Ann Thorac Surg 2007;84:1383-1386
© 2007 The Society of Thoracic Surgeons
Case Reports
Treatment of Bronchopleural Fistula With Small Intestinal Mucosa and Fibrin Glue Sealant
Scott J. Keckler, MD,
Troy L. Spilde, MD,
Shawn D. St. Peter, MD,
KuoJen Tsao, MD,
Daniel J. Ostlie, MD*
Department of Surgery, The Children’s Mercy Hospital, Kansas City, Missouri
Accepted for publication May 3, 2007.
* Address correspondence to Dr Ostlie, Department of Surgery, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108 (Email: dostlie{at}cmh.edu).
 |
Abstract
|
|---|
Bronchopleural fistula can be a devastating complication of pulmonary resections. Treatment options are often limited and carry significant morbidity or mortality, or both. We present a case of bronchopleural fistula occurring after pulmonary lobectomy for aspergilloma in a patient with recurrent acute lymphoblastic leukemia. The bronchopleural fistula was treated using bronchoscopic obliteration with Tisseel VH Fibrin Sealant (Baxter Healthcare Corp, Westlake Village, CA) and small intestinal submucosa with complete resolution and no morbidity. The relevant literature is reviewed.
|
Introduction
|
|---|
Bronchopleural fistula (BPF) is a communication between the bronchial tree and the pleural space that usually results after pulmonary resection. Fortunately BPF are rare complications; however, the development of a BPF creates a very difficult clinical scenario that carries significant morbidity or mortality, or both, associated with its management and repair. The management strategies for BPF range from thoracostomy tube drainage to surgery. Many surgical procedures have been described including chronic open drainage, muscular reinforcement using intercostal muscle flaps, and closure with omental reinforcement [1]. We present a case report of a BPF after left lower lobe lobectomy that was repaired using porcine small intestinal submucosa (SIS) (Cook Surgical, West Lafayette, IN) mesh and Tisseel VH Fibrin Sealant (Baxter Healthcare Corp, Westlake Village, CA).
An 8-year-old girl with acute lymphoblastic leukemia had undergone a left lower lobe lobectomy for aspergilloma that was unresponsive to medical treatment. Three weeks postoperatively she had malaise and fevers develop, and a computed tomographic (CT) scan of the chest revealed a BPF arising from the left lower lobe bronchus (Figs 1A,
1B). In an effort not to delay her pending bone marrow transplant due to prolonged recovery associated with a repeat thoracotomy, we elected to attempt an endoscopic repair of the BPF. Under general anesthesia, a rigid bronchoscopy was performed. A left lower lobe bronchus BPF was visualized at the site of the staple line closure from the previous lobectomy (Fig 2). Two pieces of dry 4-ply SIS mesh were placed into the fistula tract using a bronchoscopic biopsy grasper. Once the SIS had been placed into the bronchus, the fibrin sealant was placed using an endoscopic applicator (Duplocath 25 Application Catheter; Baxter Healthcare Corp) under direct bronchoscopic visualization (Fig 3). The SIS/fibrin plug was visualized for 5 minutes during spontaneous respirations to ensure that it would not become dislodged and risk movement into the adjacent bronchus. Postoperatively the patient recovered uneventfully with resolution of her fevers and improved energy levels. Chest computed tomography 1 month after repair documented resolution of the fistula (Figs 4A,
4B). Subsequently the patient has continued to do well without pulmonary complications and no evidence of recurrent BPF with 12 months of follow-up.
View larger version (140K):
[in this window]
[in a new window]
|
Fig 1. (A, B) These two views of the computed tomographic scan of the chest show the staple line (dense white) and the tiny bronchopleural fistula (arrows). The associated pneumothorax and effusion are evident.
|
|
View larger version (99K):
[in this window]
[in a new window]
|
Fig 2. This photograph shows the left lower lobe bronchus with particulate debris and air bubbles consistent with bronchopleural fistula.
|
|
View larger version (134K):
[in this window]
[in a new window]
|
Fig 3. Shown here is the fibrin glue plug over the small intestinal submucosa mesh resting in the left lower lobe bronchus. The plug and mesh component was visualized through the bronchoscope for 5 minutes to ensure it would not move into the adjacent bronchus.
|
|
View larger version (121K):
[in this window]
[in a new window]
|
Fig 4. (A, B) Two computed tomographic views of the region of the closed bronchopleural fistula are shown 2 months after placement of the small intestinal submucosa and fibrin glue. The arrows indicate the site of the staple line and fibrin glue plug. Note that the pneumothorax and effusion have completely resolved.
|
|
|
Comment
|
|---|
Although BPF is rare, it is a significant complication of pulmonary surgery. It generally occurs in the presence of infection or malignancy, and can result in an increase in morbidity. The most common cause is postoperative resection followed by necrotic lung infections, radiotherapy, or chemotherapy [2]. Anatomically, right pneumonectomy and right lower lobectomy have the highest incidence. The clinical presentations of BPF are commonly divided into acute, subacute and chronic. Acute forms can be life threatening, whereas the subacute form has a more subtle presentation including fever, malaise, and productive cough. The chronic form presents with fibrosis of the pleural space and mediastinum, which prevents shift [2]. Traditional methods of treatment include drainage followed by thoracotomy and primary repair supported by vascularized tissue including omental grafts and muscle flaps [1]. To avoid the morbidity of a thoracotomy, endoscopic approaches are being used to manage BPF. Bronchoscopy and the application of sealing compounds have all been reported. Fibrin glue has been successful in the treatment of BPF [3]. The fibrin forms a framework to facilitate a fibrin clot over the fistula. The efficacy of fibrin glue has been questioned by some authors. The use of fibrin glue was reported in 28 patients who were randomized to fibrin glue and controls and then underwent thoracotomy. No difference was observed in the duration of air-leak, hospital days, or chest tube output [4]. An alternative sealing compound was reported in 2 patients. Albumin-glutaraldehyde adhesive has been approved for vascular anastomoses; this was applied by bronchoscopy, and both patients had resolution of the BPF [5]. This same adhesive has been applied to a bronchial stump with BPF through a thoracotomy, and the patient has been free of recurrent BPF for 2 years [6]. Although movement of the fibrin glue and SIS mesh plug has been a concern by several authors, there have not been any reports of dislodgment and subsequent complications associated with movement into an adjacent bronchus. In our case, we directly observed the SIS and fibrin glue plug (Fig 3) for 5 minutes to ensure that no movement occurred. After 5 minutes the fibrin glue is completely adhered to the tissue adjacent to it and the risk for movement should be minimal. Regardless, we do recommend that the plug is visualized during this time to ensure it remains in its intended position.
In regard to the SIS, it was derived from pigs and has been used for repair of paraesophageal hernias and other soft tissue defects [7]. The SIS is an acellular material that is rich in collagen and provides a framework for tissue growth. Recent animal studies using a congenital diaphragmatic hernia model have confirmed the tissue in growth with fibroblasts and capillaries [8]. Generally SIS is reconstituted in saline to soften the mesh prior to insertion. We found that placement of wet SIS mesh was very difficult due to its tendency to adhere to the first tissue to which it came into contact. By using dry four-ply SIS mesh grasped with a bronchoscopic biopsy grasper, we were able to manipulate the mesh into the correct position without having it adhere in the proximal bronchus.
In our patient we used both SIS and fibrin glue to endoscopically close the fistula. Our patient has not had a recurrence of the BPF. The properties of both SIS and fibrin glue allow for a fibrin clot to form first, followed by tissue in growth into the scaffold provided by the SIS. We believe that this provides an excellent permanent repair and should be considered in the armamentarium of possible repairs for patients with BPF.
|
References
|
|---|
- Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for bronchopleural fistula J Thorac Cardiovasc Surg 1995;109:989-996.[Abstract]
- Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management Chest 2005;128:3955-3965.[Medline]
- Jessen C, Sharma P. Use of fibrin glue in thoracic surgery Ann Thorac Surg 1985;39:521-524.[Abstract]
- Fleisher AG, Evans KG, Nelems B, Finley RJ. Effect of routine fibrin glue use on the duration of air leaks after lobectomy Ann Thorac Surg 1990;49:133-134.[Abstract]
- Lin J, Iannettoni, MD. Closure of bronchopleural fistulas using albumin-glutaraldehyde tissue adhesive Ann Thorac Surg 2004;77:326-328.[Abstract/Free Full Text]
- Lang-Lazdunski L. Closure of bronchopleural fistula after extended right pneumonectomy after induction chemotherapy with BioGlue surgical adhesive J Thorac Cardiovasc Surg 2006;132:1497-1498.[Free Full Text]
- Oelschlager BK, Barreca M, Chang L, Pellegrini CA. The use of small intestine submucosa in the repair of paraesophageal hernias: Initial observations of a new technique Am J Surg 2003;186:4-8.[Medline]
- Dalla Vecchia L, Engum SA, Kogan B, Jenson E, Davis M, Grosfeld J. Evaluation of small intestine submucosa and acellular dermis as diaphragmatic prosthesis J Pediatr Surg 1999;34:167-171.[Medline]
This article has been cited by other articles:
|
|
|
|
 
M. L. Tedde, P. R. Scordamaglio, H. Minamoto, V. R. Figueiredo, C. C. Pedra, and F. B. Jatene
Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device.
Ann. Thorac. Surg.,
September 1, 2009;
88(3):
e25 - e26.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
