Surgically intractable bronchopleural fistula treated with endobronchial valve insertion by isolating the tract with indigo carmine: A case report

Abstract

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Herein, we report a patient with persistent air leak after necrotizing pneumonia, where tract of BPF was not apparent in computed tomography (CT). Despite control of infection, watchful observation, repetitive procedures, and surgery, air leak was not resolved. This led to consideration of the endobronchial valve (EBV) placement. After identifying the bronchial segment leading to the fistula with indigo carmine, precise occlusion of the lingular division of the left upper lobe (LUL) was performed using an EBV. Subsequently, the air leak was resolved. During 6 months of follow-up, neither recurrence of BPF nor any procedure-related complications were noted. We concluded that precise EBV placement by identifying bronchial segment leading to the BPF, could be an effective treatment for persistent air leak.

A return to 1992: Using the “blowhole” technique for diffuse subcutaneous emphysema caused by a broncho-pleural fistula

“…The management of BPFs is highly case-dependent and involves conservative or surgical interventions. Surgical repair is often used post-lung resection and involves debridement of necrotic tissue and suture reclosure of the bronchial stump with either omentum or muscle [ [6] , [7] , [8] ]. In most cases, this can be accomplished by video-assisted thoracoscopic surgical approach.…”

Bronchopleural Fistula after Pulmonary Resection: Risk Factors, Diagnoses and Management

“…Endobronchial valves (EBV) have been available since 2003 and were originally developed for the reduction of lung volume in patients with emphysema [90,91]. They were first described by Snell et al, 2005 for BPF [92].…”

“…They were first described by Snell et al, 2005 for BPF [92]. Introduced through a flexible bronchoscope, EBV have a unidirectional valve to prevent airflow into the fistula and will result in atelectasis and collapse of the fistula [90,91,93]. This results in decreased or absent air leak.…”

“…This results in decreased or absent air leak. The process of recovery would lead to resolution of the shunt, fibrosis, and eventual extraction of the EBV [90,91,93]. Complete elimination of air flow through the BPF does not always occur and does not mean the EBV is unsuccessful.…”

“…Many small fistulas (<3 mm) spontaneously heal or heal with glue placed endoscopically [94,95]. Treatment for BPF endoscopically can bridge to control infection until a patient is able to able to undergo surgical repair [90,92] (Figure 5). Amplatzer…”