WHERE IS THE AIR? THE CASE OF A NON-ISOLATING AIR LEAK IN A 19-YEAR-OLD THORACIC STAB WOUND PATIENT

Abstract

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Unidirectional bronchoscopically deployed endobronchial valves have been are indicated for emphysematous disease as an alternative to lung volume reduction surgery. These valves have found a second indication in the treatment of bronchopleural fistulas. CASE PRESENTATION: A 19 year-old male presented with multiple stab wounds after a homicide attempt. The patient had a series of intra-thoracic surgeries including partial wedge resection of the left upper lobe, removal of impaled knife from thoracic vertebra, several orthopedic procedures, and an esophageal repair. The two left sided large bore chest tubes placed intraoperatively had persistent air leaks on post-operative day 6 (image 1). We attempted a bronchoscopic balloon occlusion of the airway to isolate a suspected bronchopleural fistula with the intent to place a unidirectional endobronchial valve. However, balloon occlusion of the left upper lobe and then the left lower lobe did not result in an appreciable decrease in air leak. The entire left mainstem bronchus was then occluded without a decrease air leak (image 2). As such no valve could be deployed and the procedure was aborted. Careful consideration was given to the alternative sources of intra-thoracic air including fistulation from the esophagus or mediastinum. We considered abdominal free air crossing the diaphragm and even free air crossing the contralateral hemithorax. After these had been carefully ruled out with contrast studies and imaging, the patient was scheduled for video-assisted thoracic surgery (VATS) with wedge resection. On the morning of surgery, we noted that the patient's chest tubes were leaking around the insertion site. Furthermore there was fluid bubbling around the insertion site suggesting that the site itself was the origin of the patient's intrathoracic air. Both chest tubes were then removed and replaced with a small-bore pigtail chest tube resulting in complete resolution of air leak (image 3). DISCUSSION: The technique for placing unidirectional endobronchial valves for a bronchopleural fistula first involves isolating the source of the air leak. Segments of the affected lung are occluded using a sizing balloon starting proximally. When the segment where the bronchopleural fistula originates is occluded, the air leak will diminish indicating a decrease in airflow distally. A unidirectional endobronchial valve can then be deployed resulting in occlusion of the diseased airway, distal atelectasis, and a resolution of the bronchopleural fistula. This algorithmic approach will identify the diseased segment unless there is significant collateralization of airways, in which case a VATS is indicated. Our case highlights how alternative sources of air leak should be entertained prior to more aggressive surgical intervention. CONCLUSIONS: The patient's VATS was canceled and he has made a full recovery. REFERENCE #1: Mahajan AK, Khandhar SJ. Bronchoscopic valves for prolonged air leak: current status and technique. J Thorac Dis. 2017;9(Suppl 2):S110-S115. doi:10.21037/jtd.2016.12.63 REFERENCE #2: Travaline JM, McKenna RJ, Jr, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009;136:355-60. 10.1378/chest.08-2389 REFERENCE #3: Reed MF, Gilbert CR, Taylor MD, et al. Endobronchial Valves for Challenging Air Leaks. Ann Thorac Surg 2015;100:1181-6. 10.1016/j.athoracsur.2015.04.104 DISCLOSURES: No relevant relationships by Jonathan Xian, source=Web Response