TO THE EDITOR: Therapeutic endoscopy is underused in developing countries. We describe a case report in Vietnam, in which an adhesion of the left main bronchus was lysed and vaporized using electrocoagulation in conjunction with a flexible bronchoscope. The availability of electrocoagulation equipment and physicians trained in its use would be a major advance in these countries due to its effectiveness, its relatively low cost, the multidisciplinary utility of its electric generator, the rapid learning curve for the endoscopist, and the simplicity of equipment maintenance. High-frequency thermocoagulation is used increasingly to treat benign and malignant tracheobronchial lesions in the industrially advanced countries.1–3 As this technique is easy to use, relatively inexpensive, and very effective,4 it should be introduced in developing countries as well. Tracheal stenosis after prolonged endotracheal intubation or after tracheostomy is a recognized complication.5 Bronchial stenotic lesions are less frequent and in developing countries are often secondary to tuberculosis, when they occur. Although treatment with Nd-YAG laser has been popularized in these situations, substitution of electrocoagulation is an important alternative to consider.6,7 We describe a case of a Vietnamese woman who presented with a bronchial adhesion, which was removed by electrocautery to prepare her for surgical excision of her lower lobe. A 45-year-old woman was initially hospitalized during August 2005, for productive cough, left thoracic pains, and hemoptysis. She had been treated 20 years earlier for pulmonary tuberculosis. Plain films of the chest now indicated left lower lobe atelectasis. Flexible bronchoscopy revealed an antero-posterior adhesion, midway along the left main bronchus. Just behind the adhesion was a foreign body associated with significant suppuration. The foreign body was removed with an alligator forceps; it was very hard and could not be identified nor could the patient recall any episodes of foreign body aspiration. She was treated with antibiotics, corticosteroids, respiratory therapy, and discharged from the hospital. In October 2005, moderate hemoptysis recurred. Endoscopic examination was unchanged except for the presence of purulent secretions emanating from the left lower lobe. Plain films and computerized tomography of the chest demonstrate basilar atelectasis and bronchiectasis of the left lower lobe (Fig. 1). Virtual bronchoscopy confirmed the presence of these abnormalities and the left main bronchial adhesion. It was decided to perform a left lower lobectomy to prevent further complications from the bronchiectasis, but the anesthesiologist insisted on eliminating the adhesion before surgery, to maximize ventilatory efficiency. The adhesion was easily sectioned using a flexible thermocoagulation sound (ERBE Tubingen, Germany) passed through a flexible bronchoscope, under local anesthesia, using the mild coagulation mode at 50 W (Figs. 1A–C). The lobectomy was performed the following day with no significant postoperative sequellae.FIGURE 1.: A, Electrocoagulation of the left lower lobe adhesion. B, Blanching due to coagulation. C, Destroyed adhesion.This case illustrates the ease and effectiveness of electrocoagulation. Except in critical situations, most benign and malignant lesions may be treated in ambulatory patients, under local anesthesia using a flexible fiberscope. Electrocoagulation should be the technique of first choice in developing countries which are just beginning to institute therapeutic endoscopy because of its relatively low cost, the multidisciplinary utility of its electric generator, the rapid learning curve for the endoscopist, and the simplicity of equipment maintenance. For our patient, the origins of the adhesion and the bronchiectasis remain speculative. The presence of the foreign body and her past tuberculosis infection are likely etiologies of her pathology. Most often, tuberculosis entrains concentric bronchial stenosis. We have also seen synechial subgottic adhesions secondary to prior intubation or tracheostomy. The stringlike adhesion seen here is unusual. Presumably, the adhesion prevented expulsion of the foreign body. Aspiration of foreign bodies is rather frequent among infants and less so in adults, where it depends on the eating and drinking habits of the individual.8–10 In South Vietnam, the sapotilla pit is the most frequent bronchial foreign body encountered.11 In our case, we were unable to ascertain the source of the foreign body from either its shape or its consistency. In summary, electrocoagulation should be the technique of choice in treating tracheobronchial lesions in the developing world, although, for instance, only 3 Vietnamese hospitals have access to thermocoagulation equipment. In Vietnam, tracheobronchial stenoses due to tuberculosis are frequently encountered, as are tracheal complications after intubation. In addition, bronchogenic carcinoma is often seen at a stage where local cautery treatments may significantly palliate the patient's symptoms due to bronchial obstruction. It is time to introduce these techniques in developing countries and to ensure that physicians are properly trained in their use. Jean P. Homasson, MD, FCCP H. Bakdach, MD F. Bartobin-Larrieu, MD Y. Aelony, MD, FACP, FCCP Association Franco-Vietnamienne de Pneumologie (AFVP), 24 rue Albert Thuret, 94669 Chevilly Larue, France Thach N. Tran, MD Hôpital Pham NGOC Thach and AFVP 120 Hung Vuong Str. Q 5, Ho Chi Minh Ville City, Vietnam
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Jun 4, 2008
María Elvira Balcells + 7
Open Access
