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Fistula of the Stump

A Novel Approach With a “Stapled” Stent

Amaral, Beatriz MD; Feijó, Salvato MD

Journal of Bronchology & Interventional Pulmonology: October 2015 - Volume 22 - Issue 4 - p 365–366
doi: 10.1097/LBR.0000000000000172
Brief Reports
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Summary: Postoperative bronchopleural fistulas are serious and uncommon complications after pneumonectomy. Available therapeutic approaches are medical, endoscopic, and/or surgical. A 42-year-old man underwent left pneumonectomy. Three years later he was admitted to an intensive care unit with pneumonia of the remaining lung, severe respiratory insufficiency, and a bronchopleural fistula with an air fluid level filling in the pneumonectomy cavity. A left chest drain was placed, and broad-spectrum antibiotics and mechanical ventilation were administered. Because of the unstable clinical condition, a blind end endobronchial stent closed by a stapler was placed in the left bronchial stump. He improved in a couple of months and underwent definitive surgical sealing of the fistula.

Endoscopic interventions are usually safe and free from associated complications. They are an excellent option, when patient’s clinical condition is contraindication to immediate surgery.

Bronchology Unit, Hospital de Santa Maria, Lisbon, Portugal

Disclosure: There is no conflict of interest or other disclosures.

Reprints: Beatriz Amaral, MD, Medicinia Interna, LDA Apartado 043018, EC Boisa-Lisboa, 1601-301 Lisboa, Portugal (e-mail: beatrizaamaral@gmail.com).

Received July 9, 2014

Accepted March 31, 2015

Bronchopleural fistula (BPF) is an uncommon complication of pneumonectomy and lobectomy and is usually difficult to treat.1,2

Therapeutic approach may be medical, endoscopic, and/or surgical.2,3 Nevertheless, several patients at presentation may be poor candidates for surgery due to compromised respiratory status, comorbidities, or deconditioning.3 In these cases, endoscopic alternative, even if provisory should be the option to take into account. The known endoscopic alternatives include application of biological glue, sealants, occlusion of the fistula with vascular catheters or coils, silicone or metal prosthesis,4,5 and injection of substances to force the edges of the fistula together.1,3

When endobronchial technique fails or is considered only as a temporary solution (life-threatening cases in which the immediate closure of the fistula is indispensable), surgical procedure should be performed when patient’s clinical condition allows and is considered the definitive treatment.2 The surgical methods available in BPF are the wedge resection or the muscle flap.3

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CASE REPORT

A 42-year-old man underwent left pneumonectomy in 2009 for a squamous cell carcinoma (T3N0M0). A computed tomographic (CT) scan performed in 2011 revealed a BPF and an air fluid level involving the pneumonectomy cavity. At that time, the patient had abandoned therapy and remained untreated.

He was readmitted in 2012 into intensive care unit with a pneumonia of the remaining lung, severe respiratory insufficiency, and maintaining the previously described CT findings. A left chest drain was placed and the patient was placed on broad-spectrum antibiotics and mechanical ventilation. Because of the patient’s unstable clinic condition, no surgical approach seemed viable at that time.

The patient’s condition had worsened, so an endobronchial approach was attempted, which consisted in placing a bronchial silicon prosthesis closed in one side with a stapler, providing provisory sealing of the fistulae (Figs. 1A–C). Progressively, drainage decreased, chest drain was removed, and the pneumonia improved. Thoracic surgery became possible and a muscle patch was placed over the prosthesis.

FIGURE 1

FIGURE 1

Hospital discharge happened after 90 days. The last CT scan showed “closure of the fistula and resolution of pneumonia.”

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DISCUSSION

Management of BPF to a major extent needs to be individualized.1 The approach depends on fistula’s characteristics such as the size and site, time between surgery and presentation, presence or absence of empyema, the clinical condition of the patient, and the underlying diseases.1

Endobronchial approach may fail if the fistula is larger than 5 mm in diameter1,2 or if there is concomitant presence of an empyema.1,4 If empyema is present, besides closure of the fistula, treatment also includes prevention of infection, drainage of the pleural cavity with insertion of an intercostal drainage tube,3 and cleansing and decreasing of the empyema cavity.1,4 Considering the low probability of success with endoscopic techniques in these cases, surgery is usually required.

Ultimately, in spite of prolonged hospitalization, our patient survived. The use of silicone prosthesis through bronchoscopy was an effective provisory therapeutic option providing time to improve patient’s clinical condition before surgery. It was chosen only as a temporary attempt because of the presence of an empyema and taking into account that it was a large diameter fistula.

In conclusion, there are no randomized studies comparing the different therapeutic options in bronchial fistulas treatment. Because of the scarcity of this pathology, almost all publications describe solitary cases and consequently isolated therapeutic options providing individual experiences.

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REFERENCES

1. Mora G, de Pablo A, García-Gallo CL, et al.. Is endoscopic treatment of bronchopleural fistula useful? Arch Bronconeumol. 2006;42:394–398.
2. Tedde ML, Scordamaglio PR, Minamoto H, et al.. Endobronchial closure of total bronchopleural fistula with occlutech figulla ASD N device. Ann Thorac Surg. 2009;88:e25–e26.
3. Shah AM, Singhal P, Chhajed PN, et al.. Bronchoscopic closure of bronchopleural fistula using gelfoam. JAPI. 2004;52:508–509.
4. Shimizu J, Takizawa M, Yachi T, et al.. Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report. Ann Thorac Cardiovasc Surg. 2005;11:104–108.
5. Tayama K, Euriguchi N, Futamata Y, et al.. Modified Dumon stent for treatment of a bronchopleural fistula after pneumectomy. Ann Thorac Surg. 2003;50:30–33.
Keywords:

bronchial fistula; endobronchial stent; pneumonectomy; bronchoscopy

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