Bronchopleural fistulas (BPF) are associated with significant morbidity and mortality. Although surgery remains the cornerstone of care, no standard therapeutic approach to the management of BPFs has been established. The variability in BPF features and patient co-morbidities often mandate conservative strategies. We describe the use of a customized silicone Y-stent and an Amplatzer device to treat a patient with post-pneumonectomy BPF.
A 65-year-old man with a history of complicated cavitary Aspergillus pneumonia and persistent Mycobacterium szulgai infection who underwent left-sided pneumonectomy presented with severe dyspnea and productive cough eleven weeks postoperatively. Flexible bronchoscopy revealed a 4mm fistula on the left-sided bronchial stump. Communication with the pleural cavity was evident with purulent secretions coming from the BPF, which resulted in soiling of the contralateral lung. Therapeutic management included antibiotics, pleural space debridement and Kerlix packing, and eventually Eloesser flap creation. Despite this, aspiration of purulent secretions from the left pleural cavity into the right-sided airways impeded the patient’s clinical recovery. Thus, a customized silicone Y-stent was placed by rigid bronchoscopy. The stent was manually modified in the operating room by cutting the left limb at 10 mm from the carina and invaginating the distal end. Stapling and circumferential mattress sutures were used to tie in the distal left limb (Figure 1). Dermabond (2-Octyl cyanoacrylate) was instilled within the stent to seal any remaining spaces along the suture line. Four months later, bronchoscopic evaluation demonstrated a persistent 4mm BPF, covered by the silicone Y-stent. After multidisciplinary discussion, the decision was made to attempt to close the BPF, which if successful, would permit surgical closure of the thoracotomy window. Thus, an Amplatzer device was placed in the left mainstem bronchus proximal to the BPF and secured in place with fibrin glue delivered through a modified CRE balloon catheter. The silicone Y-stent was subsequently removed, and the patient is currently awaiting surgical closure of the Eloesser flap.
Different stent designs to support BPF epithelialization have been proven useful, but these may not always be readily available. For BPF cases which demand immediate sealing, the use of customizable silicone stents and Amplatzer devices are valuable alternative treatments. The Amplatzer device can be cemented in place by injecting fibrin glue or Onyx-34 liquid embolic system based on previous reports. These highly technical procedures necessitate multidisciplinary teamwork for success.
Full conference title:
- ATS 2018