An Innovative Solution for Prolonged Air Leaks: The Customized Endobronchial Silicone Blocker

A customized multimodality approach for prolonged air leaks (PAL) in mechanically ventilated patients

ARDS in general and severe COVID ARDS (CARDS) is particularly associated with high rates of barotrauma. Two cases with severe CARDS developed bilateral pneumothorax with persistent air leak (PAL). Conservative management with prolonged chest tube drainage did not help in PAL resolution and both patients continued to be on high-end ventilatory support. The course was further complicated by the presence of septic shock. The 1st patient was taken up for a challenging procedure after spending 23 days on the mechanical ventilator. Diagnostic pleuroscopy revealed left-sided bullae and a surgical staple bullectomy was done. The right side showed a large bronchopleural fistula (BPF) on pleuroscopy, which was occluded using a customized endobronchial silicone blocker (CESB, described in 2018). This led to the reduction and finally, resolution of the bilateral PAL with subsequent removal of chest drains and weaning off the ventilator and oxygen. The second patient was managed with 2 CESB devices for occlusion of RUL anterior and posterior segment fistulae, followed by chest drain removal. These cases highlight effective out-of-the-box multimodality treatment using a combination of interventional pulmonary techniques and surgical stapling for a life-threatening bilateral PAL secondary to CARDS.

Use of airway stents to treat malignant tracheobronchial fistulas: Our six-year experience

BACKGROUND

This study aims to investigate the indications, safety, complications, and long-term outcomes of airway stenting in the treatment of malignant tracheobronchial fistulas.

METHODS

The medical records of a total of 34 patients (24 males, 10 females; mean age: 55.4+13 years; range, 23 to 76 years) with malignant tracheobronchial fistulas treated with airway stenting between February 2014 and August 2020 were retrospectively analyzed. Data including demographic features, diagnosis, symptoms, treatment, complications and outcomes were recorded.

RESULTS

Thirty-eight airway stents were inserted in 34 patients with malignant tracheobronchial fistulas, including 19 patients with malignant tracheobronchial esophageal fistulas and 15 patients with bronchopleural fistulas. The clinical success and the technical success rates were 91% and 100%, respectively. No perioperative death or severe complications occurred. Chronic complications (>24 h) occurred in eight (23%) patients with malignant tracheobronchial fistula. Median follow-up was 3.5 (range, 1.4 to 5.5) months in patients with malignant tracheobronchial esophageal fistulas and 18 (range, 9.5 to 26.5) months in patients with bronchopleural fistulas. Mortality rates were 79% and 61%, respectively.

CONCLUSION

Airway stent insertion provides a secure and effective treatment for patients with malignant tracheobronchial fistulas.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: a clinical observation of 17 cases

BACKGROUND

Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula.

METHODS

Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed.

RESULTS

Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5-431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure).

CONCLUSIONS

The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

Bronchopleural Fistula after Surgery: Therapeutic Efficacy of Bronchial Occluders

목적

수술 후 발생하는 기관지늑막루에 대한 bronchial occluder device (이하 BOD)의 유용성 및 효과성을 평가하고자 한다.

대상과 방법

2009년도부터 2019년까지 폐암 및 폐결핵으로 수술 후 발생한 7명의 기관지늑막루 환자들 중에 BOD 치료를 실시한 6명의 환자를 대상으로 하였다. 폐암 환자가 5명, 폐결핵 환자는 1명이었다. 남자가 5명, 여자가 1명이었으며 59세에서 74세(평균: 69세)이었다. 진단은 전산화단층기관지 촬영과 기관지내시경으로 실시하였다. 시술은 진단 후 1주에서 2주 사이에 실시하였다. 치료에 사용된 BOD의 기술적 성공 및 임상적 성공을 평가하였다. 시술 후 임상적 치료 효과와 생존 기간 및 부가적인 치료에 대하여 알아보았다.

결과

총 6명 환자 모두에서 시술을 성공적으로 실시하였다. 임상성공 5명에서 있었고, 1명에서는 임상부분성공이 있었다. 임상실패한 경우는 없었다. 기구의 이동이나 천공의 합병증은 없었다. 2명은 전산화단층기관지 촬영으로, 4명은 기관지내시경으로 기관지늑막루를 진단하였다. 수술은 폐엽절제술(lobectomy) 2명, 폐이엽절제술(bilobectomy) 2명, 그리고 전폐절제술(pneumonectomy) 2명이었다. 수술 후 진단까지 걸린 시간은 1개월에서 34개월(평균: 10개월)이었다. 4명(59~103일: 평균 80.5일)은 사망하였고 2명(313일, 3331일)은 생존하였다. 사망 원인이 2명은 기저질환의 악화, 1명은 폐부종 및 흉수, 1명은 폐렴이었다. 한 명에서 부가적인 카테타 배액술, 2명에서 흉관 삽입을 유지하였다.

결론

폐절제 수술 후 발생할 수 있는 기관지늑막루 치료에 있어서 BOD는 유용하고 효과적인 치료 방법이다.

A Novel Technique for the Management of Massive Hemoptysis: The Customized Endobronchial Silicone Blocker

OBJECTIVE

Massive hemoptysis (MH) has a high mortality rate. Therapeutic options include bronchoscopy for endobronchial lesions, bronchial artery embolization (BAE), and emergency surgery. Scant options exist for patients who are not candidates for these modalities. Culprit bronchial segment occlusion is an option to prevent "spillover flooding → hypoxia." Applying this concept, we describe a case series of MH control using a novel bronchoscopically inserted customized endobronchial silicone blocker (CESB). We analyzed the safety and efficacy of CESBs in a select subset of patients with MH.

METHODS

Inclusion criteria were patients with MH who were unstable for surgery/BAE, failed BAE, or relatively contraindicated/refused BAE. CESBs were manufactured on-site by modifying silicone stents, inserted using rigid bronchoscopy and reinforced with glue. The CESB was removed after 6 weeks when possible. A successful outcome was defined as immediate bleeding control with no recurrence after removal.

RESULTS

Over 4.5 years, 13 episodes of MH in 12 patients meeting the criteria specified earlier were treated with CESBs. Seven of 12 patients had tuberculosis, 4 active and 3 inactive. One patient had mucormycosis, 1 post-lobectomy, 1 endobronchial renal cell carcinoma, 1 fibrosing mediastinitis, and 1 patient had metastatic laryngeal Ca. Eight of 12 patients were taken for primary-CESB placement. Four of 12 patients were sent for BAE, which was unsuccessful, and rescue-CESB was done for definitive management. The success rate, as defined earlier, was 92.3%, with no deaths from MH.

CONCLUSIONS

Innovative bronchoscopically inserted CESBs are an effective strategy in MH when patients are unstable or fail conventional management.