Ann Thorac Surg 2002;73:948-949
© 2002 The Society of Thoracic Surgeons
Invited commentary
Douglas E. Wood, MDa
a Division of Cardiothoracic Surgery University of Washington, Box 356310 1959 NE Pacific, AA-115 Seattle, WA 98195-6310, USA
e-mail: dewood{at}u.washington.edu
The authors have presented a small series of 8 patients over a six-year period that have been treated with Nd:YAG laser for post-resection bronchopleural fistula (BPF). This is a novel approach and it is paradoxical that the authors would have chosen the laser, usually reserved for ablation, cauterization, or vaporization of tissues, in this case to affect closure of a bronchopleural fistula by edema and creation of fibrinous exudate. What is unclear is whether the authors limited success in 4 of 8 patients provides any improvement over the natural history of small bronchopleural fistula that are treated by standard nonsurgical techniques.
Bronchopleural fistula is a more common and complex problem after pneumonectomy and the authors had a low rate of success in this group, with only two of the six pneumonectomy patients achieving successful closure of the fistula. However, this failure may be due to the inadequate treatment of pleural space infection, rather than failure of the closure technique itself. The authors mistakenly appear to believe the empyema can be avoided with prompt BPF management. In the post-pneumonectomy state, a bronchopleural fistula uniformly results in pleural space contamination and management of this infection is critical to successful management of the post-pneumonectomy BPF.
In this series, the authors attempted endobronchial closure in 3 patients who had no apparent drainage management. Five patients after pneumonectomy had chest tube drainage alone, which most would consider inadequate therapy of the infected post-pneumonectomy space. Four of these five cases failed any attempt at closure. It would be interesting to know whether the authors would have achieved a higher rate of success with more definitive external drainage that may have provided a better opportunity for closure after laser treatment, or perhaps even spontaneous closure with no laser at all. Typically, small fistulae like those reported in this paper would be successfully closed by adequate drainage of the pleural space in the absence of persistent tumor or infection, which also precluded successful management in this series.
It is important to consider the potential dangers of using a laser in this setting, before considering this intervention. The most obvious risks are the potential of actually enlarging the fistula or penetrating the adjacent pulmonary artery with disastrous consequences. Combined with the standard principles of managing bronchopleural fistulae, the laser presents an alternative to conservative management with spontaneous closure, or other endobronchial adjuncts such as glue or sealant, but with additional risks and no clear benefits over the techniques we already employ.
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Ann. Thorac. Surg. 2002 73: 945-948.
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