Amplatzer Device and Vacuum-Assisted Closure Therapy to Treat a Thoracic Empyema With Bronchopleural Fistula

Negative-pressure wound therapy in combination with bronchial occlusion to treat bronchopleural fistula: a case report

Background

Bronchopleural fistula, which usually accompanies bronchial fistula and empyema, is a severe complication of lung cancer surgery. Negative-pressure wound therapy can enhance drainage and reduce the empyema cavity, potentially leading to early recovery. This therapy is not currently indicated for bronchopleural fistulas because of the risk of insufficient respiration due to air loss from the fistula.

Case presentation

A 73-year-old man, who was malnourished because of peritoneal dialysis, was referred to our hospital for the treatment of lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed via posterolateral thoracotomy, and the bronchial stump was covered with the intercostal muscle flap. His postoperative course was uneventful and he was discharged. However, he was readmitted to our hospital because of respiratory failure and diagnosed as having bronchopleural fistula on the basis of the bronchoscopic finding of a 10-mm hole at the membranous portion of the inlet of the remnant lower lobe bronchus. Thus, thoracotomy debridement and open window thoracostomy were immediately performed. After achieving infection control, bronchial occlusion was performed using fibrin glue and a polyglycolic acid sheet was inserted through a fenestrated wound. Bronchial fistula closure was observed on bronchoscopy; therefore, a negative-pressure wound therapy system was applied to close the fenestrated wound. The collapsed lung was re-expanded and the granulation tissue around the wound increased; therefore, thoracic cavity size decreased and thoracoplasty using the latissimus dorsi was performed.

Conclusions

This bronchopleural fistula was treated successfully after a right lower lobectomy using an extra-pleural bronchial occlusion and negative-pressure wound therapy.

A Stepwise Approach for Postlobectomy Bronchopleural Fistula

Although rare, bronchopleural fistula (BPF) following anatomic lung resection is a serious complication associated with high rates of mortality (25%-71%). Risk factors for BPF include surgical approach, neoadjuvant therapy, diabetes mellitus, and chronic obstructive pulmonary disease. As neoadjuvant treatment is increasingly being administered to patients with locally advanced lung cancer, and as more patients are being diagnosed with lung cancer at an older age-elderly patients present with a higher index of multiple comorbidities-the incidence of BPF among patients undergoing anatomic resection for lung cancer is expected to increase. In this manuscript, we detail risk factors and considerations for BPF and describe a stepwise approach to treat BPF following lobectomy for lung cancer.

[Cogitum in children's neurology and psychiatry (experience in the practical use)]

The authors review current data on the role of the synthetic aspartic acid analogue N-acetyaspartate (NAA) in various biochemical metabolic reactions in the CNS. Its importance as a biomarker for neuropsychiatric disorders identified using magnetic resonance spectroscopy (MRS) is noted. The authors present their own results of the use of cogitum, a synthetic analogue of NAA, in children with the effects of traumatic brain injury, mental retardation, hyperactivity disorder and in the complex therapy of schizotypal disorder. Effects of cogitum on cognitive deficit, asthenia are evaluated. The neurotrophic effect of the drug, which specifically affects cognitive and asthenic disorders in these diseases, is shown.

Negative pressure wound therapy with instillation without open-window thoracostomy for empyema

Treatment of empyema is very challenging. The use of negative pressure wound therapy (NPWT), and NPWT with instillation and dwell time (NPWTi-d) for wound closure have attracted attention. However, they are both limited to use after open-window thoracostomy (OWT) performed to control infection. In some patients with poor general conditions, who cannot undergo surgery, no treatment for empyema is available. Therefore, we devised a new treatment for such patients with NPWTi-d without OWT (non-OWT NPWTi-d). Here we present the cases of two patients with refractory empyema after intrathoracic irrigation and drainage, who underwent non-OWT NPWTi-d using the fistula of the thoracic drain. Both the patients recovered. The first patient was treated for 31 days. As the empyema persisted, he underwent a repeat intrathoracic drainage after which the wound healed. The second patient was treated for 20 days. Non-OWT NPWTi-d may be a new option to treat empyema.