Bronchoscopic Closure Research Articles

Beyond diagnosis: maximizing the role of medical thoracoscopy in pleural disease treatment.

Medical thoracoscopy has been extensively utilized in the diagnosis of pleural disease, yet its potential therapeutic applications remain underutilized. This article presents a comprehensive overview of the various uses of medical thoracoscopy in managing pleural diseases. It has been employed to facilitate thoracic drainage and reduce hospitalization duration of patients with complicated parapneumonic effusions and empyema. Additionally, medical thoracoscopic occlusion therapy can be used for bronchoscopic closure and refractory pneumothorax. However, there is currently a lack of standardized protocols for utilizing medical thoracoscopy to reduce the volume of giant emphysematous bullae. Furthermore, medical thoracoscopy allows for pleurodesis or photodynamic therapy in patients with malignant pleural effusion. Nevertheless, further high-quality clinical research is needed to validate these findings.

Endobronchial Stenting: A Novel Intervention for Bronchoscopic Closure of Bronchopleural Fistula

Endobronchial Stenting: A Novel Intervention for Bronchoscopic Closure of Bronchopleural Fistula

“All things must pass” - Cutaneous migration of an endobronchial valve

SummaryThe Zephyr (PulmonX Inc., Redwood, CA) endobronchial valve (EBV), predominantly designed for lung volume reduction in emphysema, can also be used to close a spontaneous or post-operative prolonged air leak (PAL). We describe a previously unreported complication of cutaneous migration of an EBV, inserted for management of a PAL from a postoperative bronchopleural fistula (BPF), in a 62-year-old male following a right upper lobe posterior-apical (S1,2) segmentectomy. His PAL resulted in a chronic empyema which failed to respond to surgical debridement, anterior cavernostomy and pectoral myoplasty. Bronchoscopic closure of the air leak by EBV insertion resulted in clinical improvement but there was a residual chronic wound sinus through which the patient reported protrusion of a foreign body that was causing irritation. It was the EBV. We hypothesise that the BPF healed beneath the EBV causing it to dislodge but its route to the skin remains a mystery.

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

ObjectivesThe 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.ResultsThe 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.ConclusionsOur 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.

Bronchopleural Fistula Closure with Vascular Plug and Intrapleural Glue Administration

The presence of communication between a mainstem, lobar, or segmental bronchus and the pleural place is called a bronchopleural fistula (BPF). It is commonly caused as a result of postoperative complication of lung resection surgeries, chemotherapy or radiotherapy for lung cancer, persistent spontaneous pneumothorax, empyema, lung abscess, and tuberculosis. A 20-year-old male underwent decortication for diffuse right-sided tuberculous pleural thickening. Postsurgery, he developed BPF. He underwent open thoracic surgery for BPF closure. However, he continued to have air leak and persistent empyema. Repeat evaluation revealed a large BPF at the anterior segment of the right upper lobe on computed tomography chest, which was confirmed on bronchoscopy. He underwent bronchoscopic closure (under fluoroscopic guidance) of BPF with a 6 mm × 7 mm vascular plug successfully. Major air leak stopped and lung expansion increased on chest X-ray. However, small air leaks (alveolar-pleural fistula) persisted. Later, he was subjected to intrapleural diluted fibrin glue administration (fibrinogen + aprotinin + thrombin) via a chest tube at bedside. Application of diluted fibrin glue through the chest tube succeeded in completely sealing the small air leaks. Radiologically, there was no further lung collapse and the pleural space was nearly obliterated.

DOZ047.91: Bronchoscopic treatment of recurrent tracheoesophageal fistula: is it an effective option?

Abstract Purpose Despite technical and surgical improvements, treatment of recurrent tracheoesophageal fistula (rTEF) still remains a challenging problem in pediatric patients. Bronchoscopic closure of rTEF using different agents is described with different success rates in the literature. This study aimed to report results of patients with rTEF treated with chemocauterization using trichloroacetic acid (TCA) and with laser cauterization (LC) followed by fibrin glue (FG) application. Methods Nine patients with rTEF were included in the study from 2014 to 2018. Four patients underwent fistula closure with LC followed by FG application, while another four patients had chemocauterization with TCA. In one case both agents were used. Patients were checked for the success of the treatment by bronchoscopy. All patients had the diagnosis of rTEF. Seven patients had EA with distal TEF and the remaining two patients had H-type TEF as primary pathologies. FG application was performed by LC followed by injection of FG into the fistula. Application of the TCA was made by a TCA-soaked sponge for 30 seconds and 3 times each trial. Results Nine children of the age range 4 months to 5 years (mean 1.5 year) were treated endoscopically. Follow-up ranged between 3 months and 5 years (mean 28 months). Among the nine patients only in one patient with only laser coagulation with FG application the treatment was successful. In the remaining eight patients all attempts failed. All these patients underwent open surgical closure of the fistula. There were no acute or late complications related to either endoscopic method. Conclusion The results of this study suggest that endoscopic occlusion of recurrent TEF has a low success rate. Surgical closure is still a standard method with a high success rate. Even though endoscopic options are less invasive, they prolong the period of aspiration and may cause increased pulmonary problems.

Bronchoscopic Closure of Bronchopleural Fistula Using Gelfoam Versus Autologous Blood

AbstractBackground: Diagnosis and management of bronchopleu-ral fistula remains a major therapeutic challenge for physicians, since it is medical diagnosis and localization may be trouble-some and needs various imaging techniques, likewise it is associated with a significant morbidity and fatality so fruitful bronchoscopic management is considered a perfect choice as it is less invasive procedure especially in patients who are unsuitable for surgery and standard anesthesia or associated with comorbidities, additionally it would lessen cost and lifelong hospital stay.Aim of the Study: To compare efficacy of gelfoam and autologous blood injection in bronchoscopic closure of bron-chopleural fistula.Subjects and Methods: This study carried out at Fibrooptic Bronchoscopy Unit in Chest Department, Al-Hussein Hospital, Al-Azhar University in the period between October 2015 to October 2017. One setting of fibrooptic bronchoscopic closure trial was performed in forty patients with bronchopleural fistula using gelfoam injection in twenty patients (Group A) and autologous blood in another twenty patients (Group B) after full clinical and investigational assessment.Results: Successful closure occurred in 19 patients (95%) in (group A) using gelfoam and in 18 patients (90%) in (group B) using autologous blood, the mean hospitalization time was 7.05 days in (group A) and 9.35 days in (group B) the mean time from procedure to chest tube removal was 3.2 days in (group A) and 5.75 days in (group B) also the mean time from procedure to discharge was 3.8 days in (group A) and 6.5 days in (group B) pneumothorax and death did not occur in both groups but hemoptysis occurred in 5 patients (25%) in (group A), and 7 patients (35%) in (group B) also cough occurred in 16 patients (80%) in (group A), and 18 patients (90%) in (group B) and low grade fever occurred in 12 patients (60%) in (group A) and 15 patients (75%) in (group B).Conclusion: Bronchoscopic closure of bronchopleural fistula utilizing gelfoam or autologous blood is a straightforward procedure which can be performed safely and securely under local anesthesia with promising outcomes, it is ought to be viewed an as an ideal choice particularly in small sized fistulae in patients who are unfit for surgery and general anesthesia.

Bronchoscopic valve placement for the treatment of persistent air leaks.

Persistent air leaks (PALs) are associated with increased morbidity, prolonged hospital stay, and increased treatment costs. Endobronchial 1-way valves have been recently used as a potential less invasive treatment option. We sought to investigate the effects of valve therapy in treating this condition. The patients with evidence of continuous air leak flow whose chest tubes remained in place for more than 7 days were treated with bronchoscopic closure using 1-way valves. The source of the air leak was identified by the Chartis system.A total of 11 patients (1 woman, 10 men; mean age, 68 years) who underwent valve placement were eligible to be enrolled from January 2015 through January 2017. Six patients had postoperative PAL, and 5 had a secondary spontaneous pneumothorax. The number of used valves varied from 1 to 3 (median 1). The resolution of the leak was complete in 8 patients (72.7%), whose mean duration of air leak before and after valve deployment was 58.5 and 4.5 days, respectively. There were no complications related to the valve deployment.Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PALs. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

気管支鏡下にN-butyl-2-cyanoacrylateを用いて治癒した術後難治性肺瘻の1例

気管支鏡下にN-butyl-2-cyanoacrylateを用いて治癒した術後難治性肺瘻の1例

Spontaneous Caverno-Cutaneus Fistula: A Rare Presentation of Pulmonary TB

SESSION TITLE: Student/Resident Chest Infections SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Caverno-cutaneous fistula is a pathological communication between lung cavity and skin which usually develops following a thoracic surgery, trauma or may complicate pulmonary abscess/ infarction. Development of spontaneous caverno-cutaneous fistula in cavitary pulmonary tuberculosis is an extremely rare phenomenon. Extensive literature review revealed only six such case reports. Further, five of those were associated with lung herniation. We describe herewith a case of spontaneously ruptured caverno-cutaneous fistula in a 55-year-old immunocompetent female without lung herniation or pleural spillage. This is only the second patient with such a presentation CASE PRESENTATION: A 55-year-old female presented to us with fever, productive cough and a right-sided parasternal discharging sinus. Initially there was a swelling which ruptured spontaneously with leakage of pus and air. There was no past history of tuberculosis, chest-trauma or surgery. Examination revealed a 3x2cm right sided parasternal ulcer with undermined edges. There were bronchial breath-sounds with crepitations. Chest radiograph demonstrated right sided fibro-cavitary disease. The Sinogram (Fig 1) and contrast-enhanced CT-thorax were performed post dye injection into the sinus which demonstrated movement of dye towards the cavity in right upper lobe. The patient also coughed out the dye (Fig 2). The sputum-smear and culture was positive for acid-fast-bacilli. Hence the diagnosis of tubercular caverno-cutaneous fistula was made. Patient was put on anti-tubercular drugs and referred for surgical excision. She had good clinical response following treatment. DISCUSSION: The fistulae are rare complications of tuberculosis. These are poorly described in the medical literature with the mechanism not yet clear. Pleuro-cutaneous fistulae are thought to be secondary to tuberculous adenitis with thoracic extension while caverno-cutaneous fistulae are thought to be result of rupture of a tension cavity. The rupture may not be associated with pyopneumothorax because of pleural symphysis. Lung herniation may be present. Diagnosis is suggested by location of the sinus, leakage of air and presence of cough impulse. CT thorax is helpful with diagnosis confirmed by bronchogram, sinogram or percutaneous fibreoptic-bronchoscopy. The sinogram with methylene-blue dye, helps tracking the sinus tract to its origin, and may help the surgeon in dissection of infected tissue. Differentials include pyogenic infections, actinomycosis, trauma and malignancy. Prognosis is good with management usually surgical and medical with anti-tubercular treatment. Bronchoscopic closure with glues, sealants is needed if patient is unfit for surgery. CONCLUSIONS: The caverno-cutaneous fistula is an extremely rare complication of tuberculosis. The diagnosis requires sinogram and should be suspected if a patient presents with discharging sinus on the chest wall. Reference #1: Caverno-cutaneous fistula: A rare entity. Lung India.2016;33:474-5 DISCLOSURE: The following authors have nothing to disclose: Sumit Mehra, Rajiv Garg No Product/Research Disclosure Information

Endobronchial closure of bronchopleural fistula using Amplatzer device.

Bronchopleural fistulas (BPF) are a dreaded complication after lobectomy and pneumonectomy and are associated with high morbidity and mortality. BPF are treated by a range of surgical and endoscopic techniques. Amplatzer devices (ADs), normally used for the closure of cardiac defects, may enable the minimally invasive occlusion of these defects. Three patients with BPF were treated with the bronchoscopic closure of BPF using AD. Under general anaesthesia, the fistula was located using bronchography and the self-expanding AD was placed under direct bronchoscopic and fluoroscopic guidance into the fistula. Bronchography was used to control the complete occlusion of the BPF. Three male patients with a mean age of 63 years (range, 53-73 years) were successfully treated by AD. Two BPF occurred after lobectomy of the right lower lobe for lung cancer and one after right pneumonectomy for lung cancer. In all patients the bronchoscopic procedure was successful and symptoms of empyema and BPF showed no recurrence over a median follow-up of 22 months. Endobronchial closure of BPF using AD represents a safe, effective and promising method for postoperative BPF.

Efficacy of Bronchoscopic Closure of a Bronchopleural Fistula with Amplatzer Devices: Long-Term Follow-Up

Background: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results. Objectives: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment. Methods: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months). Results: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (<30 days) mortality was 13% (4 patients). At follow-up, 14 patients (45%) are still alive. Out of 12 patients with late mortality, in 5 patients (41%) the death was directly related to cancer relapse, and no patient died due to BPF recurrence. Conclusion: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.

Endobronchial Closure of a Bronchopleural Fistula Using a Fibrin Glue-Coated Collagen Patch and Fibrin Glue

Bronchopleural fistulas associated with empyema can occur as life-threatening sequelae after pulmonary resection, occurring most frequently after pneumonectomy. Three bronchopleural fistulas, 5-6 mm in diameter, were successfully treated using a fibrin glue-coated collagen patch (FGCCP) and fibrin glue (FG) at the site of a bronchopleural fistula. Through the clinical experiences, we introduce the methodology to perform the endobronchial closure of bronchopleural fistulas.Data were collected by reviewing the clinical charts of patients diagnosed with post-lobectomy bronchopleural fistula at Sapporo Minami-Sanjo Hospital from June 2004 to December 2010. Bronchopleural fistula was diagnosed by means of endoscopic visualization. Three cases of post-lobectomy and one case of post-pneumonectomy bronchopleural fistula were collected.A FGCCP fragment was packed within the fistula, and the fragment grasped with the forceps was kept in this position for approximately a minute, a time during which a FGCCP becomes adhesive, and the patch fragment was released. After releasing the patch fragment, the FG was applied directly on the FGCCP using a two-channel catheter.There have been few reports of the bronchoscopic closure of bronchopleural fistulas using a FGCCP and FG. Closure of small bronchopleural fistulas with the application of a FGCCP and FG may offer a valuable therapeutic alternative.

Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug

Bronchopulmonary fistula (BPF) is a severe complication following lobectomy or pneumonectomy and is associated with a high rate of morbidity and mortality. We have developed a novel minimally invasive method of central BPF closure using Amplatzer vascular plug (AVP) device that was originally designed for the transcatheter closure of vascular structures in patients with small BPF. Patients with BPFs were treated under conscious sedation by bronchoscopic closure of BPFs using AVP. After locating the fistula using bronchography, the self-expanding nitinol made AVP occluder to be delivered under direct bronchoscopic guidance over a loader wire into the fistula followed by bronchography to assure correct device positioning and sealing of the BPF. Six AVPs were placed in five patients, four males and one female, with a mean age of 62.3 years (range: 51-82 years). The underlying disorders and etiologies for BPF development were lobectomy (two patients), pneumonectomy for lung cancer (one patient), lobectomy due to necrotizing pneumonia (one patient), and post-tracheostomy tracheo-pleural fistula (one patient). In all the patients, the bronchoscopic procedure was successful and symptoms related to BPF disappeared following closure by the AVP. The results were maintained over a median follow-up of 9 months (range: 5-34 months). Endobronchial closure using the AVP is a safe and effective method for treatment of small postoperative BPF. The ease of their implantation by bronchoscopy under conscious sedation adds this novel technique to the armatorium of minimally invasive modalities for the treatment of small BPF.

Transbronchial Occlusion of a Malignant Bronchopleural Fistula With Cyanoacrylate Glue

A 73-year-old man who had undergone surgery for lingual cancer, followed by radiation therapy and chemotherapy, presented with severe dyspnea. A chest radiograph revealed a left tension pneumothorax. An immediate tube thoracostomy alleviated his dyspnea. A chest computed tomography scan showed multiple large cystic tumors in both lungs. Squamous cell carcinoma was cytologically proven in the pleural effusion. A malignant bronchopleural fistula due to a metastatic pulmonary tumor was diagnosed. Surgical interventions were tried twice. However, air leakage occurred when the rapidly recurring tumor caused bilateral pneumothoraces. Thus, bronchoscopic closure was conducted. A flexible video bronchoscope and a thin catheter were inserted into the targeted left bronchiolus. The lumen of the catheter was filled with water. Cyanoacrylate glue and lipiodol were mixed in 2 syringes, and the mixture was slowly injected and then flushed with water. As soon as the lipiodol accumulation was visualized by radiograph fluoroscopy, the air leakage stopped. Pleurodesis with the intrathoracic administration of OK-432 was added to both pleural cavities, and the left and right chest tubes were removed on the third and fifth days, respectively. The patient was discharged the following day. However, he died of the disease a month later.

Endobronchial Closure of Bronchopleural Fistulae Using Amplatzer Devices: Our Experience and Literature Review

Bronchopulmonary fistulae (BPFs) are a severe complication of lobectomy and pneumonectomy and are associated with high rates of morbidity and mortality. We have developed a novel, minimally invasive method of central BPF closure using Amplatzer devices (ADs) that were originally designed for the transcatheter closure of cardiac defects. Ten patients with 11 BPFs (eight men and two women, aged 66.3±10.1 years [mean±SD]) were treated under conscious sedation with bronchoscopic closure of the BPFs using ADs. A nitinol double-disk occluder device was delivered under direct bronchoscopic guidance over a guidewire into the fistula. By extruding a disk on either side of the BPF, the fistula was occluded. Bronchography was performed by injecting contrast medium through the delivery sheath following the procedure to ensure correct device positioning. In nine patients, the procedure was successful and symptoms related to the BPF disappeared following closure by the AD. The results were maintained over a median follow-up period of 9 months. Therefore, we state that endobronchial closure using an AD is a safe and effective method for treatment of a postoperative BPF.

Endoscopic Closure of Bronchopleural Fistula using Glue Therapy: A Case Report

The occurrence of a bronchopleural fistula (BPF) continues to represent a challenging management problem, and is associated with high morbidity and mortality. Bronchoscopic closure of BPF with instillation of n-butyl-cyanoacrylate glue is an effective, economical, minimally invasive and safe technique for managing BPFs. We present a case that was successfully treated with this method.

Fibrin glue closure of persistent bronchopleural fistula following pneumonectomy for post‐tuberculosis bronchiectasis

We report a case of a persistent bronchopleural fistula following a pneumonectomy for post-tuberculosis bronchiectasis. The patient had two unsuccessful surgical attempts at closing of the fistula. Further surgical attempts were technically were not possible. Bronchoscopic closure was achieved by injecting human fibrin glue into the fistula via a catheter. Closure of the broncho-pleural fistula was confirmed by repeated ventilation scan over a period of 2 months. Endoscopic closure of small bronchopleural fistulae is an attractive option in children with significant underlying lung disease.

Cierre efectivo por vía broncoscópica de fístula broncopleural de alto flujo en paciente con síndrome de distress respiratorio agudo grave

Background : Bronchopleural fistula (BPF) secondary to surgery or infections implies a therapeutic challenge, either expectant or surgical treatment. Nowadays, the endoscopic closure procedure is performed more often. Objective : Case-report of a child presenting a successful endoscopic closure of a bronchopleural fistula during acute respiratory distress syndrome (ARDS). Case-report : A 14 year-old boy with previous left lower lobectomy due to chronic bronchiectasis, who developed a central BPF after transthoracic drainage of a lingular abscess, associated to mechanical ventilation failure, septic shock and ARDS. The BPF was sealed through bronchoscopy with Tetracycline and Gelfoam, with great decrease of BPF high flow until definitive closure 3 weeks after the procedure. Conclusion : BPF development after pulmonary abscess drainage could be effectively treated with bronchoscopic closure during ARDS in a critically ill child, avoiding higher surgical risks.

Closure of a bronchopleural fistula using a fibrin?glue coated collagen patch

Bronchopleural fistulas can occur as a life-threatening sequelae after pulmonary resection. Two bronchopleural fistulas more than 3 mm in diameter were successfully treated by using a fibrin-glue coated collagen patch at the site of bronchopleural fistula under flexible bronchoscopic observation. This is the first report of the bronchoscopic closure of bronchopleural fistulas by using a fibrin-glue coated collagen patch. This treatment would be recommended for patients with a postoperative bronchopleural fistula with an orifice that is more than 3 mm in diameter.