Endoscopic Gluing of Bronchoplewd Fistula M. Torre, G. Chiesa, M. Ravini, M. Vercelloni, and P.A. Belloni ABSTRACT Three patients with postpneumonectomy bronchopleural fistula were treated with endoscopic gluing of the fistula. The technique and the results of this method are described. Postpneumonectomy bronchopleural fistula is a serious complication with high morbidity and mortality [l-61. Surgical treatment of the fistula is usually impossible because of the association with empyema [3].Therefore, many other methods of treatment have been suggested [5-71. In the present article, we report 3 patients treated through endoscopic gluing of the fistula with a new kind of acrylate glue (Histoacryl, L. Blau, Braun, West Germany).
Patients and Methods The following procedure was used in 3 patients. Each patient was premedicated with morphine, 1 mg, and atropine, 0.50 mg I.M.,30 minutes before treatment. Each then received local anesthesia with 4% lidocaine (Xylocaine). Each patient then assumed a sitting position, and a fiberopticbronchoscope (Olympus, model BF 1T10)was introduced through the nose. The fistula then was located, and its diameter was measured. The bronchial stump was cleaned, and the mucus was removed mechanically. Next, the glue was injected slowly through a thin plastic catheter (model ACMI 8807) advanced through the operative channel of the fiberscope. The glue then was "modeled" inside and outside the fistula, and the fiberscope was removed. Patient I A left pneumonectomy for diffuse bronchiectasis of the whole left lung was performed in a 58-year-old man. His postoperative course was uneventful, and the patient was discharged 10 days after operation. Twelve days later, the patient was rehospitalized because of acute dyspnea with cyanosis and fetid catarrh. An intercostal drain was inserted, and the empyema was confirmed. Bronchoscopy showed a bronchopleural fistula (2 mm in diameter) in the middle portion of the bronchial stump (Figure). Endoscopic gluing was performed with slow injection of 1 ml of Histoacryl around and on the fistula. Four days later, a further endoscopic gluing was necessary because of incomplete fistula closure. This
From the Thoracic Surgery Department, A. De Gasperis Ospedale Niguarda, CA Granda, Milano, Italy. Accepted for publication May 9, 1986. Address reprint requests to Dr.Torre, Via Teodosio, 55, 20131 Milano, Italy.
295 Ann Thorac Surg 43:295-297, Mar 1987
subsequent treatment was completely successful (see Figure). The patient was discharged 7 days later in good condition, and the pleural drain was removed 30 days later, after complete sterilization of the pleural cavity. Followup at 11months has shown no recurrence of the fistula.
Patient 2 A 50-year-old man was admitted to our hospital because of acute dyspnea, fever, and purulent expectoration. Three months previously, the patient had undergone a right pneumonectomy in another hospital for chronic inflammatory disease. On admission in our department, an intercostal drain was positioned and the empyema was confirmed. Fiberoptic bronchoscopy was performed the following day, and a small fistula (1-2 mm in diameter) was detected in the lateral portion of the bronchial stump. In the same session, 0.5 ml of glue was injected and the air leak through the drain decreased a few minutes later. The day after treatment the patient's condition improved, and a further bronchoscopy confirmed the closure of the fistula by a white plug of glue. The pleural drain was removed 42 days after operation. Follow-up at 7 months showed no recurrence of the fistula. Patient 3 A left pneumonectomy for gathered squamous cell carcinoma involving the left pulmonary artery with mediastinal node mestastases was performed in a 56-year-old man. The postoperative course was complicated by respiratory insufficiency and subcutaneous empyema on the second postoperative day. Four days later, the patient exhibited purulent expectoration with cyanosis and marked dyspnea. Fever and increased white blood cell count were present. Examination of the intercostal drainage confirmed empyema. The patient's condition did not improve, and 24 hours later, bronchoscopy revealed a large bronchopleural fistula (4.5 mm in diameter) in the lateral portion of the bronchial stump. Gluing with 1.5 ml of Histoacryl was performed inside and outside the fistulg. A few minutes after the gluing procedure, the patient began to cough and exhibit acute respiratory failure. Emergency bronchoscopy was performed, and an irregular plug of glue was detected in the right basal bronchus. The plug of glue was removed with the biopsy forceps, and the patient's condition improved immediately. Another endoscopic glue injection was performed 3 days later and achieved a complete closure of the fistula. The patient's clinical condition remained severe because of sepsis, and he died suddenly 7 days later. Necropsy confirmed the
296 The Annals of Thoracic Surgery Vol 43 No 3 March 1987
(Patient 1 ) (A) Bronchopleural fistula. ( B ) Result 12 days after gluing.
clinical suspicion of pulmonary embolism, and the macroscopic examination of the bronchial stump showed complete closure of the fistula by the plug of white glue. The histological examination showed local reactive proliferation of the mucosa.
Discussion Between January, 1984, and December, 1985, a total of 410 patients underwent lung resection in our department. The bronchial stump was always closed with an interrupted suture using nonreabsorbable materials (Tevdek 3-0). Bronchopleural fistula developed in 6 patients, and 50% died (3 patients). Treatment of a fistula on the bronchial stump remains a problem. The various surgical treatments suggested in the literature often turn out to be unsatisfactory because of the precocious development of thoracic empyema, which hinders any surgical intervention. The endoscopic use of silver nitrate has been suggested. However, the likelihood of success with this treatment depends on the size of the fistula, which must be particularly small [5].
More recently, some authors have proposed the use of different types of glue, principally made up of fibrin sealant (Tissucol) or isobutyl cyanoacrylate [6, 8-11]. The latter material polymerizes extremely quickly (within 10 seconds) and must be injected at a high pressure, which limits its ability to be modeled on the bronchial stump. The new material used in our department is made up of a cyanoacrylate-based monomer with the addition of inhibition stabilizer factor P.210, which delays polymerization to about 30 seconds. This property allows the product to be propelled through the operative channel of the fiberscope with greater safety, thus improving the possibility of modeling the material on the bronchial stump. Closure of the fistula initially depends on the mechanical action exerted by the plug. Subsequently, the stimulating and regenerative effect on the bronchial mucosa becomes apparent because of the reaction of the glue as an external agent on the mucosa itself. In fact, the histological analysis performed on the third patient, who died after pulmonary embolism, confirmed the proliferation of the mucosa as well as the closure of the fistula by a homogeneous plug of white glue. Our observations comply with those reported by other authors [6]. Based on our experience, we recommend the use of this technique in the treatment of postopera-
Endoscopic Closure of Postpneumonectomy Bronchopleural Fistula with Glue Study
Type of Glue
Roksvaag et a1 (1983) [6] Guerin et a1 (1984) [lo] Jessen and Sharma (1985) [ l l ] Present study (1986)
Histoacryl N Histoacryl N Tissucol Histoacryl L
+ Tissucol
No. of Patients
Maximum Follow-up (mo)
2 1 1 3
8 Not reported 7 11
297 Torre, Chiesa, Ravini, et al: Endoscopic Gluing of Bronchopleural Fistula
tive fistula for the following reasons: (1) low cost; (2) ease of treatment; (3) possible complete resolution of a high risk complication; (4)extremely good results; (5) possible application for larger fistulas through repeated treatment. The only contraindication to this method is a recurrence of cancer on the bronchial stump. The Table reviews the experiences with this technique in the world literature. The technique as well as the material applied must be further studied and improved to reduce the incidence of complications, such as those seen in Patient 3. Prolonged follow-up tests and analyses also will be of great importance to verify the efficiency of this method.
References 1. Bjork VD: Suture material and technique for bronchial closure and bronchial anastomosis. ] Thorac Surg 32:22, 1957 2. Malave G, Foster ED, Wilson ]A: Bronchopleural fistula: present day study of an old problem. Ann Thorac Surg 11:1, 1971
3. Williams NJ, Lewis C T Bronchopleural fistula: a review of eighty-six cases. Br ] Surg 63:520, 1976 4. Lams P: Radiographic signs in postpneumonectomy bronchopleural fistula. J Can Assoc Radio1 31:178, 1980 5. Madsen KH, Schulse S, Pedersen VM, Halkier E: Management of bronchopleural fistula following pneumonectomy. Scand J Thorac Cardiovasc Surg 18:263, 1984 6. Roksvaag H, Skallebert CT, Nordberg C, et al: Endoscopic closure of bronchial fistula. Thorax 38:696, 1983 7. Forrester Wood CP: Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. J Thorac Cardiovasc Surg 80:406, 1980 8. Hartmann W, Raush V: New therapeutic application of the fiberoptic bronchoscope. Chest 7237, 1977 9. Altapantakoff A, Dakoff J, Kosturkova M: Traitment endobronchique des fistulas bronchiques postoperatoires. Bronchopneumologie 2775, 1977 10. Guerin JC, Garin 8, Berger C: Obstruction d’une fistule broncho-pleurale apres pneumonectomie par une colle biologique. Rev Pneumol Clin 40337, 1984 11. Jessen C, Sharma P: Use of fibrin glue in thoracic surgery. Ann Thorac Surg 39:521, 1985