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Endoscopic closure of bronchopleural fistulas using a tissue adhesive
HOW I DO IT
Endoscopic Closure of Bronchopleural Fistulas Using a Tissue Adhesive John W. Menard, MD, Abbeville, Louisiana,Curtis A. Prejean, MD, and William Y. Tucker, MD, Shreveport, Louisiana
Bronchopleural fistulas, although declining in incidence in recent years, continue to represent serious complications of pulmonary disease and pulmonary operation. Surgical intervention will achieve closure of the fistula in 60 to 80 percent of these patients, with an overall associated mortality rate of 20 percent [1-3]. As late as 1971, the average time from onset to fistula closure was reported to be 40 months [2]. Because of these dismal results, a study was undertaken to evaluate the possibility of closure of established fistulas by endoscopic application of a tissue adhesive.
Technique Six mongrel dogs weighing between 15 and 25 kg underwent a left thoracotomy and pneumonectomy. Approximately 1 month later, they all underwent a repeat thoracotomy with formation of a bronchopleural fistula in the area of the bronchial stump. Immediately after this, the fistula was closed by endoscopic application of bucrylate (isobutyl-2-cyanoacylate) tissue adhesive, either through the chest (two dogs) or endoscopically (four dogs) (bucrylate supplied by Ethicon Laboratories, Somerville, NJ).Endoscopic application was performed by first visualizing the fistula with the flexible bronchoscope. After this was achieved, a 5 F. Teflon| catheter was introduced through the suction port of the scope and positioned near the fistula. The adhesive was then administered through the catheter. After application, the scope and catheter were removed simultaneously. Results One dog died immediately after operation secondary to anesthetic complications. All five remaining dogs did well without any complications from the procedure. Their fistulas remained closed until sacFrom the Department of Surgery, Louisiana State University Medical Center, Shreveport, Louisiana. This study was made while the senior author (JWM) was a general surgery resident at Louisiana State University Medical Center, Shreveport, Louisiana. Requests for reprints should be addressed to John W. Menard, MD, PO Box 1196, Abbeville, Louisiana 705t 1.
Volume 155, March 1988
rifice at 4, 10, 12, and 14 months when the trachea was removed. The bronchial stumps were all noted to be well healed without evidence of recurrent fistula formation (Figure 1). In all cases, the adhesive was noted to be completely encompassed by a proliferation of scar tissue.
Comments Tissue adhesives have been an elusive dream for many years. In 1951, the Eastman Kodak Company discovered the adhesive ability of the cyanoacylates [4]. In the late 1950s and early 1960s, methylcyanoacylate was investigated by several groups. It was found to be unsuitable for use in living organisms because of its innate toxicity for living cells. It was later found that as the number of carbon atoms in the side chain of the molecule were increased, the histotoxicity rapidly decreased. Subsequently, the isobutyl and n-butyl homologs were developed and successfully used in extensive clinical trials. Isobutyl-2-cyanoacylate was manufactured as bucrylate. Unlike conventional glues or adhesives, bucrylate acts without the necessity for heat, evaporation of a solvent, or addition of a catalyst. When properly spread over dry living tissue, the monomer very quickly polymerizes exothermically to a continuous waterproof film. The reaction is catalyzed by the small amounts of water or weak bases present on tissue. A small amount of heat is released for about 3 minutes but does seem to have any clinical significance. Currently, the main uses of this product have included hemostasis, when bleeding does not respond to ordinary measures; sealing of corneal perforations; and intravascular embolization for occlusion of vascular malformations. It was thought that bucrylate would work well in the tracheobronchial tree, although studies regarding its ability to close bronchopleural fistulas had not been carried out. The decrease in incidence of bronchopleural fistulas over the past several years has generally been attributed to a combination of better antimicrobials
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Menard et al
Figure 1. The anterior (A) and posterior (B) views of a carina in which a fistula In the left malnstem bronchus had been closed with bucrylate 4 months previously, As can be seen, the glue is completely encompassed by fibrous tissue.
and improved surgical technique. Nevertheless, these fistulas still pose a serious problem. Early chest drainage followed by thoracoplasty and myoplasty have been standard therapy for many years; however, these techniques often require the patient to undergo multiple operations over an extended period of time. It was these poor results along with the success of tissue adhesives reported in the neurosurgical literature that prompted us to investigate endoscopic closure using bucrylate. In the present study, it was shown that bucrylate can form a strong bond between living tissues which can be expected to last at least: until scar incorporation of the adhesive occurs. Bucrylate was successful in achieving closure of all five fistulas in which it was used. These fistulas were all surgically created and measured 0.5 to 1 cm in diameter. The endoscopic application of bucrylate to achieve closure of a bronchopleural fistula may prove to be a primary form of therapy for this complex problem, being second only to the establishment of proper chest drainage.
416
Summary
Bucrylate tissue adhesive has been found to be effective in achieving closure of surgically created bronchopleural fistulas in dogs. Success was obtained with both endoscopic and direct application. Clinical application of this method in one patient was successful [unpublished observations]. We believe that the speed, low risk, and cost-effectiveness of this approach justifies its further use in these difficult situations. References 1. Malave G, Foster ED, Wilson JA, Munro DD. Bronchopleural fistula. Present-clay study of an old problem. Ann Thorac Surg 1971; 11: 1-10. 2. Barker WL, Faber LP, Ostermiller WE Jr, Langston HTI Management of persistent bronchopleural fistulae. J Thorac Cardiovasc Surg 1971; 62: 393-401. 3. Hankins J, Miller JE, Attar S, Satterfield JR, McLaughiin JS. Bronchopleural fistula, thirteen-year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76: 755-60. 4. Matsumoto T. Tissue adhesives in surgery. New Hyde Park, NY: Medical Examination Publishing, 1972.
The American Journal of Surgery
Endoscopic Closure of Bronchopleural Fistulas Using a Tissue Adhesive John W. Menard, MD, Abbeville, Louisiana,Curtis A. Prejean, MD, and William Y. Tucker, MD, Shreveport, Louisiana
Bronchopleural fistulas, although declining in incidence in recent years, continue to represent serious complications of pulmonary disease and pulmonary operation. Surgical intervention will achieve closure of the fistula in 60 to 80 percent of these patients, with an overall associated mortality rate of 20 percent [1-3]. As late as 1971, the average time from onset to fistula closure was reported to be 40 months [2]. Because of these dismal results, a study was undertaken to evaluate the possibility of closure of established fistulas by endoscopic application of a tissue adhesive.
Technique Six mongrel dogs weighing between 15 and 25 kg underwent a left thoracotomy and pneumonectomy. Approximately 1 month later, they all underwent a repeat thoracotomy with formation of a bronchopleural fistula in the area of the bronchial stump. Immediately after this, the fistula was closed by endoscopic application of bucrylate (isobutyl-2-cyanoacylate) tissue adhesive, either through the chest (two dogs) or endoscopically (four dogs) (bucrylate supplied by Ethicon Laboratories, Somerville, NJ).Endoscopic application was performed by first visualizing the fistula with the flexible bronchoscope. After this was achieved, a 5 F. Teflon| catheter was introduced through the suction port of the scope and positioned near the fistula. The adhesive was then administered through the catheter. After application, the scope and catheter were removed simultaneously. Results One dog died immediately after operation secondary to anesthetic complications. All five remaining dogs did well without any complications from the procedure. Their fistulas remained closed until sacFrom the Department of Surgery, Louisiana State University Medical Center, Shreveport, Louisiana. This study was made while the senior author (JWM) was a general surgery resident at Louisiana State University Medical Center, Shreveport, Louisiana. Requests for reprints should be addressed to John W. Menard, MD, PO Box 1196, Abbeville, Louisiana 705t 1.
Volume 155, March 1988
rifice at 4, 10, 12, and 14 months when the trachea was removed. The bronchial stumps were all noted to be well healed without evidence of recurrent fistula formation (Figure 1). In all cases, the adhesive was noted to be completely encompassed by a proliferation of scar tissue.
Comments Tissue adhesives have been an elusive dream for many years. In 1951, the Eastman Kodak Company discovered the adhesive ability of the cyanoacylates [4]. In the late 1950s and early 1960s, methylcyanoacylate was investigated by several groups. It was found to be unsuitable for use in living organisms because of its innate toxicity for living cells. It was later found that as the number of carbon atoms in the side chain of the molecule were increased, the histotoxicity rapidly decreased. Subsequently, the isobutyl and n-butyl homologs were developed and successfully used in extensive clinical trials. Isobutyl-2-cyanoacylate was manufactured as bucrylate. Unlike conventional glues or adhesives, bucrylate acts without the necessity for heat, evaporation of a solvent, or addition of a catalyst. When properly spread over dry living tissue, the monomer very quickly polymerizes exothermically to a continuous waterproof film. The reaction is catalyzed by the small amounts of water or weak bases present on tissue. A small amount of heat is released for about 3 minutes but does seem to have any clinical significance. Currently, the main uses of this product have included hemostasis, when bleeding does not respond to ordinary measures; sealing of corneal perforations; and intravascular embolization for occlusion of vascular malformations. It was thought that bucrylate would work well in the tracheobronchial tree, although studies regarding its ability to close bronchopleural fistulas had not been carried out. The decrease in incidence of bronchopleural fistulas over the past several years has generally been attributed to a combination of better antimicrobials
415
Menard et al
Figure 1. The anterior (A) and posterior (B) views of a carina in which a fistula In the left malnstem bronchus had been closed with bucrylate 4 months previously, As can be seen, the glue is completely encompassed by fibrous tissue.
and improved surgical technique. Nevertheless, these fistulas still pose a serious problem. Early chest drainage followed by thoracoplasty and myoplasty have been standard therapy for many years; however, these techniques often require the patient to undergo multiple operations over an extended period of time. It was these poor results along with the success of tissue adhesives reported in the neurosurgical literature that prompted us to investigate endoscopic closure using bucrylate. In the present study, it was shown that bucrylate can form a strong bond between living tissues which can be expected to last at least: until scar incorporation of the adhesive occurs. Bucrylate was successful in achieving closure of all five fistulas in which it was used. These fistulas were all surgically created and measured 0.5 to 1 cm in diameter. The endoscopic application of bucrylate to achieve closure of a bronchopleural fistula may prove to be a primary form of therapy for this complex problem, being second only to the establishment of proper chest drainage.
416
Summary
Bucrylate tissue adhesive has been found to be effective in achieving closure of surgically created bronchopleural fistulas in dogs. Success was obtained with both endoscopic and direct application. Clinical application of this method in one patient was successful [unpublished observations]. We believe that the speed, low risk, and cost-effectiveness of this approach justifies its further use in these difficult situations. References 1. Malave G, Foster ED, Wilson JA, Munro DD. Bronchopleural fistula. Present-clay study of an old problem. Ann Thorac Surg 1971; 11: 1-10. 2. Barker WL, Faber LP, Ostermiller WE Jr, Langston HTI Management of persistent bronchopleural fistulae. J Thorac Cardiovasc Surg 1971; 62: 393-401. 3. Hankins J, Miller JE, Attar S, Satterfield JR, McLaughiin JS. Bronchopleural fistula, thirteen-year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76: 755-60. 4. Matsumoto T. Tissue adhesives in surgery. New Hyde Park, NY: Medical Examination Publishing, 1972.
The American Journal of Surgery