Endoscopic management of large, postresection bronchopleural fistulae with methacrylate adhesive (Super Glue)

Interventional closure of a bronchopleural fistula in a 2 year old child with detachable coils

Background

Bronchopleural fistula (BPF) is a severe complication following pneumonia or pulmonary surgery, resulting in persistent air leakage (PAL) and pneumothorax. Surgical options include resection, coverage of the fistula by video-assisted thoracoscopic surgery (VATS), or pleurodesis. Interventional bronchoscopy is preferred in complex cases and involves the use of sclerosants, sealants and occlusive valve devices.

Case presentation

A 2.5-year-old girl was admitted to our hospital with persistent fever, cough and dyspnoea. Clinical and radiological examination revealed right-sided pneumonia and pleural effusion. The child was started on antibiotics, and the effusion was drained by pleural drainage. Following removal of the chest tube, the child developed tension pneumothorax. Despite insertion of a new drain, the air leak persisted. Thoracoscopic debridement with placement of another new drain was performed after 4 weeks, without abolishment of the air leak. Bronchoscopy with bronchography revealed a BPF in right lung segment 3 (right upper-lobe anterior bronchus). We opted for an interventional approach that was performed under general anaesthesia during repeat bronchoscopy. Following bronchographic visualisation of the fistula, a 2.7 French microcatheter was placed in right lung segment 3 (upper lobe), allowing occlusion of the fistula by successive implantation of 4 detachable high-density packing volume coils, which were placed into the fistula. Subsequent bronchography revealed no evidence of residual leakage, and the chest tube was removed 2 days later. The chest X-ray findings normalized, and follow-up over 4 years was uneventful.

Conclusions

Bronchoscopic superselective occlusion of BPF using detachable high-density packing large-volume coils was a successful minimally invasive therapeutic intervention performed with minimal trauma in this child and has not been reported thus far. In our small patient, the short interventional time, localized intervention and minimal damage in the lung seemed superior to the corresponding outcomes of surgical lobectomy or pleurodesis in a young growing lung, enabling normal development of the surrounding tissue. Follow-up over 4 years did not show any side effects and was uneventful, with normal lung-function test results to date.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03298-y.

A non-surgical option in large bronchopleural fistulas: Bronchoscopic conical stent application

Background

This study aims to compare the results of the open surgical approach versus endobronchial conical stent application in the treatment of extensive fistulas.

Methods

Between December 2004 and April 2016, a total of 36 patients (34 males, 2 females; mean age 59.6±8.1 years; range, 40 to 72 years) with a bronchopleural fistula of ≥8 mm in diameter and underwent either conventional open surgery with stump-supported intercostal muscle flap or endobronchial ultra-flex expandable stenting were retrospectively analyzed. The demographic and clinical characteristics of the patients, operative data including the length of hospital stay, thoracic drainage time, and early mortality, and survival data were recorded.

Results

The mean hospitalization time was 17.4±4.5 days for the bronchoscopic group and 22.5±6.7 days for the invasive surgery group (p=0.026). The median time to removal of thoracic drains was 15 (range, 10 to 30) days for the bronchoscopic group and 26 (range, 14 to 55) days for the surgical group (p=0.027). Early mortality rates of both approaches were in favor of the bronchoscopic approach (χ²=7.058; p=0.008). Two-year survival rate was 76.47% (n=13) in the bronchoscopic group and 70% (n=7) in the surgical group. There was no statistically significant difference in the survival rates between the two groups (χ²=0.132; p=0.716).

Conclusion

Our study results suggest that bronchoscopic approach can be the first choice in the treatment algorithm of fistulas with a diameter of ≥8 mm presenting with empyema in selected cases.

Endoscopic treatment of bronchopleural fistula using ethyl-2-cyanoacrylate: A report of two cases

Bronchopleural fistula (BPF) is a serious complication after lung resection or chronic empyema. BPF often causes severe pneumonia or fatal airway bleeding due to bronchoarterial fistula. Although BPF often requires surgical treatment, another, more conservative treatment option is endoscopic bronchial occlusion for non-operable patients. Many endoscopic treatments have been reported. We report here two patients with BPF who underwent endoscopic bronchial occlusion. Patient 1 had postoperative BPF with empyema and Patient 2 had BPF due to chronic empyema. Because the BPF in Patient 1 was small, it could be successfully treated by endobronchial occlusion using only ethyl-2-cyanoacrylate. In contrast, because the BPF in Patient 2 was large, it could not be treated by endobronchial occlusion using ethyl-2-cyanoacrylate alone; it was successfully treated by endobronchial occlusion using the combination of ethyl-2-cyanoacrylate and a silicone spigot (endobronchial Watanabe spigot, EWS). When we attempt endoscopic bronchial occlusion with BPF for non-operable patients, ethyl-2-cyanoacrylate may be an option for small fistulas, while the combination of EWS and ethyl-2-cyanoacrylate may be suitable for large fistulas.

Persistent air leaks: a review with an emphasis on bronchoscopic management

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

Supramolecular Metallo-Bioadhesive for Minimally Invasive Use

A novel metallo-bioadhesive to be used as tissue sealant in minimally invasive procedures is reported. Metal complexation can be used to render gelatin derivatives adhesive, which occurs in minutes, is efficient, and fully biodegradable within weeks.

Intrabronchial valves for treatment of alveolar-pleural fistula in a patient with Pneumocystis jirovecii pneumonia

Alveolo-pleural fistula is a common complication of severe pulmonary infection. Some patients require long-term placement of chest tubes until spontaneous closure of the fistula takes place, whereas others require surgical intervention. We report a case of a patient with alveolo-pleural fistula secondary to Pneumocystis jirovecii pneumonia who was successfully treated with the use of intrabronchial unidirectional valves inserted using flexible bronchoscopy.

Fibrin glue closure of persistent bronchopleural fistula following pneumonectomy for post-tuberculosis bronchiectasis

We report a case of a persistent bronchopleural fistula following a pneumonectomy for post-tuberculosis bronchiectasis. The patient had two unsuccessful surgical attempts at closing of the fistula. Further surgical attempts were technically were not possible. Bronchoscopic closure was achieved by injecting human fibrin glue into the fistula via a catheter. Closure of the broncho-pleural fistula was confirmed by repeated ventilation scan over a period of 2 months. Endoscopic closure of small bronchopleural fistulae is an attractive option in children with significant underlying lung disease.

Bronchobiliary fistula successfully treated with n-butyl cyanoacrylate via a bronchial approach

A bronchobiliary fistula is an abnormal communication between the biliary tree and the airway that can result in debilitating amounts of bilioptysis, or bile-stained sputum. The authors present an approach for the conservative management of a bronchobiliary fistula in a patient who failed traditional conservative therapy and refused surgical intervention.

Bronchopleural Fistulas

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

Full-thickness skin necrosis of the fingertip after application of superglue

We present the case of a 39-year-old woman who applied superglue to her fingertip as a treatment for dry skin. She developed full-thickness necrosis of her thumb pad complicated by a secondary superinfection. This necrosis occurred from the degradation of the cyanoacrylate in the superglue compound to formaldehyde, causing local histotoxicity. This injury necessitated a local flap for coverage, which healed uneventfully and without lasting sequelae.

Life-saving muscle flaps in tracheobronchial dehiscence following resection or trauma

OBJECTIVE

In the presence of acute inflammation and necrosis of the wall, tracheo-bronchial defects are difficult to manage. The absence of adequate vascularization and the contaminated area prevent successful direct re-suturing.

METHODS

In order to restore a sufficient blood supply we used a pedicled latissimus dorsi or a pectoralis major flap that was entered into the thorax after a 10-cm resection of the second rib. A portion of the muscle was fitted into the tracheo/bronchial defect by reinforced sutures. The remaining muscle was sutured to the tissue surrounding the defect. This method was applied in various septic conditions: Bronchial defects; complete dehiscence of the right (n = 6) or left (n = 1) main bronchus at the carinal level following resection for lung cancer (n = 4) or for tuberculous (n = 2) on nontuberculous pleuropneumonia (n = 1). Tracheal defects; (1) destruction of one third of the tracheal circumference involving the cricoid down to the fourth ring following tracheotomy in presence of a septic sternum after intrathoracic goiter and Bechterew's disease; (2) 30% dehiscence of the anastomosis and septic sternum following tracheal resection; (3) Mediastinitis involving tracheal and esophageal wall following a 7 cm long iatrogenous laceration of the intrathoracic trachea.

RESULTS

In one case the latissimus dorsi developed venous stasis on day 2 and was replaced by the pectoralis major muscle which showed uneventful healing. In all other patients the muscle flap resulted in an uneventful closure of the defect and recovery.

CONCLUSIONS

Large, well vascularized, pedicled muscle flaps ensure a safe closure of tracheo-bronchial defects or dehiscences even in presence of gross necrosis and sepsis.

Treatment of long-standing thoracostoma and bronchopleural fistula without pulmonary resection in high risk patients

A chronic bronchopleural fistula and a fibrotic postthoracotomy space in a patient with poor functional respiratory reserve is a difficult problem. The classic management of bronchopleural cutaneous fistulas has been with further pulmonary resection to healthy bronchus, repair of the bronchus directly, and a thoracoplasty or myoplasty technique to obliterate the cavity. In a high risk patient, further pulmonary resection and thoracoplasty may be contraindicated. Myoplasty techniques alone without control of the fistula have limited success. In the last 4 years, we have treated six patients with right-sided thoracostomas after a primary open drainage procedure for bronchopleural fistula and empyema. The air leak was controlled with inversion of the sinus tract, fibrin glue, and muscle flap cavity obliteration. An average of two muscle flaps per patient were used, including the contralateral latissimus dorsi muscle. An 83 percent success rate has been achieved with this procedure in patients who otherwise would not be considered surgical candidates. Attention to the details described, including direct suture closure of the bronchial sinus, obliteration of the cavity by local muscle flaps, and avoidance of mechanical positive pressure ventilation, will make extended thoracotomy, pulmonary resection, and thoracoplasty unnecessary in these high risk patients.

Bronchopleural fistula after pneumonectomy with a hand suture technique

We have reviewed the incidence of bronchopleural fistula among 530 consecutive pneumonectomies, all carried out by one surgical team using a uniform suture technique between January 1980 and November 1993. There were 7 fistulas (1.3%); all of them occurred within 15 days postoperatively. There were no cases of late fistula during a mean follow-up period of 23 months. The pathology for which pneumonectomy was undertaken was primary lung malignancies in 488 cases (92.1%), metastatic disease in 15 cases (2.8%), and benign diseases in 27 cases (5.1%). All fistulas developed after pneumonectomy for lung cancer. Other risk factors included age, preoperative radiotherapy, and the surgeon's level of experience, as only two fistulas occurred with the consultant who performed 410 pneumonectomies (0.5%). The bronchial stump was free of tumor in all cases. There were no fistulas in the 37 completion pneumonectomies (7%). All fistulas were treated within 2 days of diagnosis by resuturing the stump through the initial thoracotomy incision. That was successful in 5 patients, whereas fatal complications developed in the other 2 patients. We believe that suture closure of the bronchial stump at pneumonectomy provides a cheap and reliable technique that gives good results in all situations.

The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery

The authors report four cases of patients in desperate clinical situations where cyanoacrylate adhesive (Krazy Glue) was successfully used to control hemorrhage. Clinical observations were supplemented with bacteriological studies which showed that commercially available cyanoacrylate adhesive showed lack of bacteriological contamination.

Update on pediatric flexible bronchoscopy

Technological advances in flexible bronchoscopy have expanded the clinician's ability to diagnose and treat pulmonary disease in children. During the neonatal period, flexible bronchoscopy has contributed to the understanding of the incidence and factors responsible for acquired airway lesions. The ability to selectively collect lower airway secretions has contributed to the care of immunocompromised patients with new pulmonary infiltrates. New therapies may use the flexible bronchoscope to specifically target lower airway tissues of interest. Because of the breadth of both current and future applications, most pediatricians will require a working familiarity with the benefits of flexible bronchoscopy in their patients.