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Case Reports

Successful Endobronchial Seal of Surgical Bronchopleural Fistulas Using BioGlue

Department of Cardiothoracic Surgery, St. George's Hospital, London, United Kingdom

Accepted for publication March 6, 2009.

^_* Address correspondence to Dr Madden, Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Rd, London, SW17 0QT, United Kingdom (Email: brendan.madden{at}stgeorges.nhs.uk).

	Abstract

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Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

	Introduction

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We describe the successful endoscopic closure of bronchopleural fistula (BPF) in 3 patients postoperatively (2 patients with bronchiectasis, 1 patient with non-small cell lung cancer) using albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA). The patient with lung cancer had a coexistent Pseudomonas aeruginosa respiratory tract infection. One patient with bronchiectasis had a right lower lobectomy and had coexistent infection, but the other patient with bronchiectasis had a left pleuropneumonectomy and was free of infection.

	Case Reports

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Patient 1
A 70-year-old man underwent elective right middle and lower lobectomies for T2N0M0 non-small cell lung carcinoma. There were no immediate complications. On postoperative day 5, an air leak developed, and he was started on antibiotics to treat Pseudomonas aeruginosa cultured from his pleural fluid. A computed tomographic scan revealed a hydropneumothorax and suggested a BPF from the right bronchial stump. Because of significant medical comorbidities and after multidisciplinary discussion involving the patient's surgeon, anesthetists, and pulmonologists, it was decided to attempt endoscopic closure on postoperative day 6. The patient received intravenous propofol and atracurium, and he was pre-oxygenated. A large adult rigid bronchoscope was deployed in the trachea, and a fiberoptic bronchoscope was used to visualise the endobronchial stump. A 1 mm x 3.5 mm defect was identified in the posterolateral aspect of the right bronchial stump. The rigid bronchoscope was deployed into the left main bronchus and the patient was pre-oxygenated for 2 minutes and obtained peripheral (SaO₂) oxygen saturations of 100%. Ventilation was then stopped and the rigid bronchoscope was deployed into the right main bronchus just above the defect. A 1.25 cm x 0.95 cm gauze pledget (Vernon-Carus Ltd, Swindon, UK) was grasped in rigid forceps and BioGlue from a prefilled syringe was applied to the outer aspect of the pledget. This was then applied directly to the BPF through the middle of the rigid bronchoscope and was held in place for 10 seconds. The gauze was then removed and discarded; the BioGlue was applied to a second gauze pledget, and the procedure was repeated by overlapping the treated area. A total of five applications of BioGlue were directly applied to the BPF within 2 minutes. The rigid bronchoscope was deployed into the left main bronchus, and the patient was ventilated with protection of the right bronchial stump. After further pre-oxygenation, the ventilation was stopped and the rigid bronchoscope was deployed into the right main bronchus just above the BPF. Five further applications of BioGlue were applied to the defect within 2 minutes. The rigid bronchoscope was deployed into the left main bronchus and the ventilation was recommenced. The patient was woken with the bronchoscope in this position and extubated uneventfully. Post-procedure there was minimal bubbling of his chest drain and the patient improved. On day 11, the patient became febrile despite antibiotics without evidence of empyema. After multidisciplinary discussion, the decision was made to re-examine the fistula endoscopically. A smaller defect was identified and sealed with Bioglue following the protocol was previously described. The defect was sealed overnight, and the drain was removed the next day. There was no evidence of recurrence at repeat bronchoscopy. Despite subsequent Aspergillus fumigatus infection within the pleural space, mechanical ventilation and tracheostomy, the bronchial stump remains intact. The patient continues to improve.

Patient 2
A 55-year-old woman with bronchiectasis, lobe sequestration, and recurrent respiratory infections had a right lower lobectomy. Four weeks postoperatively she was readmitted with raised inflammatory markers, a hydropneumothorax, and a BPF was diagnosed. Although cultures were negative, she was commenced on broad-spectrum antibiotics. Flexible bronchoscopy under sedation revealed a 3.5 mm defect in the medial aspect of the right lower lobe bronchial stump. After multidisciplinary discussion it was decided to attempt endoscopic closure. The defect was sealed following the protocol previously described. The patient was discharged from the hospital the next day. A chest roentgenogram performed 3 weeks later showed resolution of the hydropneumothorax. She remains well 3 months post-procedure with no evidence of recurrence.

Patient 3
A 63-year-old woman underwent a left pleuropneumonectomy for bronchiectasis and mycobacterium avium intracellulare infection unresponsive to standard treatment. Three weeks postoperatively she was admitted to hospital and a bronchopleural fistula was diagnosed. A thoracostomy tube was inserted and antibiotics were administered. Endobronchial repair was advised by her thoracic surgeon in the first instance, particularly as she had poor nutritional status. A 1.5 mm x 3.5 mm defect was identified in the left main bronchial stump. The defect was sealed using the protocol previously described. The patient underwent uneventful extubation and was discharged 5 days after the procedure. Repeat bronchoscopy at 6 weeks revealed the fistula to be completely sealed with no evidence of granulation tissue. She remains well 3 months after repair.

	Comment

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Bronchopleural fistulas have a reported incidence of 1.5% to 28% after pulmonary resection, 0.5% after lobectomy [1], and mortality as high as 67% [2].

Initial management includes tube thoracostomy and intravenous antibiotics. Surgical options are thoracotomy for debridement of the pleural cavity and manual closure of the bronchial stump [3]. Further surgery in these patients carries significant mortality and morbidity, particularly if complicated by infection. Increasingly endoscopic approaches are being used with different sealants.

BioGlue surgical adhesive consists of a 10% glutaraldehyde solution and a 45% bovine serum albumin solution, which when mixed polymerize immediately reaching full strength within 2 minutes [4]. The two components bind to each other, and upon contact to tissue, the cell surface proteins and extracellular matrix resulting in a strong flexible seal independent of the patient's coagulation status. In sheep, it is effective in sealing bronchial anastamoses with the adhesive being replaced by fibrous tissue rather than tissue granulation or a foreign body reaction [5].

The reported endoscopic use of BioGlue in sealing BPFs is limited, although has been used in thoracotomies [3, 4, 6]. We believe there are only two published reports of the application of BioGlue using rigid bronchoscopy [4, 6]. In one case, the procedure was used successfully after failure of a BPF to heal after re-excision of the bronchial stump and a subsequent Clagett procedure [6]. The second patient was successfully treated endoscopically for a BPF after a right pneumonectomy for lung cancer [4].

We describe the successful use of BioGlue at rigid bronchoscopy to seal BPFs in 3 patients, despite coexisting infection in 2. Bioglue was used as it is convenient to apply from a pre-filled syringe, and it seals quickly and firmly without any known local reaction [4–6]. It was applied in overlapping layers to prevent mobile plug formation with attendant risk of migration. In each patient the BPF was less than 8 mm. We appreciate that BPF greater than 8 mm may not be suitable for endoscopic closure [1], although our limited experience does not permit us to adequately define suitability with respect to size of a fistula at present.

In the first patient we were concerned with the risk of further surgery in view of infection and poor medical status. With hindsight, infection could have been more aggressively treated prior to the first application of Bioglue (CryoLife). After subsequent treatment with appropriate antibiotics the defect sealed within 12 hours of the second application. The surgical opinion was to avoid further thoracotomy (if possible) for patients 2 and 3, particularly as both wished to avoid further thoracic surgery.

We suggest that endoscopic closure of BPF should be considered early, especially for patients who have other medical comorbidities, including infection, which would significantly increase the risks of further surgery. We advocate aggressive efforts to treat infection prior to application of Bioglue.

	References

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1. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management Chest 2005;128:3955-3965.[Abstract/Free Full Text]
2. Hollaus PH, Lax F, El-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases Ann Thorac Surg 1997;63:1391-1397.[Abstract/Free Full Text]
3. 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]
4. Potaris K, Mihos P, Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery Med Sci Monit 2003;9:P179-P183.
5. Herget GW, Kassa M, Riede UN, Lu Y, Brether L, Hase J. Experimental use of an albumin-glutaraldehyde tissue adhesive for sealing pulmonary parenchyma and bronchial anastomoses Eur J Cardiothorac Surg 2001;19:4-9.[Abstract/Free Full Text]
6. Lin J, Iannettoni, MD. Closure of bronchopleural fistulas using albumin-glutaraldehyde tissue adhesive Ann Thorac Surg 2004;7:326-328.

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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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ranu, H. Articles by Madden, B. P. Search for Related Content PubMed PubMed Citation Articles by Ranu, H. Articles by Madden, B. P. Related Collections Trachea and bronchi