Endoscopic closure of a bronchopleural fistula after pneumonectomy with the Amplatzer occluder: a step forward?

Bronchopleural Fistula Management With an Amplatzer Duct Occluder: A Comprehensive Case Report and Literature Review

Bronchial stump insufficiency (BSI), also reported as bronchopleural fistula, following pneumonectomy is a rare but potentially devastating complication that can result in substantial morbidity and mortality. Despite advances in thoracic surgical techniques and perioperative care, bronchial stump dehiscence remains a challenging clinical scenario, especially when associated with severe infections and compromised patient conditions. Traditional surgical re-intervention to address this complication may carry significant risks and might be contraindicated in certain patients. As a result, innovative interventions are necessary to address these challenging cases effectively. In this report, we present an interventional endoscopic technique using an Amplatzer Duct occluder for the successful management of BSI in a 55-year-old male patient with a complex medical history.

Endobronchial closure of the bronchopleural fistula with the ventricular septal defect occluder: a case series

Objectives

The ventricular septal defect (VSD) occluder has been reported to be a novel method for the closure of bronchopleural fistula (BPF). Our study was to confirm the use of VSD occluder in treating BPF after pneumonectomy or lobectomy.

Methods

We performed a single-center, retrospective study of 10 consecutive patients (8 men and 2 women aged 29–70 years) with postoperative BPF receiving the VSD occluder treatment. We used the HeartR™ Membranous VSD occluder (Lifetech Scientific Co., Shenzhen, China) for the closure of BPF through flexible bronchoscopy under general anesthesia. Demographic characteristics, BPF characteristics, and clinical outcomes were collected from patients’ files using the standardized data abstraction forms.

Results

The underlying diseases were lung cancer in 6 patients, pulmonary tuberculosis in 3, and bronchiectasis in 1. Right-sided BPFs occurred in 6 patients, and left-sided BPFs occurred in 4. Five patients were underweight with a body mass index < 18.5 kg/m². The VSD was placed in all 10 patients with a 100% technical success rate and a 70% complete closure rate during follow-up with no complications, on a median follow-up period of 115 days (range 46–975 days). In 1 patient, the VSD occluder was reinstalled with complete closure; in 1 and 2 patients with underweight and chronic empyema, the VSD occluders partially and completely failed with good physical tolerance, respectively.

Conclusions

Our study demonstrated the bronchoscopic closure of BPF after lung resection using the VSD occluder is an off-label but safe and effective method. We prefer to stabilize the BPF by eradicating the underlying diseases and providing nutritional support to those receiving VSD occluder closure treatment.

The Amplatzer device and pedicle muscle flap transposition for the treatment of bronchopleural fistula with chronic empyema after lobectomy: two case reports

Background

Bronchopleural fistula (BPF) refers to an abnormal channel between the pleural space and the bronchial tree. It is a potentially fatal postoperative complication after pulmonary resection and a complex challenge for thoracic surgeons because many patients with BPF ultimately develop refractory empyema, which is difficult to manage and has a major impact on quality of life and survival. Therefore, an operative intervention combined with conservative and endoscopic therapies may be required to control infection completely, to occlude BPF, and to obliterate the empyema cavity during treatment periods.

Case presentation

Two patients who suffered from BPF complicated with chronic empyema after lobectomy were treated in other hospitals for a long time and did not recover. In our department, we performed staged surgery and creatively combined an Amplatzer Septal Occluder (ASO) device (AGA Medical Corp, Golden Valley, MN, USA) with pedicled muscle flap transposition. First, open-window thoracostomy (OWT), or effective drainage, was performed according to the degree of contamination in the empyema cavity after the local infection was controlled. Second, Amplatzer device implantation and pedicled muscle flap transposition was performed at the same time, which achieved the purpose of obliterating the infection, closing the fistula, and tamponading the residual cavity. The patients recovered without complications and were discharged with short hospitalization stays.

Conclusions

We believe that the union of the Amplatzer device and pedicle muscle flap transposition seems to be a safe and effective treatment for BPF with chronic empyema and can shorten the length of the related hospital stay.

An 83-year-old-male with bronchopleural fistula and empyema successfully treated with multidisciplinary management of thoracostomy, endoscopic, and surgical treatment: a case report

Bronchopleural fistula (BPF) with empyema is a severe complication in patients undergoing lobectomy or pneumonectomy and is associated with high morbidity and mortality rates. Although a wide variety of treatment options exist, refractory cases with larger fistulas are still difficult to cure, especially in elderly patients. Here, we report a case of an 83-year-old man with stage I squamous cell lung carcinoma who underwent minimally invasive right lower lobectomy. After an initially uneventful postoperative course, he was readmitted to our hospital due to the progression of severe cough with fever after lung resection. Chest computed tomography (CT) showed an empyema cavity containing pleural effusion and a drainage tube in the right lower thorax. Bronchoscopy confirmed the presence of a fistula between the right lower bronchial stump and the pleural cavity. On the basis of his clinical symptoms and these imaging findings, the patient was diagnosed with BPF with empyema after lobectomy. He was successfully treated with multidisciplinary management including adequate pleural drainage by open-window thoracostomy, closure of the BPF by endoscopic therapy using an Amplatzer device, and complete obliteration of the empyema cavity with pedicled muscle flap. Multidisciplinary management combining thoracostomy, endoscopic therapy, and pedicled muscle flap transfer is a safe and effective treatment for elderly patients with larger fistulas and empyema.