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

Treatment of late left bronchopleural fistula after left pneumonectomy through right thoracic approach assisted by extracorporeal membrane oxygenation

BACKGROUND

Bronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO).

CASE PRESENTATION

We report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO).

CONCLUSIONS

Advanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

OBJECTIVE

To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy.

METHODS

Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality.

RESULTS

During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts.

CONCLUSIONS

Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Transsternal Approach for Broncho-Pleural Fistula Closure After Right Pneumonectomy

Broncho-pleural fistula (BPF) is an abnormal communication between the bronchial lumen and the pleural space that typically occurs postoperatively. Surgical intervention is typically needed to patch the fistula; however, current literature lacks a gold standard for which treatment to use. With a high mortality rate, there is a clear urgency for quick and successful intervention. This case examines a 59-year-old patient presenting with a BPF 14 years after incidental pneumonectomy during upper lobectomy for invasive aspergillus. A fistula was appreciated during bronchoscopy with contrast injection. The fistula was closed via the transsternal approach through median sternotomy and pericardiotomy. This case report aims to provide a viable option to successfully repair a BPF via the transsternal approach.

Nil Intervention is at Times the Best Intervention: Benign emptying of pneumonectomy space

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions.

Successful surgical treatment of bronchopleural fistula caused by severe pulmonary tuberculosis: A case report and review of literature

BACKGROUND

Bronchopleural fistula (BPF) is a relatively rare, but severe complication of pulmonary tuberculosis. It is associated with significant mortality; however, its management remains a major therapeutic challenge.

CASE SUMMARY

We present a 24-year-old man with BPF resulting from severe pulmonary tuberculosis combined with mixed infections. The damaged right upper lobe and concomitant empyema were demonstrated via computed tomography. After undergoing open-window thoracostomy and tuberculosis treatment for 4 mo, decortication and right upper lobectomy were subsequently performed, leading to the resolution of tuberculosis and other concurrent pulmonary infections. Follow-up, 6 mo after surgery, failed to reveal any evidence of infection recurrence resulting in a good prognosis.

CONCLUSION

The disease course of tuberculous BPF is particularly challenging. Surgical intervention serves as an effective and safe therapeutic strategy for BPF.

Bronchopleural Fistula and Endobronchial Valve Placement in a Patient With COVID-19 Pneumonia: A Case Report With Literature Review

Bronchopleural fistulas (BPFs) are associated with high morbidity and mortality. Though most commonly seen after surgical interventions, they are increasingly reported as complications of COVID-19 infection. We present the case of an 86-year-old man with COVID-19 pneumonia and subsequent bronchopleural fistula (BPF) with persistent air leak. Endobronchial valves were placed in apical and posterior segments of the right upper lobe resulting in successful cessation of the air leak. The purpose of the case report and literature review is to help guide the management of persistent air leak.

CT Follow-Up of Postoperative Bronchopleural Fistula: Risk Factors for Progression to Chronic Complicated Infection

Purpose

Materials and Methods

Results

Conclusion

Bronchopleural fistula following a video-assisted thoracoscopic surgery lobectomy after neoadjuvant therapy of pembrolizumab: a case report and literature review

Lung cancer has the highest morbidity and mortality worldwide among the malignant tumors. The treatment of lung cancer was difficult in the decade years. Currently, the advent of immune checkpoint inhibitors (ICIs) has changed the pattern of lung cancer treatment. Programmed death-ligand 1 (PD-L1) inhibitors, such as pembrolizumab, plus platinum-based chemotherapy is the preferred treatment modality for advanced or metastatic non-small cell lung cancer (NSCLC) patients. The success of pembrolizumab in lung cancer has increased interest in expanding the use of neoadjuvant treatment. Immune-related adverse events (irAEs) are the most common adverse reactions in immunotherapy. The balance between the benefits and risks is crucial in this setting. Video-assisted thoracoscopic surgery (VATS) is a routine procedure of resectable NSCLC treatment. It appears to favor low postoperative complication rate. The prolonged air leakage (PAL) is the most common complication after VATS, and the bronchopleural fistula (BPF) is the most serious complication. The management of adverse events after VATS, especially in the setting of immune therapy, need to be raised. Here, we report a case of BPF following VATS lobectomy, which firstly presented the treatment-related adverse event with neoadjuvant combination therapy of pembrolizumab plus cisplatin/pemetrexed. Literature on novel neoadjuvant immunotherapy was also reviewed in the present study.

Postoperative complications of pulmonary resection

Thoracic surgery has seen a resurgence in recent years with increasing numbers of cases taken on since the mid-2000s. There has been a paradigm shift in how we manage lung cancer with more emphasis on surgical resection, and this has been aided by minimally invasive video-assisted thoracic surgery (VATS) techniques. As a result, the prevalence of postoperative findings and complications is also increasing, and it is increasingly important for the general radiologist to recognise and diagnose these conditions as thoracic surgical patients may present acutely to non-thoracic surgical institutions. This review will cover both the early and late complications following a variety of lung resection surgeries.

[Use of pedicled dorsal muscle flap combined with negative pressure therapy in the management of postpneumonectomy septic complications]

SUBJECT

The objective of this study is to report our experience in the management of septic complications arising from pulmonary resection surgery by placing a pedicled upper back muscle flap associated with dressings by therapy. Negative pressure in all patients supported in our center from November 2015 to March 2018.

MATERIAL AND METHODS

Characteristics of fourteen patients with a pedicled dorsal muscle flap in the context of chronic empyema associated with bronchopulmonary fistula were identified. Flap placement time, complications, and success rate were assessed.

RESULTS

The median flap placement after completion of the open window thoracostomy was 19days [3-65]. The median healing time was 3months. Healing was definitively achieved in 12 patients, a success rate of 86%.

CONCLUSION

Through this series we have shown that our coverage by pneumonectomy cavity coverage with an early dorsal muscle flap associated with negative pressure therapy, has a similar mortality rate and success rate to those found in the literature.

Respiratory failure caused by impending tension pneumothorax after extrapleural pneumonectomy: a case report

Background

Case presentation

Conclusions

Management of Postpneumonectomy Bronchopleural Fistula: From Thoracoplasty to Transsternal Closure

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.

[Analysis of Prolonged Hospitalizations (Longer than 7 days): 115 Lung Cancer Patients after Video Assistant Thoracic Surgery (VATS)]

BACKGROUND

Thoracoscopic surgery has gradually become the major procedure for lung cancer surgery in our department. Its characteristics are minimal trauma and quick recovery, which make approximately 90% of patients discharge from the hospital after surgery. However, the postoperative complications still happen now and then. We analyzed the patients who had been hospitalized for longer than 7 days after thoracoscopic lung cancer surgery, aiming to summarize the types and risk factors of complications, and improve postoperative safety of patients.

METHODS

The data were come from the prospective database of Thoracic Surgery Unit One in Peking Cancer Hospital, and patients that underwent thoracoscopic pulmonary surgery between Jan. 2010 and Dec. 2014 with length of stay more than 7 days were included in the study. The classifications of the complications were investigated and graded as mild or severe complications according to modified Claviengrading, the relationship between clinical factors and degrees of complications was also analyzed.

RESULTS

The hospitalization of 115 cases were longer than 7 days after surgery, accounting for 10.3% (115/1,112) of the whole patients that underwent surgery during the same period. Eighty-one cases had mild complications, accounting for 7.3% (81/1,112) of the whole cases that underwent surgery during the same period and 70.4% (81/115) of the cases with prolonged length of stay; the proportions of severe complications in both groups were 3.1% (34/1,112) and 29.6% (34/115), respectively; and the proportions of complications that caused perioperative deaths were 0.18% (2/1112) and 1.7% (2/115), respectively. Among all the postoperative complications, the most common was air leakage for more than 5 days after surgery, with a total of 20 cases (1.8% and 17.4%). The other common complications were: atelectasis (19 cases, 1.7% and 16.5%), pulmonary infection (18 cases, 1.6% and 15.7%), etc. The less common complications was bronchopleural fistula (4 cases, 0.36% and 3.5%) with very high risk, and 2 cases died perioperatively due to the combination of acute respiratory distresssyndrome (ARDS). In the clinical factors, only preoperative low pulmonary function (FEV1%<70%) was the potential risk factor for postoperative severe complications (45.8% vs 23.6%, P=0.038). There was no significant difference either regarding the 5 year disease free survival or the 5 year overall survival between mild complication group and severe complication group, with 5 year DFS being 52.2% and 51.9%, respectively (P=0.894) , and 5 year overall survival being 64.0% and 53.5%, respectively (P=0.673).

CONCLUSIONS

Continuous postoperative air leakage, atelectasis and pulmonary infections were the major causes for prolonged hospitalization after thoracoscopic surgery for lung cancer, and bronchopleural fistula was the most perilous complications. Patients with low preoperative pulmonary function were more likely to have severe postoperative complication, however, this would not influence the long term survival of the patients.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis

PURPOSE

Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings.

METHODS

A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis.

RESULTS

The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47).

CONCLUSIONS

The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Endoscopic bronchial occlusion for postoperative persistent bronchopleural fistula with computed tomography fluoroscopy guidance and virtual bronchoscopic navigation: A case report

RATIONALE

The development of postoperative bronchopleural fistula (BPF) remains a challenge in thoracic surgery. We herein report a case of BPF successfully treated with endoscopic bronchial occlusion under computed tomography (CT) fluoroscopy and virtual bronchoscopic navigation (VBN).

PATIENT CONCERNS

A 63-year-old man underwent right upper lobectomy with concomitant S6a subsegmentectomy for lung adenocarcinoma. On postoperative day 24, he complained of shaking chills with high fever.

DIAGNOSES

BPF with subsequent pneumonia and empyema.

INTERVENTIONS

Despite aggressive surgical interventions for the BPF, air leakage persisted postoperatively. On days 26 and 34 after the final operation, endobronchial occlusions were performed under CT fluoroscopy and VBN.

OUTCOMES

The air leaks greatly decreased and the patient was discharged.

LESSONS

CT fluoroscopy and VBN can be useful techniques for endobronchial occlusion in the treatment of BPF.

Coated expandable metal stents are effective irrespective of airway pathology

Background

Tracheobronchial stents are a treatment option for inoperable benign or malignant tracheobronchial stenosis (TBS) or postoperative bronchopleural fistulas (POBPF). The present study evaluated the outcomes of patients with TBS and POBPF who were treated by placement of recent generation, fully covered, self-expanding metallic stents (SEMS) and determined stent efficacy relative to airway pathology.

Methods

From January 2009 to January 2016, 68 patients with TBS or POBPF underwent rigid bronchoscopy, laser/mechanical debridement and placement of fully covered SEMS. Eighteen patients had benign stenosis, 38 had malignant stenosis, and 12 patients had POBPF.

Results

Seventy-four SEMS were successfully placed in 68 patients. There were no perioperative deaths. Stent-related complications occurred in 20 (29.4%) patients: granulation tissue formation [TBS group, 10.7% (n=6); POBPF group, 8.3% (n=1)]; stent fracture [TBS group, 5.4% (n=3); POBF group, 8.3% (n=1)], stent migration [TBS group, 7.1% (n=4); POBF group, 0% (n=0)], severe secretions not removable by flexible bronchoscopy [TBS group, 7.1% (n=4); POBF group, 8.3% (n=1)]. No stent migration was observed in the POBPF group. Four patients (7.1%) in the TBS group had stent migration requiring stent replacement. After stenting, all TBS patients had a Hugh-Jones classification score improvement ≥1 grade and 42 patients (75%) had an improvement ≥2 grades. Logistic regression analysis showed that the disease (stenosis vs. fistula) did not influence the occurrence of stent complications [OR 0.96, 95% confidence interval (CI): 0.71-1.13, P=0.13].

Conclusions

Fully covered SEMS are effective and provide a versatile treatment option for patients with inoperable TBS and POBPF.

Conservative management of empyema-complicated post-lobectomy bronchopleural fistulas: experience of consecutive 13 cases in 9 years

BACKGROUND

Bronchopleural fistula (BPF) is an infrequent but life-threatening complication after lung surgery. Tentative closure of the fistula and irrigation have been the conventional treatments, but are also surgically challenging and associated with a considerable failure rate. This study reports on a conservative practice of this difficult issue, in aim to examine its outcomes.

METHOD

All enrolled cases were handled consecutively from September 2006 to June 2015. The empyema was first properly drained till disseminated pneumonia controlled. After conducting lavage, tube drainage was gradually transited to postural drainage. During the follow-up, information on tube removal, fistula healing, and survival were recorded.

RESULTS

Thirteen cases were enrolled, including 9 rights and 4 lefts. The primary diseases were lung cancer [10], lung abscess [1], organizing pneumonia [1], and aspergillosis [1]. Early fistula (≤30 days postoperatively) occurred in 8 cases and late fistula (>30 days postoperatively) in 5 cases. Two patients underwent debridement to ascertain complete drainage. Chest tubes retained from 7 to 114 days (mean 40.54±30.49 days) before removal. At follow-up, we observed gradually narrowing-down of all residual cavities, and symptoms of fistula and empyema eventually disappeared in all patients. No complication or death occurred during the follow-up.

CONCLUSIONS

Conservative management by a combination of tube and postural drainage provides an effective and safe treatment for empyema-complicated post-lobectomy BPFs.

Preventive Diaphragm Plasty after Pneumonectomy on Account of Lung Cancer

Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.

Omentoplasty in Treatment of Early Bronchopleural Fistulas after Pneumonectomy

This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.

Management Strategies for Complex Bronchopleural Fistula

The management of complex bronchopleural fistula remains a major therapeutic challenge for the thoracic surgeon. Although the incidence of bronchopleural fistula following lung resection has decreased in recent years to 1% to 2%, when it occurs, it is associated with significant morbidity and mortality. Using illustrative cases, the epidemiology and pathophysiology of bronchopleural fistula are reviewed and operative strategies are discussed. Algorithms for the diagnosis and treatment are suggested on the basis of cases described in the literature. The best way to prevent a fistula is to rigorously follow the surgical techniques described, with minimal devascularization of the bronchus and prophylactic coverage of the stump in high-risk patients. Successful management of a fistula is combined with treatment of the associated empyema cavity. Definitive repair should be accomplished expeditiously, minimizing the number of procedures performed. When treatment is protracted, secondary complications are more likely and survival is adversely affected. The first step should be control of active infection and adequate drainage of the hemithorax, followed by timely repair of the bronchopleural fistula when possible and reinforcement of the stump with vascularized tissue. If a residual cavity is present it must also be obliterated with a pedicled muscle flap.

Can Peripheral Bronchopleural Fistula Demonstrated on Computed Tomography be Treated Conservatively? A Retrospective Analysis

Purpose

Peripheral bronchopleural fistulas (BPF) are communications between a peripheral bronchus or the lung parenchyma and the pleural space. Although reported cases with peripheral BPF might have typical symptoms, we postulate that there may be BPF patients without typical symptoms who are diagnosed on computed tomography (CT) for the first time.

Materials and Methods

We searched retrospectively for how frequently BPF is found on CT in cases with known or suspected empyema or hydropneumothorax. Also, we examined the clinical charts to ascertain if a diagnosis of BPF was suspected in the CT reports or clinically, and to determine the outcome of each case.

Results

Thirteen thoracic cavities of 12 patients were included in this study. Of these, BPF was suspected clinically in only 1. Mention in the CT report about the presence of BPF was found in 2 cases. An apparent finding of BPF on CT was found in 7 of 13 (53%) thoracic cavities of 6 cases. The outcomes were that 1 patient died 1 month later due to multiple organ failure, and 1 patient was discharged subsequently after CT. In the other 10 cases, there was no exacerbation of the symptom regardless of definite evidence of BPF on CT.

Conclusions

In conclusion, when there is hydropneumothorax on CT, it is important for radiologists to diligently search for findings of peripheral BPF and to document it. However, a reference about the need for a surgical approach for BPF may not be required.

Pedicle muscle flap transposition for chronic empyema with persistent bronchopleural fistula: experience of a single clinical center in China

PURPOSE

The management of chronic empyema with persistent bronchopleural fistula (BPF) is a major challenge for surgeons. We report our experience of performing pedicle muscle flap transposition for chronic empyema with BPF in a clinical center in China.

METHODS

The subjects of this study were 13 patients with postoperative chronic empyema and persistent BPF. The surgical procedure performed was chosen according to the degree of infection in the empyema cavity. Patients with mild contamination underwent one-stage cavity decortication with flap transposition, whereas patients with severe infection underwent two-stage surgery including open-window thoracostomy and pedicle muscle flap transposition.

RESULTS

Five patients underwent one-stage surgery, followed by an uneventful postoperative course in all except one. The other eight patients underwent two-stage surgery. The fistulas closed spontaneously during the course of dressings and six of these eight patients underwent second-stage surgery uneventfully. A bronchopleurocutaneous sinus developed in the wounds of the other two patients.

CONCLUSIONS

Pedicle muscle flap transposition is a viable option for chronic empyema with BPF; however, surgical procedures should be selected according to the degree of contamination. For two-stage surgery, obliteration of the cavity should be considered, preferably after closure of the fistula.

Polyglycolic acid mesh occlusion for postoperative bronchopleural fistula

BACKGROUND

Postoperative bronchopleural fistula is one of the most life-threatening complications after anatomical pulmonary resection. Bronchopleural fistula may cause empyema and aspiration pneumonia with subsequent acute respiratory distress syndrome. Surgical interventions for bronchopleural fistula can prolong hospitalization and impair postoperative quality of life. Postoperative care requires minimally invasive endoscopic occlusion.

METHODS

We retrospectively reviewed the records of 7 patients who developed bronchopleural fistula among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in Jichi Medical University from 2009 to 2013. Bronchopleural fistula occurred in the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 2, in the superior segmental bronchus of the left lower lobe in one, and in the right intermediate bronchus in one. Flexible bronchoscopy was used to occlude 3-mm fistulas with polyglycolic acid mesh in 2 patients. Larger fistulas in 5 patients were occluded with polyglycolic acid mesh plus fibrin glue to secure the mesh. The median procedure was 37 min. Procedures were considered complete upon resolution of air leakage from the chest drainage system.

RESULTS

Bronchoscopic interventions for bronchopleural fistula were repeated an average of 2 times. No procedure-related complications or death occurred. Bronchoscopic interventions were successful in all patients.

CONCLUSIONS

Bronchoscopic occlusion with polyglycolic acid mesh with or without fibrin glue is easy and feasible as the first step in postoperative management of bronchopleural fistula.

Postoperative complications after thoracic surgery for lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. Several surgical techniques are currently used as part of the standard of care for early-stage lung cancer. Differentiating normal postoperative changes from complications is essential in the management of these patients. This article will review the various surgical approaches used, ranging from wedge resection to pneumonectomy, and will outline their expected postsurgical changes. Early and late postsurgical complications will be described, some of which are unique to the type of surgery performed. In addition, local tumor recurrence is a form of postoperative complication and must be distinguished from typical postoperative or postradiation change. Knowledge of both common and uncommon postoperative complications is crucial in the follow-up of lung cancer patients.

SUMMARY STATEMENT

Familiarity with the appearance of postoperative complications in lung cancer patients is vital to distinguish it from the normal postoperative or postradiation appearance in follow-up imaging.

Laparoscopic cholecystectomy in a patient with previous pneumonectomy: a case report and discussion of anaesthetic considerations

Increasing numbers of patients require cholecystectomy after previous pneumonectomy, but there are little data to guide anaesthetic management. A laparoscopic approach is associated with less postoperative respiratory compromise than open cholecystectomy but may be relatively contraindicated due to the undesirable effects of pneumoperitoneum on respiratory function. We describe the case of a 72-year-old patient who successfully underwent elective laparoscopic cholecystectomy 23 years after left pneumonectomy. An understanding of the combined physiological consequences of pneumonectomy and pneumoperitoneum facilitated the provision of safe and uneventful anaesthesia. We propose that laparoscopic cholecystectomy is feasible and safe to perform in patients with a single lung.

Closure of a broncho-pleural fistula using an atrial septal defect occluder

Broncho-pleural fistulae (BPF) are recognised as a rare complication following pneumonectomy. We describe a patient, who after failing conservative treatment, underwent closure of a persistent fistula with an atrial septal defect (ASD) occluder. Additionally we review the literature regarding management of BPF and the emerging role of cardiac defect closure devices as a possible treatment option.

Bronchial stump coverage with fibrin glue-coated collagen fleece in lung cancer patients who underwent pneumonectomy

PURPOSE

Bronchopleural fistula (BPF) is a serious complication following pneumonectomy in lung cancer patients. The aim of this retrospective study is to investigate the efficacy of bronchial stump reinforcement with a collagen fleece coated with fibrin glue(TachoComb®).

METHODS

The bronchial stumps of 43 lung cancer patients who underwent pneumonectomy between January 1998 and January 2003 were covered with pericardial fat pad.From February 2003 to the March 2011, we used TachoComb to cover the bronchial stumps of all lung cancer patients undergoing pneumonectomy (20 cases). Several preoperative, intraoperative, and postoperative variables were recorded retrospectively.

RESULTS

Univariate analysis of comorbidities and risk factors did not show any significant differences between the two groups except for neoadjuvant chemotherapy. Postpneumonectomy BPF occurred in three of the 43 (7%) patients who had pericardial fat pad coverage and in none of the patients treated by TachoComb.

CONCLUSION

Reinforcement of the bronchial stump with TachoComb is a simple procedure, comparable to coverage with viable tissue, and should be considered in the prevention of postpneumonectomy BPF.

Multidetector computed tomography findings of central bronchopleural fistulas as sequelae of tuberculosis, chemo radiation and trauma: A report of three cases

A bronchopleural fistula (BPF) is defined as a direct pathway between the bronchial tree or lung parenchyma and the pleural space. Herein, we describe the clinical findings and imaging results of BPFs in three cases. The patients' medical histories revealed that the first had recurrent pulmonary tuberculosis, the second had small-cell lung cancer (SCLC) and had previously undergone chemoradiotherapy, and the third had trauma. Multidetector computed tomography (MDCT) showed clear communication between the airways and pleural spaces which was sufficient for a proper diagnosis without performing a bronchoscopy.

Phrenic nerve block as a novel adjunct to the local treatment of bronchopleural fistula

Bronchopleural fistula (BPF) is a life threatening complication after pneumonectomy with an incidence of about 2-5% and a mortality rate of up to 50%. Topical treatment such as fibrin glue has been previously described with limited success. We present a novel case in which blocking the phrenic nerve assisted in a successful topical closure of the BPF.

Bronchoscopic ethanolamine injection therapy in patients with persistent air leak from chest tube drainage

Background

Chest tube drainage (CTD) is an indication for the treatment of pneumothorax, hemothroax and is used after a thoracic surgery. But, in the case of incomplete lung expansion, and/or persistent air leak from CTD, medical or surgical thoracoscopy or, if that is unavailable, limited thoracotomy, should be considered. We evaluate the efficacy of bronchoscopic injection of ethanolamine to control the persistent air leak in patients with CTD.

Methods

Patients who had persistent or prolonged air leak from CTD were included, consecutively. We directly injected 1.0 mL solution of 5% ethanolamine oleate into a subsegmental or its distal bronchus, where it is a probable air leakage site, 1 to 21 times using an injection needle through a fiberoptic bronchoscope.

Results

A total of 15 patients were enrolled; 14 cases of spontaneous pneumothorax [idiopathic 9, chronic obstructive pulmonary disease (COPD) 3, post-tuberculosis 2] and one case of empyema associated with broncho-pleural fistula. Of these, five were patients with persistent air leak from CTD, just after a surgical therapy, wedge resection with plication for blebs or bullae. With an ethanolamine injection therapy, 12 were successful but three (idiopathic, COPD and post-tuberculosis) failed, and were followed by a surgery (2 cases) or pleurodesis (1 case). Some adverse reactions, such as fever, chest pain and increased radiographic opacities occurred transiently, but resolved without any further events. With success, the time from the procedure to discharge was about 3 days (median).

Conclusion

Bronchoscopic ethanolamine injection therapy may be partially useful in controlling air leakage, and reducing the hospital stay in patients with persistent air leak from CTD.

Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered self-expandable stent

The aim of the study was to assess the feasibility, efficacy and safety of the use of a conical self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula (PPBPF). Between April 2008 and November 2010, six patients underwent treatment for the PPBPF by the introduction of a tracheobronchial conical fully covered self-expandable nitinol stent with the aim of excluding the bronchial dehiscence from the airflow. We secured the prosthesis to the tracheal mucosa with titanium helical fasteners tacks. Five patients presented with a bronchial fistula larger than 5 mm following right (4) or left (1) pneumonectomy. One patient had an anastomotic dehiscence after right tracheal sleeve pneumonectomy. A chest tube showed the absence of empyema in all cases. Immediate resolution of the bronchial air leak was obtained in all the patients. Permanent closure of the bronchial dehiscence without recurrence was achieved in all the patients at a mean follow-up time of 13 months (range 3-32). The bronchial stent was successfully removed in all patients without sequelae 71-123 days after its implantation. The use of the conical self-expandable Silmet(®) stent has proved to be an effective, safe and fast method to treat even large PPBPFs.

Bronchial Stump Coverage and Postpneumonectomy Bronchopleural Fistula

To prevent postpneumonectomy bronchopleural fistula, coverage of the bronchial stump is recommended, especially for patients treated with neoadjuvant and adjuvant chemotherapy or radiochemotherapy. We compared outcomes after proximal pericardial fat pad coverage and coverage with pleura and surrounding tissues, by retrospective analysis of the records of 243 patients. Postpneumonectomy bronchopleural fistula occurred in 7/143 (4.9%) patients who had pericardial fat pad coverage, and in 6/100 (6.0%) treated by pleural covering. Bronchopleural fistula occurred in 11 patients within 21 days, in one after 2 months, and one after 6 months. Univariate analysis of comorbidities and risk factors did not show any significant differences between the groups. Advanced T stage and carcinomatous lymphangiosis at the resection margin were associated with a higher risk of bronchopleural fistula development, independent of the technique. Reinforcement of the bronchial stump by proximal pericardial fat pad coverage appears to be safe and feasible. It is comparable to coverage with pleura and surrounding tissues.

Emerging technologies for the thorax: indications, management and complications

The field of interventional pulmonology has rapidly expanded to include the management and treatment of complex diseases of the chest. The management of central airway obstruction, pleural disease diagnosis, treatment and palliation, advanced bronchoscopic techniques to aid in the diagnosis of lung cancer and innovative therapies to treat asthma and COPD have all emerged over the past decade. As astute clinicians, we are all aware of the risks and benefits of using these therapies to treat our patients. In order to appropriately treat and manage these often complex medical situations, the physician should have an expert knowledge of all available modalities, the expertise to safely perform the procedure and the ability to minimize the risk of and manage the associated complications that may arise. In this chapter we review and update some of the bronchoscopic and pleural interventions offered by interventional pulmonologists as well as the associated complications and management.

Successful endobronchial seal of surgical bronchopleural fistulas using BioGlue

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae

OBJECTIVE

Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways.

METHODS

Consecutive patients with small (<or=5 mm) bronchopleural fistulae in proximal airways were included in the study. After measurement of bronchopleural fistula size through a flexible videobronchoscopy, a standard bronchoscopic cytology brush covered with silver nitrate was passed through the working channel of the scope and was rubbed against the fistula's orifice producing blanching and edema on the mucosa. This procedure was repeated until closure of the fistula's orifice (treatment success) or absence of any tissue response after 2 bronchoscopic sessions (treatment failure).

RESULTS

Of 16 patients referred, 5 were excluded from treatment because of large (>5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2-5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8% success rate) after a median of 2.5 (range 1-10) applications of silver nitrate. After 11 (0.5-24) months of follow-up, no relapse was observed among successfully treated fistulae.

CONCLUSION

The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases.