Ann Thorac Surg 2010;89:601-603. doi:10.1016/j.athoracsur.2009.07.053
© 2010 The Society of Thoracic Surgeons
Case Reports
Acellular Dermal Matrix Closure of Catastrophic Bronchopleural Fistula
Karl G. Reyes, MD,
Thomas W. Rice, MD*,
David P. Mason, MD,
Sudish C. Murthy, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
Accepted for publication July 10, 2009.
* Address correspondence to Dr Rice, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave./J4-1, Cleveland, OH 44195 (Email: ricet{at}ccf.org).
 |
Abstract
|
|---|
Early, complete disruption of bronchial closure is a rare complication after pulmonary resection that will result in almost certain death if immediate intervention is not taken. We present a case of a catastrophic bronchopleural fistula that was successfully closed using an Alloderm patch (LifeCell Corp, Branchburg, NJ) in the acute setting.
|
Introduction
|
|---|
Bronchopleural fistula after pulmonary resection is a serious complication and potentially life-threatening problem. Management is individualized, depending on the circumstance and acuity of the situation [1]. Early occurrence of bronchopleural fistula in the postoperative period, associated with empyema and necrosis of the bronchial wall, elevates this complication to catastrophic dimensions.
A 66-year-old man underwent mediastinoscopy and right lower lobectomy through a muscle-sparing thoracotomy for a stage IIB nonsmall cell lung cancer. His postoperative course was uneventful, and he was discharged on postoperative day 5. Three days later, he presented to an outside hospital with shortness of breath, hemoptysis, and expectoration of copious amounts of foul-smelling sputum. A chest roentgenogram demonstrated a hydropneumothorax. White blood cell count was 23,000 units. The patient was treated for pneumonia with broad spectrum antibiotics; however, continued deterioration necessitated intubation. A chest tube was inserted, an empyema was drained, and a large airleak was noted. The clinical diagnosis was empyema and bronchopleural fistula complicating lobectomy, and the patient was transferred to our institution for further care.
On admission, the patient was septic and required maximum ventilatory support. After initial resuscitation in the intensive care unit, followed by an in-transit computed tomographic chest scan (Fig 1A), the patient was taken to the operating room. Bronchoscopy revealed a large defect in the region of the superior segmental bronchial stump. A right posterolateral thoracotomy through the previous incision was used for exploration. On entering the pleural space, adequate ventilation could not be maintained, and the patient was placed on extracorporeal membrane oxygenation. The empyema was evacuated, and the lung was mobilized, and decorticated. The right hilum was mobilized and the posterior membranous wall of the bronchus intermedius was absent from the open superior segmental bronchial stump to the area just below the inferior margin of the right upper bronchus. The bronchus could not be closed because of the large defect, and further pulmonary resection and repeat bronchial closure was not an option in the remaining large infected pleural space. The edges of the defect were cleared of debris, and an Alloderm patch (LifeCell Corp, Branchburg, NJ) was used to close the defect with a running 3-0 polydioxanone suture. A right latissimus dorsi flap covered the repair. The thoracotomy incision was closed after saline lavage and placement of intrapleural drains. A tracheostomy was performed, and the patient was returned to the intensive care unit. Extracorporeal membrane oxygenation was discontinued on postoperative day 1, and the patient was weaned from the mechanical ventilator on postoperative day 4. He was transferred to the regular nursing floor on postoperative day 8. His chest tubes were slowly backed out, and serial chest imaging showed well-expanded lungs with no residual pleural effusions. An inferior vena cava filter was placed for a right lower extremity deep venous thrombosis. He was discharged to a rehabilitation facility 1 month after his initial admission. Bronchoscopy at 3 months demonstrated the large intact Alloderm bronchial replacement with the beginnings of epithelization from the edges of the repair. At 18 months, a computed tomographic chest scan showed closure of the bronchopleural fistula and partial filling of the posterior pleural cavity with the latissimus dorsi muscle (Fig 1B). Bronchoscopy with biopsy (Fig 2) demonstrated near complete epithelization of the Alloderm patch with columnar epithelium. The patient is well and free of recurrence at 36 months.
View larger version (63K):
[in this window]
[in a new window]
|
Fig 1. (A) Preoperative computed tomographic scan showing a pneumothorax, consolidation, minimal residual empyema, and a large bronchopleural fistula. (B) Computed tomographic scan 18 months postoperatively.
|
|
View larger version (97K):
[in this window]
[in a new window]
|
Fig 2. (A) Image of bronchus intermedius. The posterior membranous bronchus is completely healed with only minimal granulation tissue to the right of the middle lobe (RML) orifice (white arrow) and (B) right airway endobronchial biopsy specimen showing bronchial mucosa with fibrosis and no carcinoma present.
|
|
|
Comment
|
|---|
Alloderm, initially developed to treat large burns [2], has increased in applicability and is now used for a wide spectrum of clinical problems, mostly to cover large anatomic or surgical defects [3, 4]. It provides an immune-free framework and creates a suitable biologic milieu for epithelial regeneration and healing. Furthermore, its use in grossly contaminated areas and ability to resist infections are important advantages [3] that afforded a solution to a catastrophic bronchopleural fistula and empyema. Upper airway repairs have been described using Alloderm and bovine pericardium [4, 5]. However, its use in the distal airway in an empyema cavity with bronchial necrosis has not been reported.
In conclusion, Alloderm can be used to close large bronchopleural fistulae and may in fact aid healing by enhancing tissue regeneration. Although further investigation is necessary, its effectiveness during this initial endeavor is encouraging. Its use in this setting may decrease the need for open window thoracotomies, thereby reducing patient morbidity and improving quality of life.
|
References
|
|---|
- Lois M, Noppen M. Bronchopleural fistula: an overview of the problem with special focus on endoscopic management Chest 2005;128:3955-3965.[Abstract/Free Full Text]
- Wainright DJ. Use of an acellular homograft dermal matrix (Alloderm) in the management of full-thickness burns Burns 1995;21:243-248.[Medline]
- Patton JH, Berry S, Kralovich KA. Use of acellular dermal matrix in complex and contaminated abdominal wall reconstructions Am J Surg 2007;193:360-363.[Medline]
- Su JW, Mason DP, Murthy SC, Rice TW. Closure of a large tracheoesophageal fistula using alloderm J Thorac Cardiovasc Surg 2008;135:706-707.[Free Full Text]
- Knott PD, Lorenz RR, Eliachar I, Murthy SM. Reconstruction of a tracheobronchial tree disruption with bovine pericardium Interact Cardiovasc Thorac Surg 2004;3:554-556.[Abstract/Free Full Text]
Top
Abstract
Introduction
