INTRODUCTION: Bronchopleural Fistula (BPF) is an uncommon but dreaded complication of several pulmonary conditions. Scientific evidence on the method of closure of BPF is scant, with therapeutic options ranging from conservative management to aggressive surgical management. We offer a novel method of closure not previously described in the literature.
CASE PRESENTATION: A 45-year-old female was evaluated by thoracic surgery for closure of an esophago-pulmonary-bronchial fistula into the right lung. Past medical history includes left upper lobectomy eleven years prior for bilateral upper lobe cavitary disease complicated by chronic coccidioides immitis infection. No complications were noted until one year prior to admission when the patient began coughing during meals and when lying flat. Work-up revealed an esophageal fistula 23 cm from the incisors, measuring 4 mm in length and 3 mm in diameter, communicating with an 11 cm cavity in the right lung apex and into the bronchial tree. During surgery, the esophageal fistula was closed, and the right upper lobe was found to be considerable shrunken and nonfunctional, and was removed. The bronchial fistula was stapled shut. Post-operative bronchoscopic surveillance demonstrated adequate closure of the BPF on the right, but revealed a large fistula at the left upper lobe stump, which measured 10 mm in diameter. Upon entering the pleural cavity thru the BPF, a large collection of dark brown purulent material was found, of which 250 cc was aspirated. Cultures revealed Psuedomonas Aeruginosa. The patient had a complicated post-op course requiring tracheostomy and admission to the ventilator weaning unit. A draining chest tube was placed in the left chest. However, in part due to persistent air leak through the chest tube due to the BPF, the decision was made to attempt to close the BPF using an Amplatzer Septal Occluder Device. Bronchoscopy was undertaken with the presence of an interventional cardiologist who was skilled in the use of the Amplatzer. An esophageal dilator balloon was used to measure the diameter of the BPF at 10 mm. The Amplatzer device, with a waist of 10 mm, was then introduced into the BPF and deployed. Examination revealed complete occlusion of the BPF, with the proximal portion of device situated so that the orifice of the lingular bronchus was occluded. Repeat bronchoscopy after 48 hours revealed no migration of the Amplatzer. The patient survived to discharge without complication.
DISCUSSIONS: This is the first report in the literature of the closure of a BPF using an Amplatzer Septal Occluder Device. The Amplatzer is a self-expanding double disk made from nitinol wire mesh. The disks are joined together by a connecting mesh tube, which acts to stent the defect. Polyester patches are sewn within the disks and central stent, which serve to occlude blood flow through the device. The waist portion also serves to self-center the device during deployment. The waist size varies from 4 to 40 mm. The Amplatzer device has traditionally been employed by interventional cardiologists to close atrial septal defects. BPF is a relatively rare complication of several pulmonary conditions that remains extremely difficult to treat. The incidence after lung resection has been reported from 1.5 to 28%. Reported treatment options are numerous, and include surgical closure, bronchoscopic application of sealant solutions (including ethanol, polyethylene glycol, cyanoacrylate glue, and fibrin glue), intrabronchial antibiotic injection, and calf bone occlusion.
CONCLUSION: This case demonstrates the first recorded use of the Amplatzer Septal Occluder Device to close a BPF. This technique may be applied to other similar patients in the future.
DISCLOSURE: Jason Golbin, None.