Broncho-pleural fistula (BPF) and alveolo-pleural fistula (APF) are abnormal communications between the tracheobronchial tree and/or the alveolar spaces and the pleural space, with persistent air leak for more than 24 to 48 hours. These are common problems in clinical practice and are associated with a significant morbidity, prolonged hospital stay, and mortality.1,2 Prolonged or persistent air leaks have been described in many pulmonary diseases but remain one of the common complications, especially after pulmonary resections.1 It is commonly due to parenchymal damage during wedge resections or occurs during dissection for lobectomy and spontaneously resolves within a few days in most instances. However, in about 10% of the patients, air leak persists more than 5 to 7 days and then it is traditionally considered to be “prolonged” air leak, which is a challenging complication and is associated with significant morbidity. It may cause additional serious complications, such as empyema or trapped lung. We report a case of prolonged air leak that developed after a pulmonary wedge resection that was managed with a simple and economical endobronchial method.3–5
A 28-year-old woman, who had radical surgery for lung adenoid cystic carcinoma previously, was hospitalized with multiple metastatic parenchymal nodules. She underwent wedge resections of multiple metastatic pulmonary nodule. Multiple areas of necrotic lung parenchyma were noticed during the surgery. She developed massive air leak that showed no improvement in its volume over the next 7 days. We considered conservative endoscopic management of this complication.
A flexible bronchoscopy was performed through her tracheostomy stoma. A balloon catheter was placed through the working channel of the bronchoscope to localize the segmental source of the air leak in the usual manner. Occlusion of the posterior basilar segment of the right lower lobe with the balloon produced complete cessation of the air leak; it was determined to be the source. This subsegment was occluded by using a cellular material formed of oxidized regenerated cellulose polymer (Surgicel) placed through the flexible scope with the help of the forceps (Fig. 1). Surgicel is frequently used in open surgical procedures as absorbable hemostat. It is rather inexpensive and available in all operating room settings. The air leak abated instantly and the patient was discharged home in 2 days. She has continued to do well during her 8 months of follow-up.
The idea of using a conservative bronchoscopic approach for the management of prolonged air leak after lung resection or primary pneumothorax has emerged in the last few years.6 Traditionally, the management of prolonged air leaks related to BPF and APF requires surgical repair with video-assisted thoracoscopic surgery or thoracotomy. However, nonsurgical bronchoscopic approaches are advantageous for patients with poor pulmonary or cardiovascular reserve or other systemic disorders, where general anesthesia and surgical intervention may add to morbidity and mortality.1 A number of technical vignettes and many synthetic or biological materials have been suggested to reduce the frequency and for the management of prolonged air leak, respectively.7
Endobronchial valves are also being used in the management of prolonged air leaks, and BPF; yet it was shown that, despite appropriate sizing and satisfactory placement upon insertion, endobronchial valves could still migrate.8
A number of other substances including blood clots, gelatin, gelatin capsule-shaped silicon rubber plugs, machined brass screws, lead fishing sinkers, various sponge materials, and even cyanoacrylate glue have been tried for the management of prolonged air leak. The proposed mechanism in these cases is acute mechanical occlusion of the leaky airway.9,10 Some of these may damage the bronchoscope and others may become dislodged and migrate to different parts of the tracheobronchial tree.9
Different biochemicals can be locally injected by using flexible bronchoscope to treat the prolonged air leak, but this technique may also cause complications. After injection with chemicals, such as ethanolamine, fever or chest pain may occur. In addition, some radiographic findings, patchy pulmonary infiltrations and hydropneumothorax, after ethanolamine therapy have been reported.11 In view of our patient’s limited lung functions, we chose the use of Surgicel as the most conservative and safe treatment. The patient continued to do well 8 months after this treatment.
In comparison with other alternative agents, oxidized cellulose polymer materials seem cost-effective and noninvasive; it can be easily used for prolonged air leakage even in patients with limited pulmonary reserve.
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