- Email: [email protected]
Use of a Removable Endobronchial Valve for the Treatment of Bronchopleural Fistula
CHEST Use of a Removable Endobronchial Valve for the Treatment of Bronchopleural Fistula* David Feller-Kopman, MD, FCCP; Rabih Bechara, MD; Robert Garland, RRT; Armin Ernst, MD, FCCP; and Simon Ashiku, MD, FCCP
We report the case of a patient with a prolonged bronchopleural fistula and empyema that were successfully treated by the placement of a removable, unidirectional endobronchial valve. This is the first report of the use of such a device for this indication. (CHEST 2006; 130:273–275) Key words: bronchopleural fistula; bronchoscopy; empyema; fistula; surgery; valve Abbreviation: BPF ⫽ bronchopleural fistula
of bronchopleural fistula (BPF) following T helungincidence resection in patients with lung cancer is approx-
imately 2 to 6%,1– 6 though it can be as high as 12%.7 BPF is associated with significant morbidity and mortality. Almost 90% of patients with BPF following resection for the treatment of lung cancer will require additional surgery,2 and BPF accounts for up to 33% of postoperative deaths in these patients.8 The typical therapy for BPF includes prolonged courses of antibiotics as well as providing adequate pleural drainage and obliteration of the pleural space. Surgical repair with muscle-flap closure or completion lobectomy/pneumonectomy may also be required. Endobronchial techniques such as the application of ethanol, fibrin, or acrylic glue, or the placement of *From the Divisions of Interventional Pulmonology (Drs. FellerKopman, Bechara, and Ernst, and Mr. Garland) and Thoracic Surgery (Dr. Ashiku), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Dr. Ernst serves as a principal investigator for the VENT (Endobronchial Valve for Emphysema Palliation Trial). Drs. Feller-Kopman, Bechara, and Ashiku, and Mr. Garland do not have any financial disclosures. Manuscript received September 14, 2005; revision accepted January 2, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: David Feller-Kopman, MD, FCCP, Director, Medical Procedure Service, Interventional Pulmonology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA 02215; e-mail: [email protected] DOI: 10.1378/chest.130.1.273 www.chestjournal.org
Selected Report
metal coils, decalcified spongy calf bone, or polidocanol have also been used with various degrees of success.9 –11 Additionally, Watanabe et al12 have also described the use of an endobronchial spigot to achieve the closure of a BPF, although placement in the segmental bronchi of the upper lobes may be technically difficult. These agents permanently scar the airways, and their effects are generally irreversible. We describe the novel use of a removable, one-way, endobronchial valve to facilitate BPF closure in a patient who had not responded to standard therapy.
Case Report Our patient was a 59-year-old woman with a history of severe bronchiectasis who underwent a left lower-lobe basilar segmentectomy in December 2003. She recovered from her surgery uneventfully; however, she presented 4 months postoperatively with left lower-lobe pneumonia, a BPF, and empyema. These conditions were initially managed with a latissimus dorsi muscle flap and the creation of an Eloesser flap. Unfortunately, this failed to close the BPF, and she had a persistent BPF and empyema. A culture of the patient’s pleural fluid grew Pseudomonas aeruginosa, and she was treated with IV antibiotics for 1 week prior to a repeat attempt of surgical closure of the BPF. In the operating room, under general anesthesia, bronchoscopy with both a rigid and flexible bronchoscope, and simultaneous thoracoscopy were performed. The left mainstem and upper lobe were normal. There was evidence of a lateral-basal segmentectomy in the left lower lobe. A large BPF was found in the posterior basilar segment of the left lower lobe (please see online video supplementation at www.chestnet.org). The patient had purulent secretions in the lower lobe that were therapeutically aspirated and sent for culture. She was repositioned in the right lateral-decubitus position, and the posterior-basal segmental bronchus was mobilized and closed with two layers of 4.0 vicryl suture. Fibrin glue (Tiseel; Baxter; Deerfield, IL) was then injected through the wall of the bronchus under endoscopic control to further seal the defect. A pedicled latissimus dorsi muscle flap was then used to cover the stump. Unfortunately, she continued to have an air leak 48 h after surgery. Emergent approval for the use of an investigational device was requested from our Committee on Clinical Investigations/Institutional Review Board, and, given the high risk of losing the benefits of her recent surgery, approval was granted. The patient was brought to the operating theater and, once general anesthesia was achieved, was incubated with the rigid bronchoscope. After therapeutic aspiration of the purulent secretions from the left lower lobe, the BPF was again identified. A guidewire was placed under direct vision, and a small-sized endobronchial valve (Emphasys Medical; Redwood City CA) was loaded, inserted, and deployed into the posterior-basilar segment with excellent fit and position (Fig 1). This resulted in the immediate cessation of the air leak. The patient tolerated the procedure, was extubated in the operating room, and was transferred to the recovery room. Her hospital course was remarkable for the development of acute renal failure resulting CHEST / 130 / 1 / JULY, 2006
273
Figure 1. Small endobronchial valve (courtesy of Emphasys Medical).
from tobramycin therapy and a brief period of rapid atrial fibrillation. Both of these conditions had resolved by the time of hospital discharge. The patient continued to do well, and 6 weeks after undergoing the valve placement she was taken to the operating room to undergo rigid bronchoscopy and removal of the valve. This occurred without difficulty or complication, and she continues to do well without any evidence of recurrence of her empyema or BPF.
Discussion BPF can be a devastating complication of pulmonary resection. The risk factors for the development of BPF include the presence of a long bronchial stump, carcinoma at the bronchial margin, disrupted blood supply, preexistent empyema, mechanical ventilation, and preoperative chemotherapy or radiation therapy.2,3,5,13 Additionally, current or former smoking, male gender, decreased serum albumin level (⬍ 3.5 mg/dL), and a large stump diameter may also increase the risk of BPF formation.1,7,14 The diagnosis of BPF is not always straightforward as patients can present soon after surgery or even several years later, although the majority of patients present within the first 3 months.7 In addition to signs and symptoms consistent with empyema or aspiration pneumonia, the presence of an increasing amount of air in the 274
pleural space after lung resection should prompt early investigation to rule out BPF formation. Early drainage of pleural infection, with the goals of preventing pleural sepsis and aspiration pneumonia remain essential to the initial management of these patients.7 There are currently no prospective trials studying the management of BPF, and therapies can include endoscopic as well as surgical attempts to close the fistula. Previously described endoscopic modalities attempt to permanently seal the airway. In addition to the methods described above, both metal and silicone stents have been used to cover the airway defect,15,16 but in this case the fistula could not be covered due to its distal location. Additionally, airway stents can cause granulation tissue, and metal stents can be extremely difficult, if not impossible, to remove.17 The Watanabe spigot has been successfully used in 12 patients with prolonged BPFs and empyema with excellent results and few complications.12 Our case is unique in that we used a removable endobronchial valve that is currently being investigated for its role in bronchoscopic lung-volume reduction. These valves were originally developed to be inserted similarly to a self-expanding metallic stent, with the aid of a guidewire, and this was the technique used in our patient. Recent improvements in valve delivery now allow for a “transscopic” approach, placing the valve directly through the working channel of the bronchoscope. As with bronchoscopic lung-volume reduction, a major benefit of using these valves for the treatment of patients with BPF lies in the fact that they are completely removable. A potential advantage of the one-way valve compared to the Watanabe spigot is that the valve allows for the clearance of distal mucus, and postobstructive infectious complications have been rarely seen.18 –20 Although the ideal treatment of BPF should be individualized, we stress the need for a multidisciplinary approach to these patients. Future studies will be required to assess the role of using removable, one-way, endobronchial valves in the management of these patients, and their relative efficacy and safety when compared to other occlusion techniques. Additionally, cost-benefit analyses should be performed comparing the Watanabe spigot with the valve (Emphasys).
References 1 Suzuki M, Otsuji M, Baba M, et al. Bronchopleural fistula after lung cancer surgery: multivariate analysis of risk factors. J Cardiovasc Surg (Torino) 2002; 43:263–267 2 Sirbu H, Busch T, Aleksic I, et al. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001; 7:330 –336 3 Asamura H, Naruke T, Tsuchiya R, et al. Bronchopleural fistulas associated with lung cancer operations: univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992; 104:1456 –1464 4 Kawahara K, Akamine S, Takahashi T, et al. Management of anastomotic complications after sleeve lobectomy for lung cancer. Ann Thorac Surg 1994; 57:1529 –1532 5 Sonobe M, Nakagawa M, Ichinose M, et al. Analysis of risk factors in bronchopleural fistula after pulmonary resection for Selected Report
6
7
8
9
10
11
12 13
primary lung cancer. Eur J Cardiothorac Surg 2000; 18:519 – 523 Kacprzak G, Marciniak M, Addae-Boateng E, et al. Causes and management of postpneumonectomy empyemas: our experience. Eur J Cardiothorac Surg 2004; 26:498 –502 Hollaus PH, Lax F, el Nashef BB, et al. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997; 63:1391–1396 Watanabe S, Asamura H, Suzuki K, et al. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac Surg 2004; 78:999 –1002 Takaoka K, Inoue S, Ohira S. Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol. Chest 2002; 122:374 –378 Watanabe S, Watanabe T, Urayama H. Endobronchial occlusion method of bronchopleural fistula with metallic coils and glue. Thorac Cardiovasc Surg 2003; 51:106 –108 Varoli F, Roviaro G, Grignani F, et al. Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998; 65:807– 809 Watanabe Y, Matsuo K, Tamaoki A, et al. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchol 2003; 10: 264 –267 Cerfolio RJ. The incidence, etiology, and prevention of
www.chestjournal.org
14 15 16 17 18
19
20
postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001; 13:3–7 Hollaus PH, Setinek U, Lax F, et al. Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter. Thorac Cardiovasc Surg 2003; 51:162–166 Madden BP, Sheth A, Ho TB, et al. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula. Ann Thorac Surg 2005; 79:2128 –2130 Tayama K, Eriguchi N, Futamata Y, et al. Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy. Ann Thorac Surg 2003; 75:290 –292 Ernst A, Feller-Kopman D, Becker HD, et al. Central airway obstruction. Am J Respir Crit Care Med 2004; 169:1278 – 1297 Venuta F, De Giacomo T, Rendina EA, et al. Bronchoscopic lung-volume reduction with one-way valves in patients with heterogenous emphysema. Ann Thorac Surg 2005; 79:411– 416 Hopkinson NS, Toma TP, Hansell DM, et al. Effect of bronchoscopic lung volume reduction on dynamic hyperinflation and exercise in emphysema. Am J Respir Crit Care Med 2005; 171:453– 460 Yim AP, Hwong TM, Lee TW, et al. Early results of endoscopic lung volume reduction for emphysema. J Thorac Cardiovasc Surg 2004; 127:1564 –1573
CHEST / 130 / 1 / JULY, 2006
275
We report the case of a patient with a prolonged bronchopleural fistula and empyema that were successfully treated by the placement of a removable, unidirectional endobronchial valve. This is the first report of the use of such a device for this indication. (CHEST 2006; 130:273–275) Key words: bronchopleural fistula; bronchoscopy; empyema; fistula; surgery; valve Abbreviation: BPF ⫽ bronchopleural fistula
of bronchopleural fistula (BPF) following T helungincidence resection in patients with lung cancer is approx-
imately 2 to 6%,1– 6 though it can be as high as 12%.7 BPF is associated with significant morbidity and mortality. Almost 90% of patients with BPF following resection for the treatment of lung cancer will require additional surgery,2 and BPF accounts for up to 33% of postoperative deaths in these patients.8 The typical therapy for BPF includes prolonged courses of antibiotics as well as providing adequate pleural drainage and obliteration of the pleural space. Surgical repair with muscle-flap closure or completion lobectomy/pneumonectomy may also be required. Endobronchial techniques such as the application of ethanol, fibrin, or acrylic glue, or the placement of *From the Divisions of Interventional Pulmonology (Drs. FellerKopman, Bechara, and Ernst, and Mr. Garland) and Thoracic Surgery (Dr. Ashiku), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Dr. Ernst serves as a principal investigator for the VENT (Endobronchial Valve for Emphysema Palliation Trial). Drs. Feller-Kopman, Bechara, and Ashiku, and Mr. Garland do not have any financial disclosures. Manuscript received September 14, 2005; revision accepted January 2, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: David Feller-Kopman, MD, FCCP, Director, Medical Procedure Service, Interventional Pulmonology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA 02215; e-mail: [email protected] DOI: 10.1378/chest.130.1.273 www.chestjournal.org
Selected Report
metal coils, decalcified spongy calf bone, or polidocanol have also been used with various degrees of success.9 –11 Additionally, Watanabe et al12 have also described the use of an endobronchial spigot to achieve the closure of a BPF, although placement in the segmental bronchi of the upper lobes may be technically difficult. These agents permanently scar the airways, and their effects are generally irreversible. We describe the novel use of a removable, one-way, endobronchial valve to facilitate BPF closure in a patient who had not responded to standard therapy.
Case Report Our patient was a 59-year-old woman with a history of severe bronchiectasis who underwent a left lower-lobe basilar segmentectomy in December 2003. She recovered from her surgery uneventfully; however, she presented 4 months postoperatively with left lower-lobe pneumonia, a BPF, and empyema. These conditions were initially managed with a latissimus dorsi muscle flap and the creation of an Eloesser flap. Unfortunately, this failed to close the BPF, and she had a persistent BPF and empyema. A culture of the patient’s pleural fluid grew Pseudomonas aeruginosa, and she was treated with IV antibiotics for 1 week prior to a repeat attempt of surgical closure of the BPF. In the operating room, under general anesthesia, bronchoscopy with both a rigid and flexible bronchoscope, and simultaneous thoracoscopy were performed. The left mainstem and upper lobe were normal. There was evidence of a lateral-basal segmentectomy in the left lower lobe. A large BPF was found in the posterior basilar segment of the left lower lobe (please see online video supplementation at www.chestnet.org). The patient had purulent secretions in the lower lobe that were therapeutically aspirated and sent for culture. She was repositioned in the right lateral-decubitus position, and the posterior-basal segmental bronchus was mobilized and closed with two layers of 4.0 vicryl suture. Fibrin glue (Tiseel; Baxter; Deerfield, IL) was then injected through the wall of the bronchus under endoscopic control to further seal the defect. A pedicled latissimus dorsi muscle flap was then used to cover the stump. Unfortunately, she continued to have an air leak 48 h after surgery. Emergent approval for the use of an investigational device was requested from our Committee on Clinical Investigations/Institutional Review Board, and, given the high risk of losing the benefits of her recent surgery, approval was granted. The patient was brought to the operating theater and, once general anesthesia was achieved, was incubated with the rigid bronchoscope. After therapeutic aspiration of the purulent secretions from the left lower lobe, the BPF was again identified. A guidewire was placed under direct vision, and a small-sized endobronchial valve (Emphasys Medical; Redwood City CA) was loaded, inserted, and deployed into the posterior-basilar segment with excellent fit and position (Fig 1). This resulted in the immediate cessation of the air leak. The patient tolerated the procedure, was extubated in the operating room, and was transferred to the recovery room. Her hospital course was remarkable for the development of acute renal failure resulting CHEST / 130 / 1 / JULY, 2006
273
Figure 1. Small endobronchial valve (courtesy of Emphasys Medical).
from tobramycin therapy and a brief period of rapid atrial fibrillation. Both of these conditions had resolved by the time of hospital discharge. The patient continued to do well, and 6 weeks after undergoing the valve placement she was taken to the operating room to undergo rigid bronchoscopy and removal of the valve. This occurred without difficulty or complication, and she continues to do well without any evidence of recurrence of her empyema or BPF.
Discussion BPF can be a devastating complication of pulmonary resection. The risk factors for the development of BPF include the presence of a long bronchial stump, carcinoma at the bronchial margin, disrupted blood supply, preexistent empyema, mechanical ventilation, and preoperative chemotherapy or radiation therapy.2,3,5,13 Additionally, current or former smoking, male gender, decreased serum albumin level (⬍ 3.5 mg/dL), and a large stump diameter may also increase the risk of BPF formation.1,7,14 The diagnosis of BPF is not always straightforward as patients can present soon after surgery or even several years later, although the majority of patients present within the first 3 months.7 In addition to signs and symptoms consistent with empyema or aspiration pneumonia, the presence of an increasing amount of air in the 274
pleural space after lung resection should prompt early investigation to rule out BPF formation. Early drainage of pleural infection, with the goals of preventing pleural sepsis and aspiration pneumonia remain essential to the initial management of these patients.7 There are currently no prospective trials studying the management of BPF, and therapies can include endoscopic as well as surgical attempts to close the fistula. Previously described endoscopic modalities attempt to permanently seal the airway. In addition to the methods described above, both metal and silicone stents have been used to cover the airway defect,15,16 but in this case the fistula could not be covered due to its distal location. Additionally, airway stents can cause granulation tissue, and metal stents can be extremely difficult, if not impossible, to remove.17 The Watanabe spigot has been successfully used in 12 patients with prolonged BPFs and empyema with excellent results and few complications.12 Our case is unique in that we used a removable endobronchial valve that is currently being investigated for its role in bronchoscopic lung-volume reduction. These valves were originally developed to be inserted similarly to a self-expanding metallic stent, with the aid of a guidewire, and this was the technique used in our patient. Recent improvements in valve delivery now allow for a “transscopic” approach, placing the valve directly through the working channel of the bronchoscope. As with bronchoscopic lung-volume reduction, a major benefit of using these valves for the treatment of patients with BPF lies in the fact that they are completely removable. A potential advantage of the one-way valve compared to the Watanabe spigot is that the valve allows for the clearance of distal mucus, and postobstructive infectious complications have been rarely seen.18 –20 Although the ideal treatment of BPF should be individualized, we stress the need for a multidisciplinary approach to these patients. Future studies will be required to assess the role of using removable, one-way, endobronchial valves in the management of these patients, and their relative efficacy and safety when compared to other occlusion techniques. Additionally, cost-benefit analyses should be performed comparing the Watanabe spigot with the valve (Emphasys).
References 1 Suzuki M, Otsuji M, Baba M, et al. Bronchopleural fistula after lung cancer surgery: multivariate analysis of risk factors. J Cardiovasc Surg (Torino) 2002; 43:263–267 2 Sirbu H, Busch T, Aleksic I, et al. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001; 7:330 –336 3 Asamura H, Naruke T, Tsuchiya R, et al. Bronchopleural fistulas associated with lung cancer operations: univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992; 104:1456 –1464 4 Kawahara K, Akamine S, Takahashi T, et al. Management of anastomotic complications after sleeve lobectomy for lung cancer. Ann Thorac Surg 1994; 57:1529 –1532 5 Sonobe M, Nakagawa M, Ichinose M, et al. Analysis of risk factors in bronchopleural fistula after pulmonary resection for Selected Report
6
7
8
9
10
11
12 13
primary lung cancer. Eur J Cardiothorac Surg 2000; 18:519 – 523 Kacprzak G, Marciniak M, Addae-Boateng E, et al. Causes and management of postpneumonectomy empyemas: our experience. Eur J Cardiothorac Surg 2004; 26:498 –502 Hollaus PH, Lax F, el Nashef BB, et al. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997; 63:1391–1396 Watanabe S, Asamura H, Suzuki K, et al. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac Surg 2004; 78:999 –1002 Takaoka K, Inoue S, Ohira S. Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol. Chest 2002; 122:374 –378 Watanabe S, Watanabe T, Urayama H. Endobronchial occlusion method of bronchopleural fistula with metallic coils and glue. Thorac Cardiovasc Surg 2003; 51:106 –108 Varoli F, Roviaro G, Grignani F, et al. Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998; 65:807– 809 Watanabe Y, Matsuo K, Tamaoki A, et al. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchol 2003; 10: 264 –267 Cerfolio RJ. The incidence, etiology, and prevention of
www.chestjournal.org
14 15 16 17 18
19
20
postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001; 13:3–7 Hollaus PH, Setinek U, Lax F, et al. Risk factors for bronchopleural fistula after pneumonectomy: stump size does matter. Thorac Cardiovasc Surg 2003; 51:162–166 Madden BP, Sheth A, Ho TB, et al. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula. Ann Thorac Surg 2005; 79:2128 –2130 Tayama K, Eriguchi N, Futamata Y, et al. Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy. Ann Thorac Surg 2003; 75:290 –292 Ernst A, Feller-Kopman D, Becker HD, et al. Central airway obstruction. Am J Respir Crit Care Med 2004; 169:1278 – 1297 Venuta F, De Giacomo T, Rendina EA, et al. Bronchoscopic lung-volume reduction with one-way valves in patients with heterogenous emphysema. Ann Thorac Surg 2005; 79:411– 416 Hopkinson NS, Toma TP, Hansell DM, et al. Effect of bronchoscopic lung volume reduction on dynamic hyperinflation and exercise in emphysema. Am J Respir Crit Care Med 2005; 171:453– 460 Yim AP, Hwong TM, Lee TW, et al. Early results of endoscopic lung volume reduction for emphysema. J Thorac Cardiovasc Surg 2004; 127:1564 –1573
CHEST / 130 / 1 / JULY, 2006
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