Endobronchial closure of bronchopleural fistula using Amplatzer device

Endobronchial management of bronchopleural fistula using vascular plug device—a case report

Background

Bronchopleural fistula (BPF) is a sinus tract between the pleural space and the main stem, lobar, or segmental bronchus. The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. An interdisciplinary approach, early diagnosis, and timely management of these lesions are critical in the management of such lesions.

Case presentation

We describe a case of bronchopleural fistula in a 42-year-old female patient, occurring after a surgery for pulmonary hydatid, which was successfully managed using a minimally invasive method of closure using Amplatzer vascular plug (AVP).

To our knowledge, the use of an AVP for the management of a BPF following hydatid cyst marsupialization has rarely been described in the past.

Conclusion

AVP is a useful device in the management of bronchopleural fistulas, especially in patients failing a trial of conservative management and are high-risk candidates for surgeries.

Giant bronchopleural fistula and empyema in a tuberculosis patient with diabetes mellitus: Vista from a high tuberculosis burden country in Southeast Asia

Bronchopleural fistula is a pathological tract between the bronchial tree and the pleural space, which can be life-threatening due to tension pneumothorax. It is a rare complication in tuberculosis cases with highly variable in clinical manifestations and persistent air leaks which might lead to complications such as empyema. Herein, we present a tuberculosis and diabetic patient complicated with giant bronchopleural fistula and empyema. A 48-year-old man presented with shortness of breath for two weeks and cough with phlegm for two months. The patient was a smoker with severe Brinkman Index and diabetes. Physical examination revealed hyper resonant percussion and vesicular diminished on the left hemithorax. Laboratory results indicated the patient had anemia, leukocytosis, and hypoalbuminemia. GeneXpert sputum confirmed the presence of Mycobacterium tuberculosis and chest X-ray indicated a collapsed left lung. The patient was diagnosed with left secondary spontaneous pneumothorax, pulmonary tuberculosis, and diabetes. The patient was treated with chest tube drainage and anti- tuberculosis drugs. There was no improvement based on serial chest X-ray, and empyema appeared from the chest tube. CT-scan showed tuberculosis lesion, the collapsed of the left lung and fistula in segments 7-8 inferior lobe. Exploratory thoracostomy was performed, in which a giant bronchopleural fistula was detected and then repaired with BioGlue surgical adhesive. Unfortunately, the thoracostomy led to extensive subcutaneous emphysema and was treated by cervical mediastinotomy. The drainage was unable to be removed, and the patient was discharged with Heimlich-type drainage valves on day 28 of treatment. The empyema fluid was cultured and revealed Staphylococcus haemolyticus. This case highlights that tuberculosis could cause a bronchopleural fistula and empyema may occur secondary to late diagnosis that needs immediate surgery.

Treatment of peripheral bronchopleural fistula with interventional negative pressure drainage

OBJECTIVES

Bronchopleural fistula is a serious complication of pneumonectomy and lobectomy and results in a reduction in the quality of life of patients. This study aimed to evaluate the efficacy and safety of percutaneous drainage tube placement with continuous negative pressure drainage for the treatment of peripheral bronchopleural fistula.

METHODS

Data of 16 patients with peripheral bronchopleural fistula were retrospectively analyzed. A percutaneous thoracic drainage tube was placed under fluoroscopy and connected with a negative pressure suction device. The drainage tube was removed when the residual cavity disappeared on computed tomography.

RESULTS

All 16 patients underwent lobectomy, including 11 patients with lung cancer (68.8%), 4 patients with pulmonary infection (25.0%), and 1 patient with hemoptysis (6.3%). All patients underwent successful drainage tube placement on the first attempt with a technical success rate of 100%. No serious complications occurred during or after the procedure. The drainage tubes were adjusted 3.25 ± 2.24 times (range: 1-8 times). A total of 30 drainage tubes were used (average per patient, 1.88 ± 1.36 tubes). The cure time of 16 patients was 114.94 ± 101.08 days (range, 30-354 days). The median drainage tube indwelling duration was 87 days, and the 75th percentile was 117 days.

CONCLUSION

Interventional percutaneous thoracic drainage tube placement with continuous negative pressure drainage is an effective, safe, and feasible method for the treatment of peripheral bronchopleural fistula.

Therapeutic closure of bronchopleural fistulas using ethanol

Bronchopleural fistula (BPF) leading to persistent air leak (PAL), be it a complication of pulmonary resection, radiation, or direct tumor mass effect, is associated with high morbidity, impaired quality of life, and an increased risk of death. Incidence of BPF following pneumonectomy ranges between 4.4% and 20% with mortality ranging from 27.2% to 71%. Following lobectomy, incidence ranges from 0.5% to 1.5% in reported series. BPFs are more likely to occur following right-sided pneumonectomy, while patients undergoing bi-lobectomy were more likely to suffer BPF than those undergoing single lobectomy. In addition to supportive care, including appropriate antibiotics and nutrition, management of BPF includes pleural decontamination, BPF closure, and ultimately obliteration of the pleural space. There are surgical and bronchoscopic approaches for the management of BPF. Surgical interventions are best suited for large BPFs, and those occurring in the early postoperative period. Bronchoscopic techniques may be used for smaller BPFs, or when an individual patient is no longer a surgical candidate. Published reports have described the use of polyethylene glycol, fibrin glues, autologous blood products, gel foam, silver nitrate, and stenting among other techniques. The Amplatzer device, used to close atrial septal defects has shown promise as a bronchoscopic therapy. Following their approval under the humanitarian device exemption program for treatment of prolonged air leaks, endobronchial valves have been used for BPF. No bronchoscopic technique is universally applicable, and treatment should be individualized. In this report, we describe two separate cases where we use an Olympus^© 21-gauge EBUS-TBNA (endobronchial ultrasound-transbronchial needle aspiration) needle for directed submucosal injection of ethanol leading to closure of the BPF and subsequent successful resolution of PAL.

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.

Combining Minimally Invasive Techniques in Managing a Frail Patient with Postpneumonectomy Bronchopleural Fistula

A postpneumonectomy bronchopleural fistula is a life-threatening complication requiring aggressive treatment and early repair. Reoperations are common due to initial treatment failure. Advanced bronchoscopic techniques are rapidly evolving, but permanent results are questionable. We report the minimally invasive management of a frail 79-year-old patient with postpneumonectomy fistula in respiratory failure due to repeated infections. Previous bronchoscopic closure attempts with fibrin failed. The multistep interdisciplinary management included airway surveillance by virtual bronchoscopy, percutaneous fibrin glue instillation under computed tomography, and awake thoracoscopic surgery to achieve temporary closure. This provided an acceptable long period of symptomatic and physical improvement. The bronchial stump failed again four months later, and the patient succumbed to pneumonia. Pneumonectomy has to be avoided unless strongly indicated. Complications are best managed with surgery for definite treatment. We emphasize our approach only when a patient declines surgery or is medically unfit as a temporary time-buying strategy in view of definite surgery in a high-volume center.

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.

[Interventional treatment of tracheopleural and bronchopleural fistulas]

BACKGROUND

Interventional bronchoscopy is an indispensable option to manage bronchopleural and tracheopleural fistulas in patients in a poor general condition and at high risk for developing postoperative complications.

METHODS

This article is based on a search in the PubMed database for relevant publications and own experiences as surgeons and pneumologists.

RESULTS

Various interventional techniques can be used for the treatment of bronchopleural and tracheopleural fistulas. Currently, the insertion of stents or endobronchial valves is the most frequently used treatment. Ideally, the attending anesthesiologist will have experience with high frequency jet ventilation and the attending surgeon will have experience with rigid bronchoscopy, flexible bronchoscopy, and interventional bronchoscopy.

DISCUSSION

Due to a lack of standardized treatment recommendations, individual treatment plans must be decided according to the location of the bronchopleural or tracheopleural fistula and taking existing comorbidities into account.

Extracellular matrix fistula plug for repair of bronchopleural fistula

Introduction

Bronchopleural fistula (BPF) is a feared complication of pulmonary resection. Fistula plugs (FP) have been described as an adequate treatment in anorectal disease. We describe our early experience placing an FP in the treatment of BPF.

Materials and methods

We retrospectively reviewed 5 patients for whom a FP was placed for BPF at our institution. Demographic data, initial perioperative information, method and technique of FP placement, and success is reported.

Results

Five patients (4 male, 1 female) with a median age of 63 years (range, 57–76 years) underwent 6 FP placements for BPF. Two patients were post-pneumonectomy and 3 patients post-lobectomy. The median time to presentation following surgery was 118 days (range 22–218). Upon bronchoscopic or operative re-evaluation, 3 patients had successful cessation of their air leak at 0, 1 and 4 days. Two of three patients subsequently underwent a thoracic muscle flap placement to augment healing. One patient had a persistent air leak despite 2 separate FP placements. The air leak stopped with endobronchial valves (EBV) which were deployed proximal to the FP, 9 days after placement of the FP. Another patient had a successful muscle flap placed 80 days after FP placement. There were no complications associated with the FP. Three of five patients were deemed successfully treated with FP placement alone.

Conclusion

In patients with a postoperative BPF and pleural window, placement of a FP had a modest success rate and can be considered as a treatment modality option for BPF.

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.

The Use of Polyvinyl Alcohol Sponge and Cyanoacrylate Glue in the Treatment of Large and Chronic Bronchopleural Fistulae following Lung Cancer Resection

BACKGROUND

Bronchopleural fistulae represent a relatively rare complication of pulmonary resection. For inoperable patients, several endoscopic procedures have been described. In the presence of large and chronic bronchopleural fistulae, persistent air leaks require a surgical therapy, while endoscopic airway stent represents a useful palliative treatment.

OBJECTIVE

We describe the successful closure of large and chronic bronchopleural fistulae using an expandable polyvinyl alcohol (PVA) sponge and cyanoacrylate glue.

METHODS

In all patients, a rigid bronchoscope was used to insert a small cylinder of PVA sponge within the fistula. After releasing the patch, cyanoacrylate glue was applied directly on the PVA sponge using a channel catheter. This methodology induces an expansion of the clot and the closure of the air leak. The long-term outcome of treatment was checked by flexible bronchoscopy once every month for 3 months and every 6 months until 5 years.

RESULTS

We performed endoscopic treatment in 7 consecutive patients with bronchopleural fistula ranging from 4 to 8 mm. In 6 of 7 patients, the bronchial stump was the site of the fistula. In 1 patient, the fistula was visualized on the right wall of the distal trachea. A temporary complete occlusion of the fistula was achieved in 7 of 7 patients and a definitive result in 5 of 7 patients.

CONCLUSIONS

The use of an expandable PVA sponge and cyanoacrylate glue is an available strategy for endobronchial closure of bronchopleural fistulae.

Tracheoesophageal fistula induced by invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) is commonly seen in immunocompromised patients, and tracheoesophageal fistula (TEF) induced by IPA is rare and seldom reported. Management of these critically ill patients is challenging and often requires a multidisciplinary approach. The authors reported an adult suffering from aplastic anemia who developed TEF caused by IPA. The diagnosis was confirmed following bronchoscopy and histopathological examination. Antifungal and bronchoscopic intervention provided a cure without any recurrence as yet.

A systematic review and meta-analysis-does chronic obstructive pulmonary disease predispose to bronchopleural fistula formation in patients undergoing lung cancer surgery?

BACKGROUND

we conducted this systematic meta-analysis to determine the association between chronic obstructive pulmonary disease (COPD) and risk of bronchopleural fistula (BPF) in patients undergoing lung cancer surgery.

METHODS

Literature retrieval was performed in PubMed, Embase and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) served as the summarized statistics. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Sensitivity analysis was performed to further examine the stability of pooled OR. Publication bias was detected by both Begg's test and Egger's test.

RESULTS

Eight retrospective observational studies were included into this meta-analysis. The overall summarized OR was 2.03 (95% CI: 1.44-2.86; P<0.001), revealing that COPD was significantly associated with the risk of BPF after lung cancer surgery. In subgroup analysis, the relationship between COPD and BPF occurrence remained statistically prominent in the subgroups stratified by statistical analysis (univariate analysis, OR: 1.91; 95% CI: 1.35-2.69; P<0.001; multivariate analysis, OR: 3.18; 95% CI: 1.95-5.19; P<0.001), operative modes (pneumonectomy, OR: 2.11; 95% CI: 1.15-3.87; P=0.016) and in non-Asian populations (OR: 2.36; 95% CI: 1.18-4.73; P=0.016). No significant impact of COPD on BPF risk was observed in Asian patients (OR: 1.48; 95% CI: 0.85-2.57; P=0.16). No significant heterogeneity or publication bias was discovered across the included studies.

CONCLUSIONS

Our meta-analysis indicates that COPD can significantly predispose to BPF formation in patients undergoing lung cancer surgery. Because some limitations still exist in this meta-analysis, our findings should be further verified and modified in the future.