PURPOSE: Bronchopleural fistulas (BPF) and tracheoesophageal fistulas (TEF) are difficult to treat, especially in patients after chemo and radiation therapy. Further development of endoscopic techniques that are easy to perform and durable are needed to treat these serious complications. We report on a novel technique that combines the application of silver nitrate with the injection of dehydrated alcohol for the treatment of small BPF and TEF.
METHODS: At two institutions, patients with small (<5 mm) BPF or TEF underwent bronchoscopic ablation using silver nitrate and dehydrated alcohol. Silver nitrate was applied to a bronchial brush and delivered to the mucosa of the fistula. Dehydrated alcohol (0.25-0.5 cc/injection) was then injected in a circumferential fashion around the fistula opening.
RESULTS: 5 patients with BPF and 2 patients with TEF were treated between 4/2010 - 4/2011. The median age was 57 years (43-78). 4 patients were female and 80% of the BPF were after pneumonectomy. Both TEF were following radiation therapy. Treatment was successful in 3 patients after 1 ablation, 3 patients after 2 ablations and only 1 patient required 3 ablations. One failure (14%) in a TEF was treated with airway stent placement.
CONCLUSIONS: Bronchoscopic treatment of BPF and TEF with silver nitrate and dehydrate alcohol was successful in 86% of patients, easy to perform and has durable results to date. The success of this combined modality is most likely due to an intense inflammatory and pro-fibrotic response around the fistula, resulting in closure. Further studies to assess long term durability are warranted.
CLINICAL IMPLICATIONS: Standard treatment of BPF and TEF have a high morbidity and mortality. Bronchoscopic application of silver nitrate and dehydrated alcohol for the closure of BPF and TEF is an easy to use, safe and effective minimally invasive treatment, reducing patient discomfort and risk of these serious complications.
DISCLOSURE: The following authors have nothing to disclose: David Finley, William Krimsky, Joyce Au, Inderpal Sarkaria, Valerie Rusch
The application of both silver nitrate and dehydrate alcohol for the closures of fistulas has been described in the literature, but not in combination. Both of these substances are approved for use in humans.