(Chest. 2006;130:273-275.)
© 2006
American College of Chest Physicians
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
* From the Divisions of Interventional Pulmonology (Drs. Feller-Kopman, Bechara, and Ernst, and Mr. Garland) and Thoracic Surgery (Dr. Ashiku), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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: dfellerk{at}bidmc.harvard.edu
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Abstract
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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.
Key Words: bronchopleural fistula • bronchoscopy • empyema • fistula • surgery • valve
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Introduction
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The incidence of bronchopleural fistula (BPF) following lung resection in patients with lung cancer is approximately 2 to 6%,123456 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 metal coils, decalcified spongy calf bone, or polidocanol have also been used with various degrees of success.91011 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.
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Case Report
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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 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.
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Discussion
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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.23513 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.1714
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 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,1516 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 "trans-scopic" 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.181920
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).
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Footnotes
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Abbreviation: BPF = bronchopleural fistula
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.
Received for publication September 14, 2005.
Accepted for publication January 2, 2006.
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References
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- Suzuki, M, Otsuji, M, Baba, M, et al (2002) Bronchopleural fistula after lung cancer surgery: multivariate analysis of risk factors. J Cardiovasc Surg (Torino) 43,263-267
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Abstract
Introduction
