Postprocedure, the patient reported significant improvement of symptoms. The follow-up chest radiograph showed resolution of the air fluid level and gradual obliteration of the left hemithorax (Fig. 5). She is symptom free at 3 months’ follow-up.
Postoperative BPF has been described picturesquely as a “Damocles sword” hanging over the surgeon.4 It is associated with high mortality rates ranging from 18% to 50%.5 Postoperative BPF is classified according to the time of onset after the operation as early (1 to 7 d), intermediate (8 to 30 d), and late (>30 d).6 Early fistulas are due to surgical technical problems, whereas the late BPFs are due to inadequate healing or secondary infection of the bronchial stump. The index case fitted in the latter category. Surgical management is preferred in early BPF due to instability of mediastinal structures, whereas endoscopic and conservative management may be opted in late cases. Several risk factors have been identified for the development of postoperative BPF. These include right-sided resection, presence of residual carcinoma at the bronchial stump site, and mediastinal lymph node dissection in cases of resection for malignancy, diabetes mellitus, cirrhosis, hypoalbuminemia, steroid use, and others.1,7 None of these risk factors were observed in our patient.
BPFs can present in an acute, subacute, and chronic manner. The presence of a BPF may be life threatening in case of an acute presentation, leading on to aspiration pneumonia, acute respiratory distress syndrome, and difficulty in mechanical ventilation because of the excess air leak. The diagnosis of BPF is established on a combination of clinical and radiologic parameters followed by visualization of the communication on bronchoscopy. The identification of BPF is a problem only with distal leaks, that is, alveolopleural fistula because the fistula is not visualized by flexible bronchoscopy. Computed tomography, instillation of methylene blue, and ventilation scintigraphy are required in such instances.1,8,9 Fiberoptic bronchoscopy and sequential balloon occlusion are also useful for this purpose.10
Various treatments have been tried over the years for the management of BPF. However, the treatment needs to be individualized in every case depending on the patient’s clinical condition. A wide variety of endobronchial occlusive devices have been used for this purpose. The earliest endobronchial treatments for this condition were reported in 1977, using an occlusion device (lead shots) and sealant (tissue glue).11,12 Multiple other devices have been tried since then, with variable success.9,13 Reports of endobronchial stents (both metallic and silicon) being used for treatment are available. However, the stents in these case reports were either specially designed or were used to bypass the fistula.14–16 The options available with us included glue (N-butyl cyanoacrylate and fibrin glue), spigots, and stents. The instillation of glue was tried twice but was unsuccessful; the spigots available were too small (maximum size, 9 mm) to fit the left main bronchus. Because of the problems of secretions and granulation tissue formation associated with stents, it was decided to place a customized spigot. This index report is the first to use a tracheobronchial stent in a novel way for the treatment of BPF.
In conclusion, no treatment or device has been shown to be superior to the other in the treatment of BPF. Management has to be individualized as no treatment is standardized. In addition, in developing countries, factors such as cost and local availability need to be considered.
The authors acknowledge the help of Dr Ravindra Mehta, Director, Interventional Pulmonology and Critical Care Medicine, Apollo Hospitals, Bengaluru, India, for helping them in designing and placement of the stent.
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