How to Do It

Bronchopleural fistula closed with cellulose patch and fibrin glue

Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(7) 880–883 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315577725 aan.sagepub.com

Alfonso Fiorelli, Elisabetta Frongillo and Mario Santini

Abstract We describe a bronchoscopic technique for closing small postoperative bronchopleural fistulas, using an oxidized regenerated cellulose patch and fibrin glue. The patch is mounted on the end of endoscopic forceps and introduced into the fistula to cover it. Intracavitary and submucosal injections of fibrin glue fill the bronchial stump and achieve apposition of the fistula edges. Closure was obtained in 3 of 4 patients; the 4th had complete bronchial dehiscence and empyema.

Keywords Bronchial fistula, bronchoscopy, fistula, pleural diseases, postoperative complications, tissue adhesives

Introduction

Discussion

We describe a bronchoscopic technique for closing small postoperative bronchopleural fistulas (BPF), using an oxidized regenerated cellulose patch (TaboTamp; Johnson & Johnson, Ethicon) and fibrin glue (Evicel; Johnson & Johnson, Ethicon).

In the last 3 years, this technique was performed in 4 consecutive patients with late postoperative BPF not due to tumor recurrence (Table 1). Chest computed tomography showed a newly formed air-fluid level and normal underlying lung; complete reexpansion of the lung was obtained with chest drain insertion in 3 patients, but the fistula did not close spontaneously in one. After bronchoscopic treatment, fistula closure was obtained in all but one patient who had an open window thoracostomy. No complications were found. Examples are sown in Figures 2 and 3. Postoperative BPF is a serious complication with a mortality rate of 29% to 71%.1 The initial treatment involves immediate insertion of a chest drain and systemic antibiotic therapy. Direct surgical repair is the treatment of choice for an early fistula; in a late fistula, tube thoracostomy may be all that is required, especially in the absence of underlying lung disease on computed tomography. If the fistula does not close spontaneously (as in our 4 cases), bronchoscopic

Technique The procedure, summarized in Figure 1, is performed with a flexible videobronchoscope (XT-BF 160; Olympus, Tokyo) under general anesthesia. The patient is intubated to protect the airway and facilitate introduction and removal of the bronchoscope. The fistula channel is de-epithelized with a cytology brush. An oxidized regenerated cellulose patch is cut into a section slightly larger than the fistula orifice, mounted on the end of endoscopic forceps, and introduced within the fistula to cover it. Next, 2–4 mL of fibrin glue (FG) is injected into the cavity to close the bronchial stump, and into the submucosa to achieve apposition of the fistula edges. Repeat bronchoscopy is performed weekly. After one week, the plug gradually becomes indistinguishable from the surrounding tissue, and by 10–12 weeks it is replaced by fibrous tissue. The procedure can be repeated in cases of patch expectoration.

Thoracic Surgery Unit, Second University of Naples, Naples, Italy Corresponding author: Mario Santini, MD, Chirurgia Toracica, Seconda Universita’ di Napoli, Piazza Miraglia 2, I-80138 Naples, Italy. Email: [email protected]

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Figure 1. (a) The cellulose patch is mounted on the end of a standard endoscopic bioptic forceps and pulled through the endotracheal tube. (b) Under direct view, the patch is introduced into the fistula to adequately fill the orifice. (c) Following, intracavitary injection of the two components of fibrin glue is performed with a dedicated 2-channel catheter to close entirely the bronchial stump and facilitate the adhesion of patch to the edge of fistula. (d) Finally, a needle used for transbronchial biopsy is inserted through the bronchial mucosa, and submucosal injection of fibrin glue is started until apposition of the fistula edges is obtained.

Table 1. Characteristics of 4 patients with bronchopleural fistula. Variables

Case 1

Case 2

Case 3

Case 4

Age (years) Sex Etiology Disease

75 Female Lower right lobectomy Squamous cell carcinoma Diabetes, weight loss

37 Female Lower bilobectomy Typical carcinoid

53 Male Left pneumonectomy Bronchiectasis

Prior endoscopic laser resection Bloody sputum

65 Male Right pneumonectomy Squamous cell carcinoma Induction chemotherapy Bloody sputum, fever

No 81

No 175

Lower lobe 4

Bronchus intermedius 3

Right main bronchus 5

Risk factors for fistula

Infection

Symptoms on admission Associated empyema Time from surgery to onset (days) Site of fistula Diameter of fistula (mm) No. of procedures Fistula closure Surgery

Bloody sputum, dyspnea No 125

2 Yes No

1 Yes No

2 Yes No

Time from procedure to cure (weeks) Fistula recurrence Outcome

3

1

3

Left main bronchus 8 (bronchial dehiscence) 3 No Open window thoracostomy 29

No Alive

No Alive

No Alive

No Alive

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Bloody sputum, dyspnea, fever Yes 183

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Figure 3. Bronchoscopy demonstrated a fistula, 5 mm in diameter, at the surgical stump of main right bronchus (arrow) in a 65 year-old man undergoing pneumonectomy for squamous cell carcinoma. (c) One week later, endoscopy confirmed closure of the fistula (arrow). (d) Twelve weeks later, the fistula was completely covered with granulation tissue (arrow).

Figure 2. Case 1: (a) bronchoscopy showed a fistula (arrow), 4 mm in diameter, of the right lower bronchial stump in a 75 yearold woman undergoing lobectomy for squamous cell carcinoma. (b) Ten weeks later, complete healing of fistula with granulation tissue (arrow) was obtained. Case 2: (a) a 37-year-old woman presented a typical carcinoid that occluded the bronchus intermedius. (b) The tumor originated from the lateral segment of the middle lobe bronchus and was partially resected by Nd-YAG laser with rigid bronchoscopy (arrow). (c) For complete resection, a lower bilobectomy was performed. Ten weeks later, bronchoscopy diagnosed a fistula (arrow), 3 mm in diameter, of the middle lobe bronchial stump with staple wires. (d) Bronchoscopy 1 month later showed complete healing of the fistula.

treatment is recommended. Many techniques using glues, coils, and stents have been described, but none of these were appropriate in our cases. The fistulas were 53 cm and thus difficult to treat with FG alone.2 On the other hand, if we exclude patient no. 4, there was no complete dehiscence of the bronchus to indicate the use of complex stents.3 Thus we proposed a new treatment using an oxidized regenerated cellulose patch, which was the major factor in achieving long-lasting fistula closure, and FG that filled the patch and prevented dislocation during ventilation. An oxidized regenerated cellulose patch is widely used for management of

bleeding and alveolar leakage in thoracic surgery, but its use with FG for healing BPF has not been reported before. Two reports from Japan described the use of an FG-coated collagen patch with or without FG to treat BPF.4,5 An oxidized regenerated cellulose patch is a soft and elastic material that is easily shaped to correspond to the fistula when released by forceps. Conversely, a FG-coated collagen patch has a firmness that gradually changes to an elastic gel in contact with respiratory secretions, making it difficult to insert within the fistula.5 In contrast to stents and coils, oxidized regenerated cellulose patches are easily available, can be applied without a specific delivery catheter, and readily removed if indicated. Furthermore, the patch is progressively replaced by fibrous tissue, minimizing the risk of a foreign-body reaction. Our strategy is safe, cost-saving, and may be repeated until fistula closure is achieved. No complications were observed during or after the procedure. A disadvantage is potential damage to the working channel and/or the optics of the bronchoscope by consolidation of the FG. Thus the tip of the catheter or the site of the transbronchial aspiration needle should be kept at a sufficient distance from the bronchoscope during the injection of FG. The procedure is less expensive than other devices or surgical procedures (200 Euros for an oxidized regenerated cellulose patch and 350 Euros for FG), and the materials are commercially available. Obviously, the limited number of cases does

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not allow definitive conclusions. However, patients with a fistula

Bronchopleural fistula closed with cellulose patch and fibrin glue.

We describe a bronchoscopic technique for closing small postoperative bronchopleural fistulas, using an oxidized regenerated cellulose patch and fibri...
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