Original Article
Polyglycolic acid mesh occlusion for postoperative bronchopleural fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(8) 931–936 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315594071 aan.sagepub.com
Shinichi Yamamoto, Shunsuke Endo, Kentaro Minegishi, Tomoki Shibano, Tomoyuki Nakano and Kenji Tetsuka
Abstract Background: Postoperative bronchopleural fistula is one of the most life-threatening complications after anatomical pulmonary resection. Bronchopleural fistula may cause empyema and aspiration pneumonia with subsequent acute respiratory distress syndrome. Surgical interventions for bronchopleural fistula can prolong hospitalization and impair postoperative quality of life. Postoperative care requires minimally invasive endoscopic occlusion. Methods: We retrospectively reviewed the records of 7 patients who developed bronchopleural fistula among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in Jichi Medical University from 2009 to 2013. Bronchopleural fistula occurred in the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 2, in the superior segmental bronchus of the left lower lobe in one, and in the right intermediate bronchus in one. Flexible bronchoscopy was used to occlude 3-mm fistulas with polyglycolic acid mesh in 2 patients. Larger fistulas in 5 patients were occluded with polyglycolic acid mesh plus fibrin glue to secure the mesh. The median procedure was 37 min. Procedures were considered complete upon resolution of air leakage from the chest drainage system. Results: Bronchoscopic interventions for bronchopleural fistula were repeated an average of 2 times. No procedurerelated complications or death occurred. Bronchoscopic interventions were successful in all patients. Conclusions: Bronchoscopic occlusion with polyglycolic acid mesh with or without fibrin glue is easy and feasible as the first step in postoperative management of bronchopleural fistula.
Keywords Bronchial fistula, bronchoscopy, embolization, therapeutic, pneumonectomy, postoperative complications, tissue adhesives
Introduction Postoperative bronchopleural fistula (BPF) is one of the most feared complications after lobectomy and pneumonectomy because of the high mortality rate associated with aspiration pneumonia and subsequent acute respiratory distress syndrome.1,2 Prompt and proper management of BPF is paramount to reduce its mortality rate. Surgical techniques, including Eloesser muscle flap placement, omental flap placement, transsternal bronchial closure, and thoracoplasty can impair postoperative quality of life, especially in patients with poor physical status.3 Early bronchoscopic occlusion can reduce the risk of aspiration pneumonia and subsequent acute respiratory distress syndrome, and can result in complete resolution
without any surgical intervention, if the fistula size is small. Notwithstanding large fistulas that cause lifethreatening respiratory failure, surgical intervention should be avoided if possible. The goal of this study was to review and clarify the feasibility and efficacy of the bronchoscopic occlusion procedure, depending on
Department of General Thoracic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan Corresponding author: Shinichi Yamamoto, MD, PhD, Division of General Thoracic Surgery, Department of General Thoracic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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the size of fistula, after anatomical pulmonary resection for lung cancer.
Patients and methods Six hundred eighty-nine patients underwent segmentectomy or lobectomy without sleeve resection for lung cancer from 2009 to 2013 in our institution (Table 1). The bronchial stump was closed with a mechanical stapler, without persistence of cancer, in all patients. If BPF was suspected, based on symptoms such as fever, watery sputum, and dyspnea, or abnormal examination findings such as leukocytosis, C-reactive protein elevation or detection of bacteria in the thoracic cavity, chest radiography or computed tomography was performed immediately, regardless of the presence of pneumothorax. Chest tube drainage Table 1. Surgical procedures in 689 patients and occurrence of bronchopleural fistula. Procedure Right Segmentectomy Upper lobectomy Middle lobectomy Lower lobectomy Lobectomy and segmentectomy Bilobectomy Left Segmentectomy Upper lobectomy Lower lobectomy Lobectomy and segmentectomy Total BPF: bronchopleural fistula.
No. of patients 64 171 36 103 11 24 69 122 88 1 689
BPF 1
4 1
1 7
was carried out if pneumothorax was detected on chest radiography or computed tomography, followed by bronchoscopy. If dehiscence of the bronchial stump was detected on bronchoscopy, the patient was diagnosed with postoperative BPF. When the respiratory condition of the patient could be maintained, bronchoscopic occlusion was planned instead of a surgical intervention. BPF occurred in 7 men among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in our institution from 2009 to 2013 (Table 1). BPF occurred after right-sided operations in 6 patients and after a leftsided operation in one. BPF occurred at the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 3, and in the intermediate bronchus in one. BPF diameters ranged from 3 to 7 mm. The bronchoscopic procedure was performed under local anesthesia and conscious sedation. Before bronchoscopy, 100 mg of 2% lidocaine spray was applied to the vocal cords and posterior pharyngeal wall. The patient was placed in the supine position. Pethidine 35 mg and midazolam 2 mg were administered intravenously after normal blood pressure, heart rate, and oxygen saturation were confirmed. Endotracheal intubation was undertaken through a bronchoscope, and the patient was simultaneously given supplemental oxygen at 5 Lmin1 via the endotracheal tube. The bronchoscope (BF-type 260 Video Bronchoscope; Olympus, Tokyo, Japan) was introduced orally via the endotracheal tube, and topical lidocaine was applied to the trachea and bronchus via the working channel. During bronchoscopy, intermittent 1-mg boluses of midazolam were administered intravenously as necessary to maintain sedation at a Ramsay Sedation Scale score of 2 to 3, in which the patient was cooperative and oriented.4 Polyglycolic acid (PGA) mesh (Neoveil; Gunze Co., Ltd., Tokyo, Japan) was cut into 5- to 10-mm squares (Figure 1a). A square piece of mesh
Figure 1. (a) The sheet of polyglycolic acid mesh was cut into a 5-mm square. (b) The piece of mesh was crumpled and grasped with biopsy forceps.
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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Figure 2. (a) A bronchopleural fistula detected by bronchoscopy. (b) A piece of polyglycolic acid mesh was pushed into the fistula. (c) Additional fibrin glue was applied into and onto the fistula via a central venous catheter. (d) After application of the fibrin glue, the fistula was filled with pieces of mesh and fibrin glue.
was introduced into the bronchus with biopsy forceps via the working channel of the bronchoscope (Figure 1b). The mesh was released on this side of the fistula to avoid having it catch on the biopsy forceps when placed in the fistula. The mesh was pushed into the fistula with the closed biopsy forceps and the tip of the flexible bronchoscope (Figure 2a, 2b). Several sheets were pushed into the fistula in succession until air leakage from the chest tube ceased. For fistulas >3 mm, fibrin glue (Bolheal; Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan) was applied to the surface of the mesh-filled fistula with a central venous catheter via the working channel of the bronchoscope at the end of the procedure (Figure 2c, 2d). After the procedure, the bronchoscope and endotracheal tube were removed and flumazenil 0.5 mg was administered intravenously. The patient’s blood pressure, heart rate, oxygen saturation, and respiratory condition were confirmed to be normal. Several days after the procedure, follow-up bronchoscopy was performed to confirm that the PGA mesh remained within the fistula. If the PGA mesh did not sufficiently fill the fistula, we repeated the bronchoscopic occlusion procedure. If there were no signs of BPF recurrence or empyema for more than 1 week, the chest tube was
removed. Follow-up bronchoscopy was repeated every 1 to 2 weeks until the bronchial mucosa had healed completely, which indicated resolution of the BPF (Figure 3a, 3b).
Results The bronchoscopic interventions were successful in all patients. The median procedure time for the bronchoscopic intervention was 37 min. The range of bronchoscopic interventions to resolve the BPF without surgical intervention was 1–3, with an average of 2 per patient (Table 2). The median length of hospitalization was 20 days after the onset of BPF (Table 3). No bronchoscopic intervention-associated complications or deaths occurred.
Discussion BPF is a life-threatening complication after pulmonary resection. The reported incidence of BPF after pulmonary resection for lung cancer is 4.5% to 20.0% after pneumonectomy and 0.5% after lobectomy.2,3 The mortality rate associated with BPF ranges from 16% to 72%.5–7 BPF may be complicated by secondary
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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Figure 3. (a) One month after the procedure, the polyglycolic acid mesh remained within the bronchopleural fistula. (b) Three months after the procedure, healing of the fistula was confirmed.
Table 2. Characteristics of 7 patients with bronchopleural fistula. Patient no.
Age (years)
Sex
Operation
Onset of BPF (postoperative day)
BPF size (mm)
1 2 3 4 5 6 7
74 76 69 71 77 72 76
Male Male Male Male Male Male Male
Right lower lobectomy Right lower lobectomy Right lower lobectomy LUL þ left S6 segmentectomy Right S6 segmentectomy RMLL Right lower lobectomy
29 15 7 26 23 16 34
4 4 5 7 3 5 3
BPF: bronchopleural fistula; LUL: left upper lobectomy; RMLL: right middle and lower lobectomy.
Table 3. Number of procedures for bronchopleural fistula and hospital stay. Patient no.
Procedures
Procedure time (min)
Hospitalization (days)
1 2 3 4 5 6 7
2 3 3 2 1 2 1
33, 79, 39, 37, 41 52, 24
14 20 36 25 15 151 16
36 28, 37 40, 32 28 61
empyema, aspiration pneumonia, adult respiratory distress syndrome, and death.8 Surgical interventions such as Eloesser muscle flap placement, omental flap placement, transsternal bronchial closure, or thoracoplasty can cause prolonged hospitalization and impaired the quality of life postoperatively. Bronchoscopic occlusion of BPF is less invasive than surgery as a first step.
Consequently, when BPF is diagnosed, initial management should involve chest drainage followed by bronchoscopic occlusion for temporary prevention of aspiration pneumonia. The bronchoscopic intervention can be converted to a surgical intervention, such as open window thoracostomy, if empyema worsens. Risk factors for the development of BPF include preoperative radiation of the chest, lung tissue that has been infected or destroyed by inflammatory disease, an immunocompromised state, and insulin-dependent diabetes.6 Additional risk factors include surgical procedures such as right-sided operations, a residual bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, reintubation after resection, and surgical inexperience.2,9 Postoperative ischemic bronchitis accompanied by mediastinal lymph node dissection was recently reported to be associated with a high risk of BPF development.10,11 Regular bronchoscopic followup allows early diagnosis of BPF, and is necessary in high-risk patients. Sealants for BPF include biological
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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glue, coils, covered self-expanding stents, Dumon stents (Novatech, Plan de Grasse, France), and Amplatzer vascular plugs (AGA Medical, Golden Valley, MN, USA).5,12–18 The success rate of sealants depends on the underlying disease and the location and size of the fistula.13 Sealants made of PGA mesh are easy to obtain in Japan because they are often used to manage air leakage following pulmonary resection.19 Moreover, PGA mesh is soft, thin, and easy to customize and deliver with a flexible bronchoscope for various types of BPF. This material is absorbed within 2 to 3 months, thus additional removal procedures are unnecessary. The probability of a successful bronchoscopic treatment is higher for small BPF than for large lesions. Shekar and colleagues3 reported that a BPF > 8 mm and a large central BPF are usually unsuitable for bronchoscopic management. In the present study, BPF > 3 mm were occluded with PGA mesh reinforced with fibrin glue. The success rate depends on the material characteristics of the fibrin glue, which ideally induces fibroblast proliferation and synergistic fixation.20 However, some repeat bronchoscopic interventions may be required due to mesh dislocation. In addition to the avoidance of prolonged hospitalization and excessive medical cost, bronchoscopic interventions can provide a great benefit in terms of postoperative quality of life. We concluded that bronchoscopic PGA mesh occlusion is a minimally invasive, easily performed, feasible, and effective intervention for BPF following anatomical pulmonary resection for lung cancer. Bronchoscopic PGA mesh occlusion should be the first-line management procedure for postoperative BPF, to avoid invasive surgical interventions that lead to prolonged hospitalization and impaired postoperative quality of life.
Acknowledgement We thank the staff of the endoscopic section at Jichi Medical University for their help and assistance.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P and Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997; 63: 1391–1396.
2. Cerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001; 13: 3–7. 3. Shekar K, Foot C, Fraser J, Ziegenfuss M, Hopkins P and Windsor M. Bronchopleural fistula: an update for intensivists. J Crit Care 2010; 25: 47–55. 4. Ramsay MA, Savege TM, Simpson BR and Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974; 2: 656–659. 5. Spiliopoulos S, Krokidis M, Gkoutzios P, et al. Successful exclusion of a large bronchopleural fistula using an Amplatzer II vascular plug and glue embolization. Acta Radiol 2012; 53: 406–409. 6. Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O and Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001; 7: 330–336. 7. Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa M and Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000; 18: 519–523. 8. Pop D, Nadeemy AS, Venissac N and Mouroux J. Bronchopleural fistula: the Damocles sword of all pneumonectomies. Interact Cardiovasc Thorac Surg 2011; 13: 107–108. 9. Naranjo Gomez JM, Carbajo Carbajo M, Valdivia Concha D and Campo-Canaveral de la Cruz JL. Conservative treatment of post-lobectomy bronchopleural fistula. Interact Cardiovasc Thorac Surg 2012; 15: 152–154. 10. Satoh Y, Okumura S, Nakagawa K, et al. Postoperative ischemic change in bronchial stumps after primary lung cancer resection. Eur J Cardiothorac Surg 2006; 30: 172–176. 11. Benhamed L, Bellier J, Fournier C, et al. Postoperative ischemic bronchitis after lymph node dissection and primary lung cancer resection. Ann Thorac Surg 2011; 91: 355–359. 12. Imai K, Matsuzaki I, Minamiya Y, et al. Postoperative bronchial stump fistula after lobectomy: response to occlusion with polyglycolic acid mesh and fibrin glue via bronchoscopy. Gen Thorac Cardiovasc Surg 2011; 59: 771–774. 13. Fruchter O, Bruckheimer E, Raviv Y, Rosengarten D, Saute M and Kramer MR. Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug. Eur J Cardiothorac Surg 2012; 41: 46–49. 14. Andreetti C, D’Andrilli A, Ibrahim M, et al. Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered self-expandable stent. Interact Cardiovasc Thorac Surg 2012; 14: 420–423. 15. Hamid UI and Jones JM. Closure of a bronchopleural fistula using glue. Interact Cardiovasc Thorac Surg 2011; 13: 117–118. 16. Sivrikoz CM, Kaya T, Tulay CM, Ak I, Bilir A and Doner E. Effective approach for the treatment of bronchopleural fistula: application of endovascular metallic
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ring-shaped coil in combination with fibrin glue. Ann Thorac Surg 2007; 83: 2199–2201. 17. Ferraroli GM, Testori A, Cioffi U, et al. Healing of bronchopleural fistula using a modified Dumon stent: a case report. J Cardiothorac Surg 2006; 1: 16. 18. Tsukada H and Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula. Ann Thorac Surg 2005; 80: 1928–1930. 19. Ueda K, Tanaka T, Li TS, Tanaka N and Hamano K. Sutureless pneumostasis using bioabsorbable mesh and
glue during major lung resection for cancer: who are the best candidates? J Thorac Cardiovasc Surg 2010; 139: 600–605. 20. Yonezawa H, Yamada S, Yanamoto S, Yoshitomi I, Kawasaki G and Umeda M. Effect of polyglycolic acid sheets with fibrin glue (MCFP technique) on the healing of wounds after partial resection of the border of the tongue in rabbits: a preliminary study. Br J Oral Maxillofac Surg 2012; 50: 459–463.
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
Polyglycolic acid mesh occlusion for postoperative bronchopleural fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(8) 931–936 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315594071 aan.sagepub.com
Shinichi Yamamoto, Shunsuke Endo, Kentaro Minegishi, Tomoki Shibano, Tomoyuki Nakano and Kenji Tetsuka
Abstract Background: Postoperative bronchopleural fistula is one of the most life-threatening complications after anatomical pulmonary resection. Bronchopleural fistula may cause empyema and aspiration pneumonia with subsequent acute respiratory distress syndrome. Surgical interventions for bronchopleural fistula can prolong hospitalization and impair postoperative quality of life. Postoperative care requires minimally invasive endoscopic occlusion. Methods: We retrospectively reviewed the records of 7 patients who developed bronchopleural fistula among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in Jichi Medical University from 2009 to 2013. Bronchopleural fistula occurred in the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 2, in the superior segmental bronchus of the left lower lobe in one, and in the right intermediate bronchus in one. Flexible bronchoscopy was used to occlude 3-mm fistulas with polyglycolic acid mesh in 2 patients. Larger fistulas in 5 patients were occluded with polyglycolic acid mesh plus fibrin glue to secure the mesh. The median procedure was 37 min. Procedures were considered complete upon resolution of air leakage from the chest drainage system. Results: Bronchoscopic interventions for bronchopleural fistula were repeated an average of 2 times. No procedurerelated complications or death occurred. Bronchoscopic interventions were successful in all patients. Conclusions: Bronchoscopic occlusion with polyglycolic acid mesh with or without fibrin glue is easy and feasible as the first step in postoperative management of bronchopleural fistula.
Keywords Bronchial fistula, bronchoscopy, embolization, therapeutic, pneumonectomy, postoperative complications, tissue adhesives
Introduction Postoperative bronchopleural fistula (BPF) is one of the most feared complications after lobectomy and pneumonectomy because of the high mortality rate associated with aspiration pneumonia and subsequent acute respiratory distress syndrome.1,2 Prompt and proper management of BPF is paramount to reduce its mortality rate. Surgical techniques, including Eloesser muscle flap placement, omental flap placement, transsternal bronchial closure, and thoracoplasty can impair postoperative quality of life, especially in patients with poor physical status.3 Early bronchoscopic occlusion can reduce the risk of aspiration pneumonia and subsequent acute respiratory distress syndrome, and can result in complete resolution
without any surgical intervention, if the fistula size is small. Notwithstanding large fistulas that cause lifethreatening respiratory failure, surgical intervention should be avoided if possible. The goal of this study was to review and clarify the feasibility and efficacy of the bronchoscopic occlusion procedure, depending on
Department of General Thoracic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan Corresponding author: Shinichi Yamamoto, MD, PhD, Division of General Thoracic Surgery, Department of General Thoracic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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Asian Cardiovascular & Thoracic Annals 23(8)
the size of fistula, after anatomical pulmonary resection for lung cancer.
Patients and methods Six hundred eighty-nine patients underwent segmentectomy or lobectomy without sleeve resection for lung cancer from 2009 to 2013 in our institution (Table 1). The bronchial stump was closed with a mechanical stapler, without persistence of cancer, in all patients. If BPF was suspected, based on symptoms such as fever, watery sputum, and dyspnea, or abnormal examination findings such as leukocytosis, C-reactive protein elevation or detection of bacteria in the thoracic cavity, chest radiography or computed tomography was performed immediately, regardless of the presence of pneumothorax. Chest tube drainage Table 1. Surgical procedures in 689 patients and occurrence of bronchopleural fistula. Procedure Right Segmentectomy Upper lobectomy Middle lobectomy Lower lobectomy Lobectomy and segmentectomy Bilobectomy Left Segmentectomy Upper lobectomy Lower lobectomy Lobectomy and segmentectomy Total BPF: bronchopleural fistula.
No. of patients 64 171 36 103 11 24 69 122 88 1 689
BPF 1
4 1
1 7
was carried out if pneumothorax was detected on chest radiography or computed tomography, followed by bronchoscopy. If dehiscence of the bronchial stump was detected on bronchoscopy, the patient was diagnosed with postoperative BPF. When the respiratory condition of the patient could be maintained, bronchoscopic occlusion was planned instead of a surgical intervention. BPF occurred in 7 men among 689 patients who underwent segmentectomy or lobectomy without sleeve resection for lung cancer in our institution from 2009 to 2013 (Table 1). BPF occurred after right-sided operations in 6 patients and after a leftsided operation in one. BPF occurred at the right lower bronchial stump in 3 patients, in the superior segmental bronchus of the right lower lobe in 3, and in the intermediate bronchus in one. BPF diameters ranged from 3 to 7 mm. The bronchoscopic procedure was performed under local anesthesia and conscious sedation. Before bronchoscopy, 100 mg of 2% lidocaine spray was applied to the vocal cords and posterior pharyngeal wall. The patient was placed in the supine position. Pethidine 35 mg and midazolam 2 mg were administered intravenously after normal blood pressure, heart rate, and oxygen saturation were confirmed. Endotracheal intubation was undertaken through a bronchoscope, and the patient was simultaneously given supplemental oxygen at 5 Lmin1 via the endotracheal tube. The bronchoscope (BF-type 260 Video Bronchoscope; Olympus, Tokyo, Japan) was introduced orally via the endotracheal tube, and topical lidocaine was applied to the trachea and bronchus via the working channel. During bronchoscopy, intermittent 1-mg boluses of midazolam were administered intravenously as necessary to maintain sedation at a Ramsay Sedation Scale score of 2 to 3, in which the patient was cooperative and oriented.4 Polyglycolic acid (PGA) mesh (Neoveil; Gunze Co., Ltd., Tokyo, Japan) was cut into 5- to 10-mm squares (Figure 1a). A square piece of mesh
Figure 1. (a) The sheet of polyglycolic acid mesh was cut into a 5-mm square. (b) The piece of mesh was crumpled and grasped with biopsy forceps.
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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Figure 2. (a) A bronchopleural fistula detected by bronchoscopy. (b) A piece of polyglycolic acid mesh was pushed into the fistula. (c) Additional fibrin glue was applied into and onto the fistula via a central venous catheter. (d) After application of the fibrin glue, the fistula was filled with pieces of mesh and fibrin glue.
was introduced into the bronchus with biopsy forceps via the working channel of the bronchoscope (Figure 1b). The mesh was released on this side of the fistula to avoid having it catch on the biopsy forceps when placed in the fistula. The mesh was pushed into the fistula with the closed biopsy forceps and the tip of the flexible bronchoscope (Figure 2a, 2b). Several sheets were pushed into the fistula in succession until air leakage from the chest tube ceased. For fistulas >3 mm, fibrin glue (Bolheal; Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan) was applied to the surface of the mesh-filled fistula with a central venous catheter via the working channel of the bronchoscope at the end of the procedure (Figure 2c, 2d). After the procedure, the bronchoscope and endotracheal tube were removed and flumazenil 0.5 mg was administered intravenously. The patient’s blood pressure, heart rate, oxygen saturation, and respiratory condition were confirmed to be normal. Several days after the procedure, follow-up bronchoscopy was performed to confirm that the PGA mesh remained within the fistula. If the PGA mesh did not sufficiently fill the fistula, we repeated the bronchoscopic occlusion procedure. If there were no signs of BPF recurrence or empyema for more than 1 week, the chest tube was
removed. Follow-up bronchoscopy was repeated every 1 to 2 weeks until the bronchial mucosa had healed completely, which indicated resolution of the BPF (Figure 3a, 3b).
Results The bronchoscopic interventions were successful in all patients. The median procedure time for the bronchoscopic intervention was 37 min. The range of bronchoscopic interventions to resolve the BPF without surgical intervention was 1–3, with an average of 2 per patient (Table 2). The median length of hospitalization was 20 days after the onset of BPF (Table 3). No bronchoscopic intervention-associated complications or deaths occurred.
Discussion BPF is a life-threatening complication after pulmonary resection. The reported incidence of BPF after pulmonary resection for lung cancer is 4.5% to 20.0% after pneumonectomy and 0.5% after lobectomy.2,3 The mortality rate associated with BPF ranges from 16% to 72%.5–7 BPF may be complicated by secondary
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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Figure 3. (a) One month after the procedure, the polyglycolic acid mesh remained within the bronchopleural fistula. (b) Three months after the procedure, healing of the fistula was confirmed.
Table 2. Characteristics of 7 patients with bronchopleural fistula. Patient no.
Age (years)
Sex
Operation
Onset of BPF (postoperative day)
BPF size (mm)
1 2 3 4 5 6 7
74 76 69 71 77 72 76
Male Male Male Male Male Male Male
Right lower lobectomy Right lower lobectomy Right lower lobectomy LUL þ left S6 segmentectomy Right S6 segmentectomy RMLL Right lower lobectomy
29 15 7 26 23 16 34
4 4 5 7 3 5 3
BPF: bronchopleural fistula; LUL: left upper lobectomy; RMLL: right middle and lower lobectomy.
Table 3. Number of procedures for bronchopleural fistula and hospital stay. Patient no.
Procedures
Procedure time (min)
Hospitalization (days)
1 2 3 4 5 6 7
2 3 3 2 1 2 1
33, 79, 39, 37, 41 52, 24
14 20 36 25 15 151 16
36 28, 37 40, 32 28 61
empyema, aspiration pneumonia, adult respiratory distress syndrome, and death.8 Surgical interventions such as Eloesser muscle flap placement, omental flap placement, transsternal bronchial closure, or thoracoplasty can cause prolonged hospitalization and impaired the quality of life postoperatively. Bronchoscopic occlusion of BPF is less invasive than surgery as a first step.
Consequently, when BPF is diagnosed, initial management should involve chest drainage followed by bronchoscopic occlusion for temporary prevention of aspiration pneumonia. The bronchoscopic intervention can be converted to a surgical intervention, such as open window thoracostomy, if empyema worsens. Risk factors for the development of BPF include preoperative radiation of the chest, lung tissue that has been infected or destroyed by inflammatory disease, an immunocompromised state, and insulin-dependent diabetes.6 Additional risk factors include surgical procedures such as right-sided operations, a residual bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, reintubation after resection, and surgical inexperience.2,9 Postoperative ischemic bronchitis accompanied by mediastinal lymph node dissection was recently reported to be associated with a high risk of BPF development.10,11 Regular bronchoscopic followup allows early diagnosis of BPF, and is necessary in high-risk patients. Sealants for BPF include biological
Downloaded from aan.sagepub.com at University of Birmingham on November 14, 2015
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glue, coils, covered self-expanding stents, Dumon stents (Novatech, Plan de Grasse, France), and Amplatzer vascular plugs (AGA Medical, Golden Valley, MN, USA).5,12–18 The success rate of sealants depends on the underlying disease and the location and size of the fistula.13 Sealants made of PGA mesh are easy to obtain in Japan because they are often used to manage air leakage following pulmonary resection.19 Moreover, PGA mesh is soft, thin, and easy to customize and deliver with a flexible bronchoscope for various types of BPF. This material is absorbed within 2 to 3 months, thus additional removal procedures are unnecessary. The probability of a successful bronchoscopic treatment is higher for small BPF than for large lesions. Shekar and colleagues3 reported that a BPF > 8 mm and a large central BPF are usually unsuitable for bronchoscopic management. In the present study, BPF > 3 mm were occluded with PGA mesh reinforced with fibrin glue. The success rate depends on the material characteristics of the fibrin glue, which ideally induces fibroblast proliferation and synergistic fixation.20 However, some repeat bronchoscopic interventions may be required due to mesh dislocation. In addition to the avoidance of prolonged hospitalization and excessive medical cost, bronchoscopic interventions can provide a great benefit in terms of postoperative quality of life. We concluded that bronchoscopic PGA mesh occlusion is a minimally invasive, easily performed, feasible, and effective intervention for BPF following anatomical pulmonary resection for lung cancer. Bronchoscopic PGA mesh occlusion should be the first-line management procedure for postoperative BPF, to avoid invasive surgical interventions that lead to prolonged hospitalization and impaired postoperative quality of life.
Acknowledgement We thank the staff of the endoscopic section at Jichi Medical University for their help and assistance.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P and Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997; 63: 1391–1396.
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