Closure of a Bronchopleural Fistula Using Decalcified Human Spongiosa and a Fibrin Sealant

doi:10.1016/S0003-4975(97)00282-8

The Annals of Thoracic Surgery

Volume 64, Issue 1, July 1997, Pages 230-233

https://doi.org/10.1016/S0003-4975(97)00282-8 Get rights and content

Abstract

Bronchopleural fistulas associated with empyema can occur as a life-threatening sequelae after pulmonary resection, most frequently occurring after pneumonectomy. With the use of the flexible bronchoscope, the bronchopleural fistula of a 62-year-old critically ill woman was permanently sealed with a fibrin sealant and a small section of demineralized human spongiosa. Closure of bronchopleural fistulas with the application of fibrin sealant plus human spongiosa may offer a valuable addition to the armament of therapeutic alternatives.

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Comment

The applicability of rigid and flexible bronchoscopes in the abatement of bronchopleural fistulas has been well documented in the medical literature 1, 2, 5, 7, 8, 10, 11. The flexible bronchoscope is more advantageous, providing superior and precise access to a greater portion of the bronchial tree than does the rigid scope [1]. Fistulas measuring less than 3 mm have been closed using fibrin sealant alone [9]. Fistulas more than 3 mm are difficult to treat owing to the patient’s expectoration

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Cited by (32)

Bronchopleural fistula: An update for intensivists
2010, Journal of Critical Care
Citation Excerpt :
Pulmonary surgical procedures remain the leading cause of a BPF, although refinements in surgical techniques have substantially reduced the incidence [2]. The incidence after pulmonary resection for lung cancer is reported between 4.5% and 20% after pneumonectomy and 0.5% after lobectomy [3,4]. The incidence is highest after right pneumonectomy and right lower lobectomy [5].
Bronchopleural fistula is a potentially fatal condition that may result after a variety of clinical conditions, most commonly after pulmonary resection. Either surgical or bronchoscopic repair is required to definitively correct these lesions, though a small number may resolve spontaneously with optimal ventilatory care and other options available to an intensivist in the management of this complex condition. The successful management of a bronchopleural fistula depends on formulating a treatment strategy tailored to individual patient needs.
Bronchial Stump Dehiscence: Update on Prevention and Management
2007, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
Other strategies include injection of a sclerosant material such as polidocanol,46 or the use of pressure release mode for ventilation.47 Bronchoscopic measures to eliminate or reduce air leak in such patients may be employed46 and include covered stents overlying the orifice that is leaking, Fogarty balloon occlusion of the offending bronchus,48 YAG laser treatment,49 as well as local application of fibrin sealant,50-53 tissue glue,54 Gelfoam or Surgicel.48 Bronchial stump dehiscence is an important cause of morbidity following pulmonary resection and is associated with significant mortality.
Effective Approach for the Treatment of Bronchopleural Fistula: Application of Endovascular Metallic Ring-Shaped Coil in Combination With Fibrin Glue
2007, Annals of Thoracic Surgery
Citation Excerpt :
Applying more than one coil to close a large fistula will be more effective. In the literature, there are successful applications such as decalcified human spongiosa and fibrin sealant combinations, metallic expandable wall stent, and Dumon stent insertions in bronchopleural fistula treatment apart from metallic coil applications [8–10]. Recently, endobronchial valve applications were reported, but these approaches do not concern the treatment of the fistula after pneumonectomy [11, 12].
The development of bronchopleural fistula is an important complication after pulmonary resections. Generally, conventional treatment methods are used in patients having bronchopleural fistulas. Recently, there has been an increase in the use of minimally invasive methods yielding better results. In our study, we applied a combination of endovascular metallic ring coil and fibrin glue. We hereby think that such an approach for a combination might be a contribution to improving the already existing minimally invasive treatment methods.
Bronchoscopic treatment of postpneumonectomy bronchopleural fistula with a collagen screw plug
2006, Journal of Thoracic and Cardiovascular Surgery
Bronchopleural fistula is a critical complication that may occur after pulmonary resection. Early closure of the fistula is required to prevent thoracic empyema or aspiration pneumonia. We have designed a novel procedure for bronchoscopic occlusion of the fistula with a collagen screw plug and assessed its feasibility in an experimental animal model.
Adult beagle dogs underwent right or left pneumonectomy, and the bronchial stump was closed with the Sweet method. A silicone bar (2 mm in diameter) was then placed in the middle of the bronchial stump. Seven days after the operation, the silicone bar was removed bronchoscopically, and fistula formation was confirmed. A screw-shaped 2% collagen screw plug (20 mm long and 3 mm in diameter) was mounted at the end of a modified endoscopic cannula and then inserted into the fistula. Autologous platelet-rich plasma was then soaked onto the inserted plug.
Nine of 10 beagle dogs with bronchopleural fistula were treated successfully by plug occlusion. One dog died of pneumothorax caused by dislocation of the plug. Pathologic examination revealed that the collagen sponge had been replaced by fibrous tissue and that the fistula was covered with normal epithelium. Although soaking with platelet-rich plasma made the plug airtight immediately, the use of platelet-rich plasma seemed to make no distinct difference with respect to the treatment result or pathologic findings.
Bronchoscopic occlusion with a collagen screw plug is a promising option for treatment of small bronchopleural fistulas after pulmonary surgery.
Pleurodesis using autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome
2006, Journal of Critical Care
Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax.
The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1).
The study took place at the Torrecardenas Hospital (Andalusian Health Service, Almería, Spain).
Participants were 2 groups of 27 patients, all with ARDS, pneumothorax, and PAL.
One group received conventional treatment whereas the other received PAB.
The severity of the conditions of both groups is homogeneous, shown by sex; age; Murray, Marshall, and Acute Physiology and Chronic Health Evaluation II scores; and etiology of ARDS. The patients in the PAB group had a shorter stay in the ICU, shorter weaning time (WT), and lower death rate. The average differences between the groups were 11 days less WT (adjusted odds ratio [OR] = 0.1) and 9 days less on average time spent in the ICU (adjusted OR = 0.24). The death rates in the PAB group and the control group were 3.7% and 29.6%, respectively (adjusted OR = 0.6).
The use of PAB makes possible a decrease in ventilator WT and a shorter stay in the ICU, with a resulting increase in functional recuperation and decrease in patient mortality.
Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol
2002, Chest
Citation Excerpt :
The mechanical occlusion of swollen mucosa epithelium due to regional edema may initially close the orifice of the fistula. Tissue granulation generally covers the spongiosa in 2 to 3 weeks.489 The processes of healing in animal models after a similar procedure9 are as follows: increased redness, indicating an increase of tissue blood supply, occurs 3 days after ethanol injection, and, in addition, a disintegration of the fibrin and an increase in tissue granulation are present; and 2 months after ethanol injection, connective tissue and fibrin were completely covered over with epithelial tissue.4
Five consecutive bronchopleural fistulas (BPFs) were successfully treated by injecting absolute ethanol directly into the submucosal layer of the fistula under flexible bronchoscopic observation. No complications occurred as a result of this treatment. Our nonsurgical treatment may be very useful to reduce the costs of and duration of hospitalization and to improve the patient's quality of life. This is the first report of the bronchoscopic closure of BPFs by injecting absolute ethanol, and we would recommend this treatment as a first-line therapy for patients with a postoperative central BPF with an orifice that is < 3 mm in diameter.

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Case ReportsClosure of a Bronchopleural Fistula Using Decalcified Human Spongiosa and a Fibrin Sealant

Abstract

Section snippets

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Occlusion of bronchopleural fistula after lung injury—a new treatment by bronchoscopy

J Trauma

Case Reports
Closure of a Bronchopleural Fistula Using Decalcified Human Spongiosa and a Fibrin Sealant