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• W2042217919 abstract "Bronchopleural fistula (BPF) after pneumonectomy remains a major challenge for thoracic surgeons.1Regnard J.F. Alifano M. Puyo P. Fares E. Magdeleinat P. Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection.J Thorac Cadiovasc Surg. 2000; 120: 270-275Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Gharagozloo F. Trachiotis G. Wolfe A. DuBree K.J. Cox J.L. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema.J Thorac Cardiovasc Surg. 1998; 116: 943-948Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Conventional treatment combines chest tube drainage with intravenous antibiotic therapy followed by one or several of the following procedures: thoracotomy for debridement of the pleural cavity and manual closure of the bronchial stump, sternotomy and transpericardial closure of the main bronchial stump, intrathoracic transposition of a pedicled skeletal muscle or omental flap, video-assisted closure through a short cervicotomy, and open window thoracostomy.1Regnard J.F. Alifano M. Puyo P. Fares E. Magdeleinat P. Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection.J Thorac Cadiovasc Surg. 2000; 120: 270-275Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Gharagozloo F. Trachiotis G. Wolfe A. DuBree K.J. Cox J.L. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema.J Thorac Cardiovasc Surg. 1998; 116: 943-948Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 3Azorin J.F. Francisci M.P. Tremblay B. Larmignat P. Carvaillo D. Closure of a postpneumonectomy main bronchus fistula using Video-Assisted Mediastinal Surgery.Chest. 1996; 109: 1097-1098Crossref PubMed Scopus (28) Google Scholar My colleagues and I intended to seal a BPF after right pneumonectomy using BioGlue surgical adhesive (CryoLife Inc, Kennesaw, Ga) in a patient who had received three cycles of induction chemotherapy and wished not to have any major procedure performed. A 53-year-old woman was referred to our department with a potentially operable bronchial adenocarcinoma. Bronchoscopy, chest computed tomography, and positron emission tomography had revealed a T4 N2 M0 tumor in the right upper lobe and right main bronchus invading the superior vena cava and azygos arch (Figure 1). The patient received three cycles of induction chemotherapy with gemcitabine and cisplatin, and repeat chest computed tomography demonstrated a good response, allowing us to undertake a right pneumonectomy. Extended right pneumonectomy was performed, including en bloc resection of the right main bronchus and azygos arch. Radical mediastinal lymphadenectomy was performed. The right main bronchus was cut 5 mm from the carina. The bronchial stump was closed with interrupted 3-0 polydioxanone suture (PDS; Ethicon, Inc, Somerville, NJ) and was reinforced by a pedicled intercostal muscle flap. The postoperative course was uneventful and the patient was discharged home after 9 days. Histopathologic examination revealed a pT2 N0 M0 bronchial adenocarcinoma. All margins were clear. The patient was readmitted 2 weeks later with empyema. A chest drain was inserted and the patient was started on a regimen of intravenous cefotaxime and metronidazole. Pleural fluid grew Streptococcus milleri. Examination with a flexible bronchoscope revealed no obvious fistula on the right main bronchial stump. The patient rejected any major procedure but agreed to reoperation for debridement of the cavity and revision of bronchial stump. The thoracotomy was partly reopened, and the pleural cavity was debrided with video-assistance and copiously washed out with povidone-iodine and hydrogen peroxide. The bronchial stump was carefully dissected, and positive-pressure ventilation revealed a small BPF. Five milliliters of the albumin-glutaraldehyde tissue adhesive BioGlue was injected onto the bronchial stump, and the minithoracotomy was closed in layers. A chest drain was inserted and remained on water seal for 7 days. The patient was discharged home receiving cephadroxil and metronidazole with the drain connected to a Portex bag (Portex, Inc, Keene, NH). The chest drain was removed 2 weeks later and antibiotics were discontinued. There has been no recurrence of BPF or empyema after 2 years and the patient lives a normal life. The mortality associated with BPF after pneumonectomy ranges between 11% and 40% in recent series,1Regnard J.F. Alifano M. Puyo P. Fares E. Magdeleinat P. Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection.J Thorac Cadiovasc Surg. 2000; 120: 270-275Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Gharagozloo F. Trachiotis G. Wolfe A. DuBree K.J. Cox J.L. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema.J Thorac Cardiovasc Surg. 1998; 116: 943-948Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 4Deschamps C. Allen M.S. Trastek V.F. Pairolero P.C. Empyema following pulmonary resection.Chest Surg Clin North Am. 1994; 4: 583-592PubMed Google Scholar justifying an aggressive approach. Current techniques include drainage and debridement of the cavity, open window thoracostomy, transpericardial closure of the bronchial stump, and intrathoracic muscle or omental flap transposition.1Regnard J.F. Alifano M. Puyo P. Fares E. Magdeleinat P. Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection.J Thorac Cadiovasc Surg. 2000; 120: 270-275Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Recently, Azorin and associates3Azorin J.F. Francisci M.P. Tremblay B. Larmignat P. Carvaillo D. Closure of a postpneumonectomy main bronchus fistula using Video-Assisted Mediastinal Surgery.Chest. 1996; 109: 1097-1098Crossref PubMed Scopus (28) Google Scholar proposed a less invasive approach involving closure of the bronchial stump through a cervicotomy using a video-mediastinoscope and an endolinear stapler. None of these techniques was an option in our patient, who had a short right main bronchial stump and who refused any major procedure. Therefore, we decided to debride the cavity and seal any eventual BPF with BioGlue surgical adhesive. BioGlue adhesive consists of a 10% glutaraldehyde solution and a 45% bovine serum albumin solution binding to each other, to cell surface proteins, and to the extracellular matrix.5Potaris K. Mihos P. Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.Med Sci Monit. 2003; 9: 79-83Google Scholar The reaction is spontaneous and immediate and results in a strong but flexible bond reabsorbing in approximately 2 years.5Potaris K. Mihos P. Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.Med Sci Monit. 2003; 9: 79-83Google Scholar Herget and associates6Herget G.W. Kassa M. Riede U.N. Lu Y. Brethner L. Hasse J. Experimental use of an albumin-glutaraldehyde tissue adhesive for sealing pulmonary parenchyma and bronchial anastomoses.Eur J Cardiothorac Surg. 2001; 19: 4-9Crossref PubMed Scopus (59) Google Scholar have shown that BioGlue adhesive is progressively replaced by fibrous tissue in bronchial anastomoses and that healing is not complicated by foreign body reaction or tissue granulation after 12 weeks. BioGlue adhesive does not possess the potential histotoxicity of formaldehyde.7Hewitt C.W. Marra S.W. Kann B.R. Tran H.S. Puc M.M. Chrzanowski Jr, F.A. et al.BioGlue surgical adhesive for thoracic aortic repair during coagulopathy: efficacy and histopathology.Ann Thorac Surg. 2001; 71: 1609-1612Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Biocompatibility is better than that of cyanoacrylate, and by comparison fibrin glues have a relatively low adhesive strength.5Potaris K. Mihos P. Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.Med Sci Monit. 2003; 9: 79-83Google Scholar Recently, Potaris, Mihos, and Gakidis5Potaris K. Mihos P. Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.Med Sci Monit. 2003; 9: 79-83Google Scholar have used BioGlue adhesive to seal air leaks and BPFs 38 patients, with no occurrence of empyema. This group has reported closure of a BPF after right pneumonectomy, using BioGlue adhesive injected trough a rigid bronchoscope. Considering these encouraging results, we suggest that BioGlue adhesive be used to seal small BPFs after pneumonectomy, in association with video-assisted debridement of the pleural cavity. Where this fails, open window thoracostomy or other techniques remain an option. Although this technique needs to be evaluated in a larger cohort of patients, this may represent a less invasive approach, particularly in debilitated patients. Dr Lang-Lazdunski" @default.
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• W2042217919 title "Closure of a bronchopleural fistula after extended right pneumonectomy after induction chemotherapy with BioGlue surgical adhesive" @default.
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