Ann Thorac Surg 2010;90:1061-1062. doi:10.1016/j.athoracsur.2010.02.091
© 2010 The Society of Thoracic Surgeons
Correspondence
What Is Standard Treatment for Bronchopleural Fistulas?
Mitsuhiro Kamiyoshihara, MD, PhD,
Toshiteru Nagashima, MD
Department of General Thoracic Surgery, Maebashi Red Cross Hospital, 3-21-36 Asahi-Cho, Maebashi, Gunma 371-0014, Japan
(Email: micha2005jp{at}yahoo.co.jp).
To the Editor:
We read with interest the article by Chae and colleagues [1] on the use of a silicone-covered bronchial occlusion stent to treat a bronchopleural fistula. We congratulate them on an original idea and an innovative technique. However, we have three questions from the description and would like to add to the discussion.
First, what is the material of the skeleton of the "silicone-covered bronchial occlusion stent"? It appears to be a self-expandable metallic stent. If so, we are concerned about the durability of the stent. Chae and colleagues did not refer to this point. Disruption of the bronchial wall by metallic stents has been reported [2, 3]. Given the point about the durability of the stent, we would rather have performed a thoracotomy than use a stent device because the middle-aged patient seemed able to tolerate the operation.
We consider that the standard treatment for bronchopleural fistulas is a thoracotomy with primary closure and coverage with a vascularized muscle flap of the bronchial leak site. We think that almost all of the reports in their reference list [1] say as much. Stents should be used only in patients for whom a conventional operation is ineffective or where surgical treatment is medically contraindicated. In addition, once a metallic stent is placed, it cannot be removed.
Second, Chae and colleagues [1] stated that the transsternal ligation of the left main bronchus is difficult because of the short bronchial stump length and concomitant possible aspiration in the right lung. However, we estimate that a 15-mm length is enough to suture the stump or perform a tracheobronchial plasty [4].
Third, another concern is the length of the left main bronchial stump after pneumonectomy. According to the authors' Figure 2 [1] of the bronchial occlusion stent, we estimate that the length of the left main bronchial stump was too long. In context, it was described as 15 mm, but the stent body, which was supposed to be placed in the remaining "bronchus pocket," is more than 2 cm long. Too long a bronchial stump is one cause of fistulas due to poor blood supply.
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References
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- Chae EY, Shin JH, Song HY, Kim JH, Shim TS, Kim DK. Bronchopleural fistula treated with a silicone-covered bronchial occlusion stent Ann Thorac Surg 2010;89:293-296.[Abstract/Free Full Text]
- Hind CRK, Donnelly RJ. Expandable metal stents for tracheal obstruction: permanent or temporary? A cautionary tale Thorax 1992;47:757-758.[Abstract/Free Full Text]
- Hiramiec JE, Haasler GB. Tracheal wire stent complications in malacia: implication of position and design Ann Thorac Surg 1997;63:209-212.[Abstract/Free Full Text]
- Suzuki T, Suzuki S, Kamio Y, Hori G. Closure with bronchial wall flap and omental pedicle of defect caused by dehiscence of tracheal suture line after extended right upper sleeve lobectomy J Thorac Cardiovasc Surg 1996;112:1116-1117.[Free Full Text]
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