1987: Endoscopic gluing of bronchopleural fistula. Updated in 1994

Repair of postpneumonectomy bronchopleural fistula using pedicled pericardial flap supported by fibrin glue

Effective closure of the postpneumonectomy bronchopleural fistula (PBF) with the use of different techniques still remains a challenge for thoracic surgeons. The aim of this study was to evaluate the efficacy of modified method of PBF closure using pedicled pericardial flap (PPF) supported by fibrin glue (FG). The efficacy of the late PBF closure with the use of two surgical methods was compared. In 10 patients, the edges of the PBF were covered with FG and PPF. In the second group of nine patients, myoplasty was used to close the bronchial fistula. Postsurgical follow-up was for 1 year. In the first group, the healing of the fistula was achieved in 100% of the cases, whereas in the second, myoplasty group, healing was achieved in only 66·67% of the cases. The number of complications was similar in both groups. Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of PBF in selected patients.

Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula

BACKGROUND

We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue.

METHODS

We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months.

RESULTS

The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group.

CONCLUSION

Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.

Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue

BACKGROUND

The incidence of clinically relevant anastomotic leaks after upper gastrointestinal surgery is approximately 4% to 20%, and the associated mortality is up to 80%. Depending on the clinical presentation, the treatment options include surgery, conservative treatment with or without external drainage or endoscopic treatment.

METHODS

This report presents nine cases of anastomotic leaks or fistulae after surgery for upper gastrointestinal cancers that were treated by insertion of a Vicryl plug and sealing with fibrin glue. Under sedation, all nine patients underwent endoscopic lavage of the cavity at the site of anastomotic leakage. The entrance to the cavity then was filled with Vicryl mesh and sealed off with fibrin glue. After the procedure, the patients underwent endoscopy and a water-soluble contrast study for assessment of the result.

RESULTS

Seven of the nine patients had complete healing of the anastomotic leak or fistula after one to two endoscopic treatments. In one case, the treatment failed immediately because of a large and direct tracheoesophageal fistula. Another patient experienced recurrent intrathoracic abscesses after initial technical success.

CONCLUSIONS

Postoperative upper gastrointestinal fistulas or anastomotic leaks can be managed successfully with little morbidity by means of endoscopic insertion of Vicryl mesh with fibrin glue, thereby avoiding repetitive major surgery and its associated risks.

A new instrument for endoscopic gluing for bronchopleural fistulae

Fibrin glue was developed as a biologic adhesive and is frequently used in thoracic surgery, but no endoscopic instrument is available to spray fibrin glue. We developed an instrument, a new tube system, to aerosolize fibrin glue endoscopically to treat bronchopleural fistulae. This instrument was made of polypropylene, 2 mm diameter, and consisted of three microtubes, 0.3 mm diameter. Fibrinogen and thrombin glue were applied at the same time and aerosolized by burst pressure. The use of this instrument during bronchoscopy was found to increase the effectiveness of endoscopic treatment for bronchopleural fistulae.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

BACKGROUND

The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively.

METHODS

The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared.

RESULTS

Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment.

CONCLUSIONS

Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome

BACKGROUND

Lesions of the trachea or main-stem bronchi with air leakage are a grave complication of oesophagectomy.

METHODS

Prevalence, predisposing factors and outcome of non-malignant lesions of the trachea or main-stem bronchi were analysed retrospectively in a consecutive series of 785 patients who had oesophagectomy for oesophageal cancer.

RESULTS

Overall 31 of 785 patients developed a tracheobronchial fistula 1-30 days after oesophagectomy. Based on the location of the lesions and clinical circumstances, the tracheobronchial fistulas were thought to be due to surgical injury (four patients), cuff pressure of the tracheostomy tube (two), local peritracheal infection resulting from a cervical anastomotic leak (seven) or 'ischaemia' after extensive peritracheal dissection (18). On multivariate analysis, transthoracic en bloc resection (P < 0.01) and preoperative radiochemotherapy for locally advanced tumours located at or above the level of the tracheal bifurcation (P < 0.01) predisposed to this complication.

CONCLUSION

Non-malignant tracheobronchial lesions are a serious complication of transthoracic oesophagectomy with extensive lymph node dissection, particularly in patients undergoing preoperative radiochemotherapy for locally advanced tumours.

Endoscopic treatment of bronchopleural fistulas

BACKGROUND

Bronchial fistula is one of the most serious complications of pulmonary resection.

METHODS

We present an endoscopic treatment that consists of multiple submucosal injections of polidocanol-hydroxypoliethoxidodecane (Aethoxysklerol Kreussler) on the margins of the fistula using an endoscopic needle inserted through a flexible bronchoscope.

RESULTS

From 1984 to 1995, 35 consecutive nonselected patients with a postresectional bronchopleural fistula were treated. All 23 partial postpneumonectomy or postlobectomy bronchopleural fistulas, ranging from 2 to 10 mm in diameter, healed completely. This did not occur in the 12 total bronchial dehiscences. No complications occurred due to the injection of the drug.

CONCLUSIONS

In our opinion this treatment can be considered a valid therapeutic approach, as it is simple, safe, scarcely traumatic, and inexpensive, particularly considering that, in patients in stable condition, it can be performed as an outpatient treatment.

Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases

BACKGROUND

Various therapeutic approaches to bronchopleural fistula have been reported. Its natural history, which may be key to the best therapeutic management, early detection, and possibly, prevention of fistula formation, has received little attention.

METHODS

The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at primary bronchoscopic diagnosis, time of occurrence after operation (days), cause of death, and survival after fistula formation (days) were analyzed. Management consisted of bronchoscopic closure with fibrin sealant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thoracostomy.

RESULTS

Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) died during the observation period; in 25, the cause of death was aspiration pneumonia. Only 2 patients who died of aspiration pneumonia had development of a fistula after 90 postoperative days. The aspiration rate dropped with increasing interval between operation and fistula occurrence (p = 0.000). Patient survival after fistula formation was positively correlated to this interval (p = 0.002). Successful fistula closure was achieved by surgical intervention in 21 patients and endoscopically in 11 patients. The overall postoperative mortality rate irrespective of treatment method was 31%.

CONCLUSIONS

The incidence of aspiration pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently represents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postoperative months should detect bronchopleural fistula before aspiration occurs.