft apposition by creating a space. Hence by sealing the fistula up front, the collagen plug favored wound healing and omental engraftment.
Future applications of the collagen plug may be a sole means of bronchopleural fistula treatment rather than as an adjunct (as in our case). The collagen plug could be deployed endoscopically either through rigid or flexible bronchoscopy. After deployment into the bronchopleural fistula, fibrin glue could be applied to further seal the fistula as has been done previously as a primary means of treatment. Further studies are needed to verify the utility of this collagen plug, but it is a promising aid in dealing with a difficult problem.
In conclusion, porcine collagen plug closure of bronchopleural fistulae maybe a useful tool in treating resectional bronchopleural fistulas primarily or as an adjunct to already described means.
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References
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- Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategies for bronchopleural fistula J Thorac Cardiovasc Surg 1995;109:989-995discussion 995–6.[Abstract]
- Beltrami V, Angelici A, Bertagni A, et al. Transsternal approach to closure of bronchopleural fistulas after pneumonectomyA fifteen cases report. Lung Cancer 2000;29:43-47.[Medline]
- Zaheer S, Allen MS, Cassivi SD, et al. Postpneumonectomy empyema: results after the Clagett procedure Ann Thorac Surg 2006;82:279-286discussion 286–7.[Abstract/Free Full Text]
- Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas Dis Colon Rectum 2006;49:371-376.[Medline]
- Tao H, Araki M, Sato T, et al. Bronchoscopic treatment of postpneumonectomy bronchopleural fistula with a collagen screw plug J Thorac Cardiovasc Surg 2006;132:99-104.[Abstract/Free Full Text]
- Raghavan D, Kropp BP, Lin HK, et al. Physical characteristics of small intestinal submucosa scaffolds are location-dependent J Biomed Mater Res A 2005;73:90-96.[Medline]
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Abstract
Introduction
