Use of an Amplatzer Device for Endoscopic Closure of a Large Bronchopleural Fistula following Lobectomy for a Stage I Squamous Cell Carcinoma

Abstract

Bronchopleural fistulas can occur as a rare but severe complication after pulmonary resection. Established guidelines for the proper treatment of patients with bronchopleural fistulas do not exist. Apart from attempts to close the fistula, emphasis is placed on preventive measures, early treatment with antibiotics, drainage of the empyema and aggressive nutritional and rehabilitative support. For inoperable patients, endoscopic procedures are the only therapeutic option. Unfortunately, large (>8 mm) or central bronchopleural fistulas are usually not suitable for such endoscopic management. Recently, some groups have published a few case reports about a novel technique for the endobronchial closure of bronchopleural fistulas, using an Amplatzer device, originally designed for transcatheter closure of cardiac septal defects. We applied the same technique as a life-saving treatment in a ventilated patient who was considered inoperable due to a high oxygen need. The operation was successful. The patient could be weaned from ventilation and was eventually discharged from the hospital to a rehabilitation facility several weeks after the insertion of the device. Until now, endoscopic techniques have only been useful for the treatment of small, peripheral, bronchopleural fistulas and even then only as a bridge to surgery in high-risk surgical patients. In this case report, we demonstrate that the use of an Amplatzer device can expand the importance of endoscopic techniques in the treatment of bronchopleural fistulas. An Amplatzer device, for endobronchial closure, can indeed be administered for large and central bronchopleural fistulas. Moreover, it can be considered as a definite alternative to surgery in inoperable patients.

Closure of bronchopleural fistula by a septal occluder device: a case for close collaboration between heart and lung specialists

“…Its management remains challenging, no randomised scientific studies exist and no evidence for best treatment is available. All reported interventions are based on small, often retrospective series or individual cases 1 13 17. Surgical intervention is considered the definitive approach to controlling the source of the leak, but sometimes surgery or even repeated surgical interventions fail, or the patient is a suboptimal operative candidate 6…”

The Use of Polyvinyl Alcohol Sponge and Cyanoacrylate Glue in the Treatment of Large and Chronic Bronchopleural Fistulae following Lung Cancer Resection

“…For nonoperable patients, because of a high operative risk, an endoscopic approach may be the only alternative with curative intent of surgical repair [2]. Different bronchoscopic techniques depending on the size of the BPF have been reported with varying degrees of success [7]. Cyanoacrylate glues are widely used for endoscopic control of bleeding from gastric varices and for closure of fistulae or anastomotic leaks [8].…”

“…The failure of sealing compounds in large fistulae can be due to insufficient stability in the lesion resulting in the expectoration of the plug. In recent times, an Amplatzer device has been used in larger BPF, resulting in an effective and promising method for the closure of the bronchial stump [7,10]. …”

“…Actually, there is no general consensus about this endoscopic procedure as a first-line option for the closure of BPF, since simultaneous use of bronchoscopy, fluoroscopy, and thoracoscopy is necessary for the correct placement of the device [7]. Furthermore, the absence of a local reaction leading to definitive healing and the high cost of the device deter from the further use of this endoscopic procedure.…”

Management of Pneumothorax and Prolonged Air Leak

“…For large defects in proximal bronchi, an Amplatzer device designed for atrial septal defect closure has proved successful. 51,[53][54][55]70,71 In a study from Israel of 10 patients with 11 BPF, associated with lung cancer resection in 8, surgery from bronchiectasis in 1, and a giant bulla in another, successful closure was achieved in 9 patients. 53 In the patient with bronchiectasis, the device failed to provoke any inflammatory reaction and fell into the pleural cavity.…”