INTRODUCTION: The presence of bronchopleural fistula (BPF) after pulmonary surgery is a serious and well-known complication. Different approaches for correction have been used in the past when surgery is not an option; this includes fibrin glue, collagen and acellular patches, and stenting. All these techniques have proven limitations based on the location and size of the BPF. We present a case of BPF after right upper lobe (RUL) lobectomy, treated successfully with a combination of fibrin glue, acellular patch and bronchial stent.
CASE PRESENTATION: A 48 year old man with chronic obstructive lung disease, tobacco and marijuana abuse, was evaluated for cough, hemoptysis and chest pain for two months, and associated weight loss. A computed tomography (CT) of the chest showed a RUL opacification with signs of cavitation. The patient underwent flexible bronchoscopy, with negative results for AFB, fungal and bacterial cultures, Grocott and gram stain, cytology, galactomanam, and skin PPD test. The patient was treated as a complicated pneumonia and discharged home. On follow up, his hemoptysis persisted with worsening cavitation. New sputum cultures were positive for aspergillus and intravenous voriconazole was started. The hemoptysis continued and lead to a RUL lobectomy, with the resected lung positive for aspergilloma. This lobectomy was complicated with post obstructive pneumonia over the right middle lobe and associated hydropneumothorax. A chest tube was placed for drainage of the pleural effusion, which was positive for pseudomonas. The chest tube was noted to have a persistent air leak despite resolution of the hydropneumothorax and appropriate antibiotic therapy. Interventional pulmonology was consulted and the patient taken for flexible bronchoscopy, showing a 3 mm fistula of the RUL stump. Rigid bronchoscopy was performed; an alloderm patch was cut and placed with forceps over RUL stump. Subsequently, fibrin glue was instilled covering the entire patch and completely filling the stump. Finally, an ultraflex stent was deployed over the above mentioned defect. The patient was discharged home with a casp tube in place and no air leak. In follow up, an air leak was again noted with associated distal migration of the stent; this one was then replaced with a Dumon Y stent with no further migration, and on follow up bronchoscopies only re-instillation of fibrin glue into the stump was needed. After 10 months from the initial BPF repair, the bronchial stent was removed, without recurrence of air leak or new symptoms.
DISCUSSION: Bronchopleural fistulas are still a serious complication of lung lobectomy and pneumonectomy due to its high morbidity and mortality. Correction techniques are based on location, diameter of the defect, and concomitant risk factors (e.g. empyema, steroid use, prolonged intubation, malnutrition, radiation treatment). Unfortunately, no consensus exists on the treatment of BPF, and the approach to this problem has been based on personal experience or reported case series. In complicated cases, like the one we present, the presence of empyema increases the risk of failure of endobronchial treatment; although with a combination of the current techniques, including pleural drainage, fibrin sealant, acellular patch and bronchial stent, the outcome in our patient was favorable, and did not require further surgical intervention.
CONCLUSIONS: Although rare, bronchopleural fistulas are one of the most serious complications of lung surgery due to its high morbidity and mortality. Different approaches and techniques have been used according to the characteristics of the fistula, but there are no current guidelines or consensus for its treatment. Our approach is based on the combination of current techniques to achieve the best results and minimize future complications or failures of treatment, decreasing the need for further interventions on an already weakened patient.
Reference #1 Lois M, Noppen M. Bronchopleural Fistulas: An overview of the problem with special focus on endoscopic management. Chest 2005;128;3955-3965
DISCLOSURE: The following authors have nothing to disclose: Eduardo Celis Valdiviezo, Cynthia Ray, Javier Diaz-Mendoza, Michael Simoff
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