INTRODUCTION: Bronchopleural fistula is an uncommon severe complication encountered post pneumonectomy and is associated with high morbidity and mortality. We describe the 4th report of successful closure of Bronchopleural fistula through Amplatzer ASD occlusion device in the entire literature.
CASE PRESENTATION: 66-year-old male underwent left-sided pneumonectomy for non-small-cell lung cancer in August 2009. Postoperative course was complicated by development of a Bronchopleural fistula leading to operative repair with latissimus dorsi and intercostal muscle flap. Recurrence of fistula was again documented in 3 weeks of the procedure and another open attempt was performed with evacuation of the chest cavity and an intercostal muscle flap was done to repair the defect inthe bronchus. Procedure was unsuccessful with recurrence of the Bronchopleural fistula in following 3 weeks. Patient was then hospitalized and IV antibiotics were instituted. A decision was then made to proceed with Endobronchial placement of Amplatzer ASD Occluder device.PROCEDURE: Patient was intubated with single lumen ET tube and general anesthesia was induced on January 17 2010. Bronchoscope was advanced and examination of left bronchial stump revealed the persistent Bronchopleural fistula. Serial measurements to measure the diameter of the aperture in the bronchus and fluoroscopic markers were placed on the skin of location of Bronchopleural fistula. Based on the careful measurements a 6-French guiding sheath was passed through the therapeutic bronchoscope and placed across the Bronchopleural fistula opening. Under fluoroscopic guidance the ASD occlusion device was then passed and deployed. To provide airtight occlusion 2 ml of Tissel and 2ml of BioGlue were infiltrated into the sub sinus of the device. Patient was then extubated successfully and was sent home.Follow up: Our patient has had 3 bronchoscopies since his procedure in January 2010 and has shown no evidence of recurrence of the Bronchopleural fistula. Excellent healing is documented on repeated bronchoscopies.
DISCUSSIONS: Bronchopleural fistula (BPF) after pneumonectomy represents the most dreaded complication in thoracic surgery. Although the incidence has decreased in the recent years due to understanding of the bronchial healing process , diagnosis and therapeutic management of these fistulas remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. BPF may be treated by a range of surgical and medical techniques, including chest drain, Eloesser muscle flap, omental flap, transsternal bronchial closure, thoracoplasty, and prolonged antibiotic regimens.The use of bronchoscopy has been reported for the delivery of biological glue, coils, covered stents, and sealants. The degree of success is variable, and depends on the size and proximity of the fistula and the underlying disease. In this case, we describe a novel method of BPF closure using the Amplatzer device, which is commonly used for transcatheter closure of atrial septal defects (ASDs) with remarkable results when it was deployed endoscopically using flexible bronchoscopy. Kramer et al and Gulkarov et al have described successful use of this device in case of BPF post pneumonectomy .
CONCLUSION: The continued success at closure of BPF with Amplatzer warrants future studies to assess their use as the one of the first line treatment modalities for Bronchopleural fistula post pneumonectomy.
DISCLOSURE: Sanober Butt, No Financial Disclosure Information; No Product/Research Disclosure Information