Customized airway stenting for bronchopleural fistula after pulmonary resection by interventional technique: single-center study of 148 consecutive patients

A pilot study of endobronchial repairment for bronchopleural fistulas

BACKGROUND

Bronchopleural fistulas (BPFs) are severe medical condition with high mortality. When the conventional surgical therapy failed, endobronchial intervention could function as the supplementary option. Several studies reported successful endobronchial managements of BPFs whereas the optimal strategies remain elusive.

METHODS

We retrospectively reviewed the medical records of patients with BPFs underwent endobronchial interventions with Vaseline gauze, shape-adjustable silicone plug, sutured silicone tube or covered metallic stent in our institution.

RESULTS

From 2018 to 2024, a total of 30 patients (11 females VS. 19 males; mean age 48.03 ± 20.33 years) with primary etiology of tumor (n = 19), empyema (n = 6), gastro-bronchial fistula (n = 1), lung infection with immune suppressed status (n = 1) and spontaneous pneumothorax (n = 3) were treated. Different occlusive materials were placed including covered metallic stent (n = 6), shape-adjustable silicone plug (n = 4), sutured silicone tube (n = 1) and Vaseline gauze(s) (n = 21). The dislocation of devices occurred in two patients with covered metallic stent occlusion. On the first day post procedure, 17 patients (56.7%) had complete resolution of the fistulas, compared with 13 patients (43.3%) had incomplete resolution. At the end of the first week post procedure, 19 patients (63.3%) showed complete resolution and 10 patients (33.3%) with partial resolution, whereas one patient (3.3%) failed to have effective closure of the fistula. The representative computer tomography images showed the closure of fistulas and ameliorated hydropneumothorax.

CONCLUSION

Four endobronchial interventional maneuvers, the Vaseline gauze, shape-adjustable silicone plug, sutured silicone tube and covered metallic stent, showed both safe and effective managements for patients with BPFs.

Bronchoscopic Closure of Bronchopleural Fistula with Occluder

Bronchopleural Fistula (BPF) represents one of the gravest complications post-lobectomy. Present treatment strategies encompass a wide array of surgical techniques complemented by essential adjunct therapies. Despite numerous treatment modalities, mortality rates associated with BPF remain disconcertingly high. Advances in bronchoscopic technology have led to the widespread adoption of bronchoscopic interventions, celebrated for their safety, minimal invasiveness, and efficacy. The cornerstone of BPF management involves the use of sealants, metal-covered stents, and occlusion devices, with the success of these occlusions critically dependent on the fistula's dimensions. Particularly for expansive BPFs deemed inappropriate for surgical intervention, metal-covered stents and occlusion devices are frequently favored. This review critically assesses the therapeutic efficacy and clinical utility of metal-covered stents and occlusion devices through a comprehensive analysis of the extant literature. Additionally, it outlines risk stratification and management strategies for BPF, with the intent to furnish novel insights and methodologies for the clinical diagnosis and treatment of this complex condition.

Unplanned reoperation after pulmonary surgery: Rate, risk factors and early outcomes at a single center

Background

Unplanned reoperation is a potential risk factor for worse prognoses and reflects the quality of surgical treatment. This study compared the short-term outcomes between patients with and without reoperation and identified clinical factors predicting reoperation within 90 days following pulmonary surgery.

Methods

Consecutive patients undergoing pulmonary resection from January 2012 to August 2021 at our institution were retrospectively reviewed. Clinical and operation-related data were collected and analyzed. Kaplan‒Meier, Cox hazard proportional regression, and propensity score matching were adopted for prognostic evaluation.

Results

A total of 90263 patients were included: 247 (0.27%) patients required reoperation within 90 days. Patients undergoing unplanned reoperation had higher mortality and more postoperative complications than the nonreoperation group. Reoperation within 24 h was associated with reduced odds of mortality relative to reoperation beyond 24 h. Independent risk factors for unplanned reoperation were male sex, benign lung disease, specific surgical locations, lobectomy, and pneumonectomy. A history of smoking, pulmonary tuberculosis, intraoperative pleural adhesion, and postoperative complications were also identified as predisposing factors. The most common complication was hemorrhage in 75.7% (187 of 247).

Conclusion

Our study found that unplanned reoperation was a rare but serious event that increased the risk of postoperative complications and mortality. We identified several risk factors that could be used to stratify patients according to their reoperation risk and suggest that high-risk patients should receive more intensive monitoring and preventive measures. Moreover, our study indicated that reoperating within 24 h could improve the outcomes for patients who needed reoperation.

Covered SEMS failed to cure airway fistula closed by an amplatzer device

BACKGROUND

Airway fistula is a rare but threatening complication associated with high rates of morbidity and mortality. We report the experience of Amplatzer device application in airway fistulae that failed to be cured with a covered self-expandable metallic stent (SEMS).

MATERIALS AND METHODS

Patients who failed occlusion with a covered self-expandable metallic stent and received Amplatzer device placement from Jan 2015 to Jan 2020 were retrospectively enrolled. A total of 14 patients aged 42 to 66 years (55.14 ± 7.87) were enrolled in this study. The primary diseases, types of fistula, types of stents, duration, size of fistula, and follow-up were recorded.

RESULTS

All 14 patients with airway fistula failed to be occluded with a covered metallic stent and received Amplatzer device placement. Among the 14 patients, 6 had BPF, 3 had TEF and 5 had GBF. The average stent time was 141.93 ± 65.83 days. The sizes of the fistulae ranged from 3 to 6 mm. After Amplatzer device placement, the KPS score improved from 62.14 ± 4.26 to 75.71 ± 5.13 (P < 0.05). No procedure-related complications occurred. During the 1-month, 3-month and 6-month follow-ups, all the Amplatzer devices were partially surrounded with granulation. Only 1 patient with BPF failed with Amplatzer device occlusion due to the recurrence of lung cancer.

CONCLUSION

In conclusion, the application of the Amplatzer device is a safe and effective option in the treatment of airway fistula that failed to be occluded with SEMSs.

An update on bronchopleural fistulae following cancer-related surgery

PURPOSE OF REVIEW

Bronchopleural fistulae (BPF) are rare complications in cancer-related surgery but impart significant morbidity and mortality. BPF may be difficult to identify, with a broad differential diagnosis at presentation, so it is critical to be aware of newer diagnostic and therapeutic approaches for this disease entity.

RECENT FINDINGS

Multiple novel diagnostic and therapeutic interventions are featured in this review. Reports of newer bronchoscopic techniques to localize BPF, as well as approaches for bronchoscopic management, like stent deployment, endobronchial valve placement, or alternative interventions when indicated are discussed, paying particular attention to factors that influence procedure selection.

SUMMARY

Management of BPF remains highly variable, but several novel approaches have shown improved identification and outcomes. Although a multidisciplinary approach is imperative, an understanding of these newer techniques is important to provide optimal care for patients.

A 3D-engineered silicone stent to treat a refractory bronchopleural fistula

A novel 3D-engineered silicone stent was successfully used to treat a refractory bronchopleural fistula of the right lower lobe in a patient with an open-window thoracostomy who complained of severe dysphonia and recurrent infections https://bit.ly/3GrKs2p.

Preliminary experience of autologous free myocutaneous flap combined with free dermal graft in the treatment of refractory empyema with bronchopleural fistula

Objectives

To explore the effects of autologous free dermal graft combined with free myocutaneous flap on bronchopleural fistula (BPF) with empyema, we summarized and analyzed two cases.

Methods

Two patients with refractory empyema and BPF were treated with autologous free dermal graft combined with free myocutaneous flap. The treatment included debridement of empyema, rib resection drainage, repair of bronchopleural fistula, and free vastus lateralis myocutaneous flap transplantation to eliminate the empyema. After the free dermal graft was harvested from the healthy skin around the incision, it was inserted into the fistula and sutured with the surrounding pleural tissue. The keys to the operation lies in the anastomosis of the lateral circumflex femoral artery (LCFA), vein and nerve that supply the vastus lateralis muscle flap to the thoracodorsal vessels and nerves. After surgery, the empyema, air leakage, and the survival of the myocutaneous flap were observed.

Results

There was no disease recurrence after follow-up for seven and six months, respectively. Re-examination of the chest computed tomography (CT) or magnetic resonance imaging (MRI) indicated that the abscess cavity had disappeared. No necrosis of the myocutaneous flap was observed after surgery.

Conclusion

The application of autologous free dermal graft combined with free vastus lateralis myocutaneous flap transplantation is effective in the treatment of patients with bronchopleural fistula with refractory chronic empyema, and the clinical effect is satisfactory.

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Surgical treatment of refractory empyema.

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Autologous free dermal graft combined with free myocutaneous flap in the treatment of refractory bronchopleural fistula with empyema.

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Application of free myocutaneous flap in patients with empyema.

Treatment of peripheral bronchopleural fistula with interventional negative pressure drainage

OBJECTIVES

Bronchopleural fistula is a serious complication of pneumonectomy and lobectomy and results in a reduction in the quality of life of patients. This study aimed to evaluate the efficacy and safety of percutaneous drainage tube placement with continuous negative pressure drainage for the treatment of peripheral bronchopleural fistula.

METHODS

Data of 16 patients with peripheral bronchopleural fistula were retrospectively analyzed. A percutaneous thoracic drainage tube was placed under fluoroscopy and connected with a negative pressure suction device. The drainage tube was removed when the residual cavity disappeared on computed tomography.

RESULTS

All 16 patients underwent lobectomy, including 11 patients with lung cancer (68.8%), 4 patients with pulmonary infection (25.0%), and 1 patient with hemoptysis (6.3%). All patients underwent successful drainage tube placement on the first attempt with a technical success rate of 100%. No serious complications occurred during or after the procedure. The drainage tubes were adjusted 3.25 ± 2.24 times (range: 1-8 times). A total of 30 drainage tubes were used (average per patient, 1.88 ± 1.36 tubes). The cure time of 16 patients was 114.94 ± 101.08 days (range, 30-354 days). The median drainage tube indwelling duration was 87 days, and the 75th percentile was 117 days.

CONCLUSION

Interventional percutaneous thoracic drainage tube placement with continuous negative pressure drainage is an effective, safe, and feasible method for the treatment of peripheral bronchopleural fistula.

Endobronchial closure of the bronchopleural fistula with the ventricular septal defect occluder: a case series

Objectives

The ventricular septal defect (VSD) occluder has been reported to be a novel method for the closure of bronchopleural fistula (BPF). Our study was to confirm the use of VSD occluder in treating BPF after pneumonectomy or lobectomy.

Methods

We performed a single-center, retrospective study of 10 consecutive patients (8 men and 2 women aged 29–70 years) with postoperative BPF receiving the VSD occluder treatment. We used the HeartR™ Membranous VSD occluder (Lifetech Scientific Co., Shenzhen, China) for the closure of BPF through flexible bronchoscopy under general anesthesia. Demographic characteristics, BPF characteristics, and clinical outcomes were collected from patients’ files using the standardized data abstraction forms.

Results

The underlying diseases were lung cancer in 6 patients, pulmonary tuberculosis in 3, and bronchiectasis in 1. Right-sided BPFs occurred in 6 patients, and left-sided BPFs occurred in 4. Five patients were underweight with a body mass index < 18.5 kg/m². The VSD was placed in all 10 patients with a 100% technical success rate and a 70% complete closure rate during follow-up with no complications, on a median follow-up period of 115 days (range 46–975 days). In 1 patient, the VSD occluder was reinstalled with complete closure; in 1 and 2 patients with underweight and chronic empyema, the VSD occluders partially and completely failed with good physical tolerance, respectively.

Conclusions

Our study demonstrated the bronchoscopic closure of BPF after lung resection using the VSD occluder is an off-label but safe and effective method. We prefer to stabilize the BPF by eradicating the underlying diseases and providing nutritional support to those receiving VSD occluder closure treatment.

A Large Central Bronchopleural Fistula Closed by Bronchoscopic Administration of Recombinant Bovine Basic Fibroblast Growth Factor: A Case Report

A large central bronchopleural fistula (BPF) surrounded by mediastinal tissue was successfully closed by local administration of recombinant bovine basic fibroblast growth factor (rbFGF) using the bronchoscope. No complications were observed during and after this bronchoscopic treatment. This is the first report of the bronchoscopic treatment of a large central BPF by the local spray of rbFGF. The bronchoscopic treatment with rbFGF is a potentially cost-effective method for central BPF surrounded by mediastinal tissue.

The Amplatzer device and pedicle muscle flap transposition for the treatment of bronchopleural fistula with chronic empyema after lobectomy: two case reports

Background

Bronchopleural fistula (BPF) refers to an abnormal channel between the pleural space and the bronchial tree. It is a potentially fatal postoperative complication after pulmonary resection and a complex challenge for thoracic surgeons because many patients with BPF ultimately develop refractory empyema, which is difficult to manage and has a major impact on quality of life and survival. Therefore, an operative intervention combined with conservative and endoscopic therapies may be required to control infection completely, to occlude BPF, and to obliterate the empyema cavity during treatment periods.

Case presentation

Two patients who suffered from BPF complicated with chronic empyema after lobectomy were treated in other hospitals for a long time and did not recover. In our department, we performed staged surgery and creatively combined an Amplatzer Septal Occluder (ASO) device (AGA Medical Corp, Golden Valley, MN, USA) with pedicled muscle flap transposition. First, open-window thoracostomy (OWT), or effective drainage, was performed according to the degree of contamination in the empyema cavity after the local infection was controlled. Second, Amplatzer device implantation and pedicled muscle flap transposition was performed at the same time, which achieved the purpose of obliterating the infection, closing the fistula, and tamponading the residual cavity. The patients recovered without complications and were discharged with short hospitalization stays.

Conclusions

We believe that the union of the Amplatzer device and pedicle muscle flap transposition seems to be a safe and effective treatment for BPF with chronic empyema and can shorten the length of the related hospital stay.

Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience

OBJECTIVES

Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina.

METHODS

All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice.

RESULTS

A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days.

CONCLUSIONS

Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Bronchopleural Fistula after Surgery: Therapeutic Efficacy of Bronchial Occluders

목적

수술 후 발생하는 기관지늑막루에 대한 bronchial occluder device (이하 BOD)의 유용성 및 효과성을 평가하고자 한다.

대상과 방법

2009년도부터 2019년까지 폐암 및 폐결핵으로 수술 후 발생한 7명의 기관지늑막루 환자들 중에 BOD 치료를 실시한 6명의 환자를 대상으로 하였다. 폐암 환자가 5명, 폐결핵 환자는 1명이었다. 남자가 5명, 여자가 1명이었으며 59세에서 74세(평균: 69세)이었다. 진단은 전산화단층기관지 촬영과 기관지내시경으로 실시하였다. 시술은 진단 후 1주에서 2주 사이에 실시하였다. 치료에 사용된 BOD의 기술적 성공 및 임상적 성공을 평가하였다. 시술 후 임상적 치료 효과와 생존 기간 및 부가적인 치료에 대하여 알아보았다.

결과

총 6명 환자 모두에서 시술을 성공적으로 실시하였다. 임상성공 5명에서 있었고, 1명에서는 임상부분성공이 있었다. 임상실패한 경우는 없었다. 기구의 이동이나 천공의 합병증은 없었다. 2명은 전산화단층기관지 촬영으로, 4명은 기관지내시경으로 기관지늑막루를 진단하였다. 수술은 폐엽절제술(lobectomy) 2명, 폐이엽절제술(bilobectomy) 2명, 그리고 전폐절제술(pneumonectomy) 2명이었다. 수술 후 진단까지 걸린 시간은 1개월에서 34개월(평균: 10개월)이었다. 4명(59~103일: 평균 80.5일)은 사망하였고 2명(313일, 3331일)은 생존하였다. 사망 원인이 2명은 기저질환의 악화, 1명은 폐부종 및 흉수, 1명은 폐렴이었다. 한 명에서 부가적인 카테타 배액술, 2명에서 흉관 삽입을 유지하였다.

결론

폐절제 수술 후 발생할 수 있는 기관지늑막루 치료에 있어서 BOD는 유용하고 효과적인 치료 방법이다.

Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer: Two case report

RATIONALE

Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases.

PATIENT CONCERNS

Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier.

DIAGNOSIS

Both patients were diagnosed with BPF with empyema.

INTERVENTIONS

After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity.

OUTCOMES

The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up.

LESSONS

It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula

Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.

Airway stenting: Technological advancements and its role in interventional pulmonology

AS offers rapid and sustained relief of symptoms in most patients treated for malignant or benign CAO and can also be curative in itself in cases of benign tracheobronchial stenosis. In the past 30 years, this field has seen significant progress, from the misuse of vascular non-covered metallic stents to the development of silicone airway stents with an increasingly large panel of shapes and of hybrid, partially or fully covered, SEMS customized to the airways. This study aims to offer an overview on: (i) the respective advantages and drawbacks of these two main categories of devices; (ii) the main indications for AS and the rationale behind the choice of stent in each situation; and (iii) the main promises borne from the progress made in the field in the past few years, including the development of drug-eluting, biodegradable or patient-specific customized AS.

Bronchoscopic device closure of postoperative bronchopleural fistulae: Novel devices and innovative techniques

Background

Bronchoscopic device closure plays a significant role in the nonsurgical management of bronchopleural fistulae (BPF). Herein, we describe our 10-year experience in the management of postoperative BPF using various device closure modalities. This is the largest series of bronchoscopic device closure of BPF being reported from India.

Materials and Methods

This was a retrospective analysis of data of patients who underwent bronchoscopic device closure with various techniques for the management of postoperative BPF. In total, 11 patients (six males and five females) with a mean age (±standard deviation) of 42.72 ± 14.40 years with BPFs were treated with various bronchoscopic interventions for BPF closure. We used various devices such as endobronchial coils, occluder devices, and covered tracheobronchial self-expandable stents for BPF closure depending on the size of air leaks. We describe the various devices used, technique, and outcome of bronchoscopic management of BPF.

Results

All our patients had developed BPFs postoperatively. Pulmonary tuberculosis was the most common etiology seen in nine of our patients. All the devices were placed using a fiberoptic bronchoscope, and all patients were followed up for a minimum duration of 6 months. We successfully localized and closed BPFs in nine (81.81%) of our patients.

Conclusions

Bronchoscopic device closure can be a successful strategy to manage postoperative BPF with minimal complications.

[Interventional treatment of tracheopleural and bronchopleural fistulas]

BACKGROUND

Interventional bronchoscopy is an indispensable option to manage bronchopleural and tracheopleural fistulas in patients in a poor general condition and at high risk for developing postoperative complications.

METHODS

This article is based on a search in the PubMed database for relevant publications and own experiences as surgeons and pneumologists.

RESULTS

Various interventional techniques can be used for the treatment of bronchopleural and tracheopleural fistulas. Currently, the insertion of stents or endobronchial valves is the most frequently used treatment. Ideally, the attending anesthesiologist will have experience with high frequency jet ventilation and the attending surgeon will have experience with rigid bronchoscopy, flexible bronchoscopy, and interventional bronchoscopy.

DISCUSSION

Due to a lack of standardized treatment recommendations, individual treatment plans must be decided according to the location of the bronchopleural or tracheopleural fistula and taking existing comorbidities into account.