Combining Minimally Invasive Techniques in Managing a Frail Patient with Postpneumonectomy Bronchopleural Fistula

Abstract

A postpneumonectomy bronchopleural fistula is a life-threatening complication requiring aggressive treatment and early repair. Reoperations are common due to initial treatment failure. Advanced bronchoscopic techniques are rapidly evolving, but permanent results are questionable. We report the minimally invasive management of a frail 79-year-old patient with postpneumonectomy fistula in respiratory failure due to repeated infections. Previous bronchoscopic closure attempts with fibrin failed. The multistep interdisciplinary management included airway surveillance by virtual bronchoscopy, percutaneous fibrin glue instillation under computed tomography, and awake thoracoscopic surgery to achieve temporary closure. This provided an acceptable long period of symptomatic and physical improvement. The bronchial stump failed again four months later, and the patient succumbed to pneumonia. Pneumonectomy has to be avoided unless strongly indicated. Complications are best managed with surgery for definite treatment. We emphasize our approach only when a patient declines surgery or is medically unfit as a temporary time-buying strategy in view of definite surgery in a high-volume center.

An update on bronchopleural fistulae following cancer-related surgery

“…Occlusive or sclerosing materials have also been published in several case reports and small case series to show successful closure of BPF. Although the data are not robust, N-butyl-cyanoacrylate [53,54], ethanol [55], and fibrin glue [56,57] have all been instilled bronchoscopically for BPF treatment. When utilized, occlusive materials act to form a sealant or mechanical barrier, whereas sclerosing agents create a localized inflammatory reaction, tissue edema, and eventual scar at the site of the fistula with the aim that occlusion will allow for BPF healing over time.…”

The use of fibrin glue for the endoscopic management of post-intubation tracheal lacerations: a case series

“…Some possible advantages reside in the fibrin glue properties: fibrin sealant is a plasma-derived biomaterial, commonly used in surgery as a hemostatic agent and tissue sealant (16). It has applications in thoracic surgery, such as closure of bronchopleural fistulae, often in combination with other treatments (17)(18)(19). The possible advantages of endoscopic fibrin glue application for PTILs reside in the fibrin clot physically occluding the tracheal laceration and in the adhesion of the sealant to the surrounding tissues.…”