SESSION TITLE: Procedures Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Bronchopleural fistulas remain a therapeutic challenge and, despite various treatments, can lead to significant mortality from fistula-related complications. We present the case of a complicated bronchopleural fistula after lye ingestion that was successfully repaired using fibrin sealant and a modified studded silicone Dumon stent.
CASE PRESENTATION: A 56 year-old male with history of depression presented after attempted suicide with lye ingestion. Endoscopy revealed esophageal and jejunal strictures as well as a gastric outlet obstruction. He underwent gastroesophagectomy and esophageal reconstruction complicated by necrosis of the reconstructed esophagus, requiring an extensive debridement procedure; this led to a complex left tracheobronchomediastinopleural fistula for which multiple chest tubes were placed in the resultant empyema space. We then performed a simultaneous video-assisted thoracoscopy and rigid bronchoscopy under general anesthesia. The empyema space was cleaned and the fistula space debrided, packed, and stapled with sheets of cellulose absorbable hemostat (Surgicel). Rigid bronchoscopy revealed a 15x8 mm irregular fistula at the left tracheobronchial juncture. Nd-YAG laser at low power density (10W) was used to create swelling circumferentially. A tight packing-plug was made using Surgicel and absorbable sutures and positioned inside the fistula after infusion with fibrin sealant (Tisseel). A customized Dumon Y-stent was then deployed, covering most of the left mainstem bronchus, right mainstem bronchus and the lower 3 cm. of the trachea. The empyema healed and surveillance bronchoscopies showed gradual fistula healing. The stent was removed 1 year after initial placement and the patient remained asymptomatic.
DISCUSSION: The use of silicone stents is well-established for tracheal stenosis and has become more common in the management of bronchopleural fistulas (1). Fibrin sealant is most commonly used for hemostasis in various surgical procedures, however has been described in the closure of bronchopleural fistulas with flexible bronchoscopy. The combination of a fibrin sealant and Surgicel with laser coagulation and stent placement has not yet been documented for the successful management of bronchopleural fistula.
CONCLUSIONS: The successful management of bronchopleural fistulas may require innovative therapies to assist with achieving closure of the defect.
Reference #1: Lois M and Noppen M. An Overview of the Problem With Special Focus on Endoscopic Management. CHEST 2005; 128(6)3955-3965
DISCLOSURE: The following authors have nothing to disclose: Dharmi Patel, Mohsen Davoudi
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