Treatment Of Post-pneumonectomy Bronchopleural Fistula Research Articles

A novel approach for the treatment of post-pneumonectomy bronchopleural fistula by using an autologous corticocancellous bone graft.

Post-pneumonectomy bronchopleural fistula (PPBPF) is a devastating complication in thoracic surgery, with reported incidences varying from 3.1% to 20% (1-3). The diversity of incidence depends on a number of factors including malignancy or benign conditions and the extent of the resection and the resection technique used (4).

Closure of a large bronchopleural fistula by omentoplasty and free myocutaneous latissimus dorsi muscle flap

The treatment of post-pneumonectomy bronchopleural fistula requires both closure of the fistula and control of the infection usually by obliteration of the thoracic cavity. A 53-year-old man developed a large airway defect (4 × 2 cm) after right pneumonectomy performed for lung cancer. To close such a large defect a two-stage operation consisting of omentoplasty and free lattisimus dorsi muscle flap transposition was performed. This report illustrates the feasibility of overcoming this demanding complication with collaboration of plastic surgery.

Treatment of a complex tracheobronchial malignant stenosis with a modified conical semicovered self-expanding stent

Treatment of a complex tracheobronchial malignant stenosis with a modified conical semicovered self-expanding stent

EComment. Hybrid conservative approach in the treatment of post-pneumonectomy bronchopleural fistula

We have read with great interest the article by Botianu and Botianu concerning Andrews thoracoplasty for post-pneumonectomy empyema and we have to congratulate them on their results [1]. The aim of our brief comment is to highlight the importance of the hybrid approach, especially in cases of small-sized (<5 mm), early post- pneumonectomy bronchopleural fistulae. In such cases endoscopic application of fibrin sealants combined with pleural drainage tube could solve the problem. If no improvement is observed, the endoscopic procedure can be repeated. Surgery seems to be the gold standard in cases with complete dehiscence of the suture or extensive endobronchial infection and fibrin around the edges [2]. Surgery is also indicated when endoscopic treatment fails. However, endoscopic interventions are safe and free from severe complications and could be the first therapeutic approach. Conflict of interest: none declared

EComment. Post-pneumonectomy bronchopleural fistula: covered metallic stent or Amplatzer occluder?

Andreetti and colleagues reported their experience with the use of a conical fully covered self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula [1]. A bronchopleural fistula (BPF) is an alarming complication of pneumonectomy, which leads to significant morbidity and mortality. The incidence of BPF ranges from 4.5% to 20% and such wide variability is correlated to the patient's condition, the pathology, the resection technique, and the experience of the surgeon. The standard approach includes an open wound thoracostomy, skin flap, and antiseptic packing for several months. This procedure is complicated by persistent or recurrent BPF and a long hospital stay. A most recent surgical technique consists of the debridement of the pleural space followed by the suture of the bronchial stump buttressed with omentum or a muscular flap [2]. Innovative minimally invasive techniques have been proposed for the patients who are unable to tolerate major surgical procedures. Various endoscopic approaches (fibrin glue, surgical sponges, ethanol injection, etc.) seem to be effective for small BPFs with the highest success rate for fistulas of 1 mm in diameter. The use of airway stents in the management of large post-pneumonectomy BPF has been reported; silicone was initially the preferred material [3], but the use of covered self-expandable metallic stents has been reported since 2005. Recently, Dutau and colleagues reported their experience with a custom-made self expandable covered metallic stent in 7 patients with large post-pneumonectomy BPF (>6 mm); the air leak was stopped in all the patients after stent placement, but the mortality was still high (57%), mainly due to sepsis [4]. Although Dutau and colleagues noted two stent migrations, the technique can be positively regarded, especially for the immediate stop of the air leak. The Andreetti's report is similar to the Datau paper in terms of technique and number of patients but some differences must be underlined. All patients had early BPFs (within 7 days from pneumonectomy) and pleural spaces were still spared from infection. The use of a standard-sized instead of a custom-made stent allowed its prompt positioning, which was probably the key point for Andreetti's good results. In addition, the use of titanium helical tacks was a smart idea that prevented any stent migration. A new technique has been proposed for treatment of post-pneumonectomy BPF. Fruchter and colleagues recently published their experience with the positioning of the Amplatzer atrial septal occluder in 10 patients (8 post-pneumonectomy BPF, 2 post-lobectomy BPF) [5]. The Amplatzer occluder was inserted directly into the fistula. The presence of two disks, one on each side of the defect, ensured good occlusion without impairing airway patency. The device induced local granulation that resulted in the total encapsulation of the occluder. Fruchter, who included a literature review in his paper, reported that the procedure had been well tolerated without side effects or complications [5]. The Amplatzer occluder seems more attractive than the covered metallic stent: the occluder is easily-positioned with a flexible bronchoscope under direct vision. The occluder leaves the airway free from foreign material. The problem of the sputum retention within the covered metallic stent is avoided and the occluder does not need to be removed with a second procedure as is required by a metallic stent. All these theoretical advantages have led us to use the Amplatzer occluder in a BPF after a superior right sleeve lobectomy. The procedure was simple and uneventful, the rate of flow of the air leak was dramatically reduced, the clinical condition improved and the patient was discharged within few days. Unfortunately, 31 days after the procedure a suddenly lethal hemoptysis occurred. Such previously unreported complications should be considered when a surgeon needs to choose a device for BPF treatment. In conclusion, the covered metallic stent and the Amplatzer occluder are promising devices for minimally invasive BPF treatment. Considering the low prevalence of the post-pneumonectomy BPF, a multi-institutional randomized trial is advisable to guide surgeons toward the safer procedure for the treatment of a difficult and challenging disease such as BPF. Conflict of Interest: None declared

EComment. Post-pneumonectomy bronchopleural fistula

We read with interest the article by Andreetti et al. regarding the treatment of post-pneumonectomy bronchopleural fistula (PPBPF) by self-expandable stent and we agree that this modality can be in the armamentarium of cardiothoracic surgeons [1]. PPBPF is one of the most serious and lethal complications in thoracic surgery. There are well-known predisposing factors related to this devastating postoperative complication such as extensive bronchial devascularization, right-sided pneumonectomy, long residual bronchial stump, neoadjuvant or adjuvant chemotherapy, regional radiotherapy, diabetes mellitus, steroid therapy, prolonged mechanical ventilation, history of smoking, pre-existing empyema, incomplete resection of cancer at the bronchial margins, decreased albumin levels (less than 3.5 mg/dL), male gender, and technique of bronchial stump closure [2, 3]. From the beginning of thoracic surgery, many different methods have been used to prevent the development of PPBPF [2, 3]. Pedicled pericardial flap or pericardial fat pad, pleura, intercostal muscle, diaphragm, and azygos vein (for right pneumonectomy) have been used as an additional coverage of bronchial stub wound with very good results [2, 3]. Brewer et al. in 1953 were the first ones who reported on their experimental and clinical work on the use of pedicled pericardial fat graft for reinforcement of bronchial closure in patients with pulmonary resection [4]. Taghavi et al. in 2005, in their retrospective study of 96 patients who underwent pneumonectomy (89.2% for primary lung cancer) and had covered bronchial stump with a pedicled pericardial flap, did not notice any evidence of PPBPF during the perioperative and postoperative period (mean follow up 15 ± 21.2 months) [2]. Sfyridis et al. in 2007, in their prospective randomised trial of 70 patients with diabetes mellitus who underwent pneumonectomy and were randomised to have their bronchial stump covered with an intercostal muscle flap or not; found that the group with the covered bronchial stump had a lower incidence of PPBPF (0% versus 8.8%; p = 0.02) and of empyema (0% versus 7.4%; p = 0.05) compared with the group not covered, at a mean follow-up of 18 ± 9.2 months [3]. Endobronchial valves have also been used to good effect in patients with persistent pulmonary air leaks (refractory to other therapy) secondary to alveolopleural fistula and to bronchopleural fistula as well [5]. In conclusion, in high risk patients the consideration of an effective method for covered bronchial stump for the prevention of the development of PPBLF is very important. Therefore, the multidisciplinary approach for the ideal treatment of patients with PBPF should be on an individual basis and is of paramount importance. Conflict of Interest: None declared

Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered self-expandable stent

The aim of the study was to assess the feasibility, efficacy and safety of the use of a conical self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula (PPBPF). Between April 2008 and November 2010, six patients underwent treatment for the PPBPF by the introduction of a tracheobronchial conical fully covered self-expandable nitinol stent with the aim of excluding the bronchial dehiscence from the airflow. We secured the prosthesis to the tracheal mucosa with titanium helical fasteners tacks. Five patients presented with a bronchial fistula larger than 5mm following right (4) or left (1) pneumonectomy. One patient had an anastomotic dehiscence after right tracheal sleeve pneumonectomy. A chest tube showed the absence of empyema in all cases. Immediate resolution of the bronchial air leak was obtained in all the patients. Permanent closure of the bronchial dehiscence without recurrence was achieved in all the patients at a mean follow-up time of 13 months (range 3-32). The bronchial stent was successfully removed in all patients without sequelae 71-123 days after its implantation. The use of the conical self-expandable Silmet(®) stent has proved to be an effective, safe and fast method to treat even large PPBPFs.

Transdiaphragmatic Harvesting of the Omentum Through Thoracotomy for Bronchial Stump Reinforcement

We present our technique of omental flap transposition performed through a thoracotomy for bronchial stump protection, and employed over 11 years. Between February 1997 and January 2008, the transdiaphragmatic harvesting of the omentum was performed, using an original technique through a thoracotomy approach, in 45 patients. Forty-three patients (29 male, 14 female), considered at high risk for bronchial dehiscence, simultaneously underwent pneumonectomy and 2 patients (1 male, 1 female) were treated for an early postpneumonectomy bronchopleural fistula by the standard thoracotomy route. The omental flap was mobilized through a radial incision in the diaphragm avoiding an additional laparotomy. The only contraindication for this technique was a previous abdominal intervention. Duration of follow-up ranged between 6 and 102 months (median, 46). There were no complications related to the omentoplasty. Major complications related to pneumonectomy occurred in 4 patients (9%). Perioperative mortality rate was 2.1% (1 of 45). The non-life threatening complication rate was 11.1% (5 of 45). Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentoplasty and was 11 and 14 days, respectively, in the 2 patients receiving omentoplasty after bronchial dehiscence. No neoplastic recurrence on the bronchial stump or late fistula occurred during follow-up. This technique of omental flap transposition for bronchial stump coverage through a thoracotomy is an effective method for the prevention and treatment of postpneumonectomy bronchopleural fistula. The amount of omentum obtained by this technique is appropriate for bronchial reinforcement but not for filling the pleural cavity. This procedure can be performed safely through thoracotomy access avoiding an additional laparotomy.

Bronchoscopic treatment of postpneumonectomy bronchopleural fistula with a collagen screw plug

Bronchopleural fistula is a critical complication that may occur after pulmonary resection. Early closure of the fistula is required to prevent thoracic empyema or aspiration pneumonia. We have designed a novel procedure for bronchoscopic occlusion of the fistula with a collagen screw plug and assessed its feasibility in an experimental animal model. Adult beagle dogs underwent right or left pneumonectomy, and the bronchial stump was closed with the Sweet method. A silicone bar (2 mm in diameter) was then placed in the middle of the bronchial stump. Seven days after the operation, the silicone bar was removed bronchoscopically, and fistula formation was confirmed. A screw-shaped 2% collagen screw plug (20 mm long and 3 mm in diameter) was mounted at the end of a modified endoscopic cannula and then inserted into the fistula. Autologous platelet-rich plasma was then soaked onto the inserted plug. Nine of 10 beagle dogs with bronchopleural fistula were treated successfully by plug occlusion. One dog died of pneumothorax caused by dislocation of the plug. Pathologic examination revealed that the collagen sponge had been replaced by fibrous tissue and that the fistula was covered with normal epithelium. Although soaking with platelet-rich plasma made the plug airtight immediately, the use of platelet-rich plasma seemed to make no distinct difference with respect to the treatment result or pathologic findings. Bronchoscopic occlusion with a collagen screw plug is a promising option for treatment of small bronchopleural fistulas after pulmonary surgery.