Healing of bronchopleural fistula using a modified Dumon stent: a case report

Direct Insertion of a Dumon Stent Into an Intermediate Bronchus Fistula From the Surgical Field

A 54-year-old man underwent right S6 segmentectomy for right lung cancer. After discharge, he presented with fever, hemoptysis, and cough, and computed tomography showed an intermediate bronchus fistula. Because direct closure or bronchoplasty was challenging, a Dumon (Novatech) stent was inserted directly into the fistula from the surgical field and covered with an autologous pericardial patch, pedicled mediastinal fat, and intercostal muscle. The Dumon stent was removed by rigid bronchoscopy 1 year later. For an intermediate bronchus fistula that was difficult to repair by bronchoplasty, a Dumon stent was effective for maintaining bronchial patency and preserving the peripheral lung.

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.

Modified silicone stent for difficult-to-treat massive hemoptysis: a pilot study of 14 cases

Background

Massive hemoptysis is a life-threatening event with limited therapeutic options. Bronchoscopic placement of stents may offer an alternative option for massive hemoptysis. However, traditional silicone stents have not been customized, making it difficult to tailor to individual patient’s needs for achieving optimal hemostasis. To investigate the efficacy and safety of the modified silicone stent in patients with difficult-to-treat massive hemoptysis.

Method

Between May 2016 and November 2018, we enrolled 14 patients who underwent bronchoscopic placement of the modified silicone stent, which was fabricated manually based on the Y-shaped silicone stent by tailoring and suturing on site. We recorded the technical success, clinical success, and complications. Patients were followed up for recording the recurrence of massive hemoptysis and complications.

Results

Placement of the modified silicone stent was successful in all 14 patients with a mean duration of 69.6 minutes (technical success rate: 100%). After stenting, no further massive hemorrhage episodes recurred in 12 patients (clinical success rate: 85.7%). Two cases suffered from recurrent hemoptysis in 4 and 6 days after stenting, respectively. The main complications were sputum plugging, granuloma proliferation and pulmonary infection such as pneumonia. There were no adverse events of stent migration and suture dehiscence. After a median follow-up of 5.8 (range, 0.3–21.3) months, three patients withdrew and seven patients succumbed. Only one patient died of uncontrolled pneumonia which was possibly related to stent placement.

Conclusions

The modified silicone stent is an effective and safe gate-keeping therapeutic option for difficult-to-treat massive hemoptysis.

Treatment of airway stenosis with a customized bronchial stent using a three-dimensional printer and flexible filaments

Stent placement is recommended for patients with airway stenosis. However, ready-made stents may be difficult to fit over lesioned areas. In the current case report, we describe the creation and placement of a custom stent in an 84-year-old woman with airway stenosis. We made a bronchial mould and customized stent with a three-dimensional printer and flexible filaments. This stent was able to successfully maintain our patient's airway patency.

Bronchoscopic management of prolonged air leak

Bronchopleural fistula (BPF) with prolonged air leak (PAL) is most often, though not always, a sequela of lung resection. When this complication occurs post-operatively, it is associated with substantial morbidity and mortality. Surgical closure of the defect is considered the definitive approach to controlling the source of the leak, but many patients with this condition are suboptimal operative candidates. Therefore there has been active interest for decades in the development of effective endoscopic management options. Successful use of numerous bronchoscopic techniques has been reported in the literature largely in the form of retrospective series and, at best, small prospective trials. In general, these modalities fall into one of two broad categories: implantation of a device or administration of a chemical agent. Closure rates are high in published reports, but the studies are limited by their small size and multiple sources of bias. The endoscopic procedure currently undergoing the most systematic investigation is the placement of endobronchial valves. The aim of this review is to present a concise discussion on the subject of PAL and summarize the described bronchoscopic approaches to its management.

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.

Omentoplasty and thoracoplasty for treating postpneumonectomy bronchopleural fistula in a patient previously submitted to aortic prosthesis implantation

Bronchopleural fistula following pneumonectomy is a serious and frightening complication in chest surgery with a high mortality rate. The possibility of curing this complication using a conservative treatment is extremely poor. Below we describe a case of a patient affected by left pleural empyema due to a postpneumonectomy bronchopleural fistula. The patient had previously undergone an aortic prosthesis implantation. He was successfully treated using omental pedicle in order to cover the bronchial stump, to fill the pleural space and to protect the aortic prosthesis. He also underwent thoracoplasty to collapse the residual pleural space. The postoperative course was uneventful. During the follow-up, after thirty months, the patient was asymptomatic, and no recurrence of the fistula was present.