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• W2079074523 abstract "Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula. Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula. The treatment most often recommended for persistent, complex, symptomatic bronchopleural fistulas (BPFs) involves a thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. However, this major operation can be ineffective or medically contraindicated. We report an innovative approach with transthoracic injection of coils into and adjacent to the BPF of a postpneumonectomy bronchial stump. Both coils and glue were introduced through transthoracic needles placed under guidance or thoracoscopic visualization to achieve closure in 2 consecutive patients. The postpneumonectomy space could then be irrigated, sterilized, and filled with antibiotics, and the chest tubes could be removed.TechniqueInstitutional review board approval was obtained for a retrospective chart review. Patient number 1, a 57-year-old man, underwent a right pneumonectomy for stage IIB adenocarcinoma. The right bronchial stump was stapled and covered with parietal pleura. Four months after pneumonectomy he was treated for pulmonary embolus. One week later he complained of recurrent chest pain. A chest computed tomographic scan showed a fluid level change in the postpneumonectomy space with a BPF at the right main stem bronchial stump (Fig 1A). The BPF was confirmed by bronchoscopy and two large bore chest tubes were placed to evacuate air and fluid. No signs of empyema were present. A pathologic fracture of the right pelvis from metastatic lung cancer was confirmed. Therefore, he was judged a poor candidate for major surgery.Under computed tomographic guidance, two 18-gauge needles were inserted percutaneously to transfix the BPF by puncturing the adjacent perihilar soft tissue. Endovascular coils (8 mm × 4 cm) (Cook, Inc, Bloomington, IN) were inserted through the needle and across the BPF. Then 1 cc of cyanoacrylic glue was injected through both needles into the fistula and adjacent soft tissues (Fig 1B). Chest tubes were placed to balanced suction. A small air leak was detected by inhalation xenon scanning 14 days later. Fistula closure was repeated by visualization of the air leak site using video-assisted thoracic surgery. Two more coils were inserted across the fistula, followed by glue injection into the adjacent tissues (Fig 2). The postpneumonectomy space was irrigated and filled with Dakin’s antibiotic solution (sodium hypochlorite, 0.45% to 0.5%; and boric acid, 4%) and the chest tubes were removed.Fig 2Computed tomographic guided transthoracic coil and glue injection. (A) Set-up of procedure. (B) Detail of image-guided coil insertion into bronchopleural fistula (BPF) and adjacent tissues. (C) Detail of needle injecting cyanoacrylate glue into coils and surrounding tissues.View Large Image Figure ViewerDownload (PPT)A week later the patient became short of breath; chest roentgenogram showed air and fluid levels with subcutaneous emphysema. The coil and glue procedure was repeated under computed tomographic guidance with successful closure. A fine needle aspiration of a lymph node adjacent to the bronchial stump was positive for metastasis. The BPF remained closed until death 1 month later due to systemic progression of cancer.Patient number 2, a 47-year-old woman, had a right pneumonectomy for stage IIB nonsmall cell lung cancer followed by four cycles of chemotherapy postoperatively. Six months later she presented with cough, dyspnea, and a feeling of fluid in her chest, confirmed by an increased air and fluid level on chest roentgenogram. She was afebrile with a normal white blood cell count. Bronchoscopy showed a small air leak at the stump. Thoracentesis yielded gram negative organisms and she was started on vancomycin and pipperacillin–tazobactam (Zosyn, Wyeth Pharmaceuticals, Madison, NJ) with tube thoracostomy. This patient was unwilling to undergo a major surgical procedure and opted for our less invasive approach for treatment. A percutaneous coil and glue closure of the right BPF was performed under computed tomographic guidance using the technique previously described. Five days later the right thoracic cavity was irrigated with tissue plasminogen activator (due to septations) and antiseptic solution (cefipime). A xenon ventilation scan showed no leaks. She was discharged the next day after Dakin’s solution irrigation and chest tube removal. Oral linezolid and levofloxacin were prescribed for 2 weeks. One month later the patient is asymptomatic with no change in air and fluid levels.CommentA bronchopleural fistula is defined as “communication between lobar or segmental pulmonary bronchi and the pleural space” with an incidence of 0.5% after lobectomy and 4.5% to 20% after pneumonectomy [1Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula.Semin Thorac Cardiovasc Surg. 2001; 13: 3-7PubMed Scopus (139) Google Scholar]. Darling and colleagues [2Darling G.E. Abdurahman A. Yi Q.L. et al.Risk of a right pneumonectomy: role of bronchopleural fistula.Ann Thorac Surg. 2005; 79: 433-437Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar] reported an incidence of BPF formation after right pneumonectomy of 13.2% and after left pneumonectomy of 5%. Perioperative risk factors for BPF include radiation, chemotherapy, or immunocompromised states. Intraoperative risk factors are surgical inexperience, right pneumonectomy, long stump, stump devascularization, residual cancer, and tension on the bronchial closure. Prolonged ventilation, systemic steroids, and reintubation are postoperative risk factors.A thoracotomy with transposition of muscle flaps or mobilization of omentum to cover the defect, vascularize the tissue, and occupy the empty postpneumonectomy space is recommended for primary closure of a BPF. These open BPF closure techniques have reported a recurrence rate of 25% to 72% [3Asamura H. Kondo H. Goya T. Tsuchiya R. Naruke T. Suemasu K. [Bronchopleural fistulas developing after pulmonary resections for lung cancer predisposing factors, management, and prognosis].Nippon Kyobu Geka Gakkai Zasshi. 1991; 39: 1894-1901PubMed Google Scholar, 4Chichevatov D. Gorshenev A. Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy.Asian Cardiovasc Thorac Ann. 2005; 13: 211-216Crossref PubMed Scopus (15) Google Scholar, 5Michaels B.M. Orgill D.P. Decamp M.M. Pribaz J.J. Eriksson E. Swanson S. Flap closure of postpneumonectomy empyema.Plast Reconstr Surg. 1997; 99: 437-442Crossref PubMed Scopus (26) Google Scholar]. Recently, isolated reports of successful management of BPF with placement of stents, both Dumon Bronchial Stent (Bryan Corp, Woburn, MA) and Ultraflex (Boston Scientific, Watertown, MA) have emerged [6Garcia Franco C.E. Flandes Aldeyturriaga J. Zapatero Gaviria J. Ultraflex expandable metallic stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2005; 79: 386Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 7Madden B.P. Sheth A. Ho T.B. McAnulty G.R. Sayer R.E. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula.Ann Thorac Surg. 2005; 79: 2128-2130Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 8Tayama K. Eriguchi N. Futamata Y. et al.Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2003; 75: 290-292Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Tsukada H. Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula.Ann Thorac Surg. 2005; 80: 1928-1930Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 10Watanabe S. Shimokawa S. Yotsumoto G. Sakasegawa K. The use of a Dumon stent for the treatment of a bronchopleural fistula.Ann Thorac Surg. 2001; 72: 276-278Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar]. The majority of successful BPF closures with intrameatal stents are left-sided postpneumonectomy BPF, with tracheobronchial right-sided size similarity, allowing a seal with a long covered stent. However, we wanted to avoid placing a foreign body into the normal trachea and left main bronchus due to the inherent problems of granulation tissue formation at the stent edges, inefficient clearance of secretions across the stented segment, and the lumen differential. Use of endobronchial closure techniques has gained popularity as a minimally invasive option for small BPFs or in poor surgical candidates [11Salmon C.J. Ponn R.B. Westcott J.L. Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula.Chest. 1990; 98: 233-234Crossref PubMed Scopus (23) Google Scholar]. Hollaus and colleagues [12Hollaus P.H. Lax F. Janakiev D. et al.Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.Ann Thorac Surg. 1998; 66: 923-927Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] have reported use of endobronchial closure using submucosal injected fibrin glue with a closure rate of 51%, although some still required a chronic drainage system. Ponn and colleagues [13Ponn R.B. D’Agostino R.S. Stern H. Westcott J.L. Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils.Ann Thorac Surg. 1993; 56: 1343-1347Abstract Full Text PDF PubMed Scopus (29) Google Scholar] have reported the use of vascular occlusion coils placed endobronchially using fluoroscopic guidance to successfully close parenchymal BPFs after failed surgical and sealant management. The endobronchial approach requires several repeat procedures in most patients to achieve adequate closure.In this report, we describe the evolution of an image-guided technique utilizing transthoracic placement of coils and cyanoacrylate glue. In contrast to endobronchial techniques, our technique combines vascular occlusion coils as scaffolding and a sealant that potentially decreases the number of procedures and even successfully closes a major bronchial stump leak. Transthoracic needle biopsy of mediastinal and hilar lesions is a well-established technique with a low incidence of serious complications (ie, namely, a 0% to 34% reported incidence of pneumothorax and a hemoptysis rate of 0% to 10%) [14Protopapas Z. Westcott J.L. Transthoracic hilar and mediastinal biopsy.Radiol Clin North Am. 2000; 38: 281-291Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. However, due to the presence of a postpneumonectomy space in our patients, the chance of either of these complications was low to nonexistent. The hilar vessels can be avoided with careful technique, computed tomographic fluoroscopy imaging, and a tangential approach.Our technique successfully managed two recalcitrant postpneumonectomy BPFs. Image guidance allows insertion of coils transversely through the BPF into the tissues adjacent to the fistula tract while avoiding major vessels. The coils serve as scaffolding to which the injected cyanoacrylate glue adheres, providing anchorage to aid fistula closure. This is superior to prior reports in which glue plugs were placed directly into the lumen of a BPF and were then subsequently dislodged [15Walser E.M. Gomez G. Zwischenberger J.B. et al.Combined transthoracic and transtracheal closure of large bronchopleural fistulae.J Laparoendosc Adv Surg Tech A. 2004; 14: 97-101Crossref PubMed Scopus (7) Google Scholar]. Although further experience is needed to validate this approach, our image-guided technique for BPF closure provides a sound basis for less invasive management of postpneumonectomy BPF. The treatment most often recommended for persistent, complex, symptomatic bronchopleural fistulas (BPFs) involves a thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. However, this major operation can be ineffective or medically contraindicated. We report an innovative approach with transthoracic injection of coils into and adjacent to the BPF of a postpneumonectomy bronchial stump. Both coils and glue were introduced through transthoracic needles placed under guidance or thoracoscopic visualization to achieve closure in 2 consecutive patients. The postpneumonectomy space could then be irrigated, sterilized, and filled with antibiotics, and the chest tubes could be removed. TechniqueInstitutional review board approval was obtained for a retrospective chart review. Patient number 1, a 57-year-old man, underwent a right pneumonectomy for stage IIB adenocarcinoma. The right bronchial stump was stapled and covered with parietal pleura. Four months after pneumonectomy he was treated for pulmonary embolus. One week later he complained of recurrent chest pain. A chest computed tomographic scan showed a fluid level change in the postpneumonectomy space with a BPF at the right main stem bronchial stump (Fig 1A). The BPF was confirmed by bronchoscopy and two large bore chest tubes were placed to evacuate air and fluid. No signs of empyema were present. A pathologic fracture of the right pelvis from metastatic lung cancer was confirmed. Therefore, he was judged a poor candidate for major surgery.Under computed tomographic guidance, two 18-gauge needles were inserted percutaneously to transfix the BPF by puncturing the adjacent perihilar soft tissue. Endovascular coils (8 mm × 4 cm) (Cook, Inc, Bloomington, IN) were inserted through the needle and across the BPF. Then 1 cc of cyanoacrylic glue was injected through both needles into the fistula and adjacent soft tissues (Fig 1B). Chest tubes were placed to balanced suction. A small air leak was detected by inhalation xenon scanning 14 days later. Fistula closure was repeated by visualization of the air leak site using video-assisted thoracic surgery. Two more coils were inserted across the fistula, followed by glue injection into the adjacent tissues (Fig 2). The postpneumonectomy space was irrigated and filled with Dakin’s antibiotic solution (sodium hypochlorite, 0.45% to 0.5%; and boric acid, 4%) and the chest tubes were removed.A week later the patient became short of breath; chest roentgenogram showed air and fluid levels with subcutaneous emphysema. The coil and glue procedure was repeated under computed tomographic guidance with successful closure. A fine needle aspiration of a lymph node adjacent to the bronchial stump was positive for metastasis. The BPF remained closed until death 1 month later due to systemic progression of cancer.Patient number 2, a 47-year-old woman, had a right pneumonectomy for stage IIB nonsmall cell lung cancer followed by four cycles of chemotherapy postoperatively. Six months later she presented with cough, dyspnea, and a feeling of fluid in her chest, confirmed by an increased air and fluid level on chest roentgenogram. She was afebrile with a normal white blood cell count. Bronchoscopy showed a small air leak at the stump. Thoracentesis yielded gram negative organisms and she was started on vancomycin and pipperacillin–tazobactam (Zosyn, Wyeth Pharmaceuticals, Madison, NJ) with tube thoracostomy. This patient was unwilling to undergo a major surgical procedure and opted for our less invasive approach for treatment. A percutaneous coil and glue closure of the right BPF was performed under computed tomographic guidance using the technique previously described. Five days later the right thoracic cavity was irrigated with tissue plasminogen activator (due to septations) and antiseptic solution (cefipime). A xenon ventilation scan showed no leaks. She was discharged the next day after Dakin’s solution irrigation and chest tube removal. Oral linezolid and levofloxacin were prescribed for 2 weeks. One month later the patient is asymptomatic with no change in air and fluid levels. Institutional review board approval was obtained for a retrospective chart review. Patient number 1, a 57-year-old man, underwent a right pneumonectomy for stage IIB adenocarcinoma. The right bronchial stump was stapled and covered with parietal pleura. Four months after pneumonectomy he was treated for pulmonary embolus. One week later he complained of recurrent chest pain. A chest computed tomographic scan showed a fluid level change in the postpneumonectomy space with a BPF at the right main stem bronchial stump (Fig 1A). The BPF was confirmed by bronchoscopy and two large bore chest tubes were placed to evacuate air and fluid. No signs of empyema were present. A pathologic fracture of the right pelvis from metastatic lung cancer was confirmed. Therefore, he was judged a poor candidate for major surgery. Under computed tomographic guidance, two 18-gauge needles were inserted percutaneously to transfix the BPF by puncturing the adjacent perihilar soft tissue. Endovascular coils (8 mm × 4 cm) (Cook, Inc, Bloomington, IN) were inserted through the needle and across the BPF. Then 1 cc of cyanoacrylic glue was injected through both needles into the fistula and adjacent soft tissues (Fig 1B). Chest tubes were placed to balanced suction. A small air leak was detected by inhalation xenon scanning 14 days later. Fistula closure was repeated by visualization of the air leak site using video-assisted thoracic surgery. Two more coils were inserted across the fistula, followed by glue injection into the adjacent tissues (Fig 2). The postpneumonectomy space was irrigated and filled with Dakin’s antibiotic solution (sodium hypochlorite, 0.45% to 0.5%; and boric acid, 4%) and the chest tubes were removed. A week later the patient became short of breath; chest roentgenogram showed air and fluid levels with subcutaneous emphysema. The coil and glue procedure was repeated under computed tomographic guidance with successful closure. A fine needle aspiration of a lymph node adjacent to the bronchial stump was positive for metastasis. The BPF remained closed until death 1 month later due to systemic progression of cancer. Patient number 2, a 47-year-old woman, had a right pneumonectomy for stage IIB nonsmall cell lung cancer followed by four cycles of chemotherapy postoperatively. Six months later she presented with cough, dyspnea, and a feeling of fluid in her chest, confirmed by an increased air and fluid level on chest roentgenogram. She was afebrile with a normal white blood cell count. Bronchoscopy showed a small air leak at the stump. Thoracentesis yielded gram negative organisms and she was started on vancomycin and pipperacillin–tazobactam (Zosyn, Wyeth Pharmaceuticals, Madison, NJ) with tube thoracostomy. This patient was unwilling to undergo a major surgical procedure and opted for our less invasive approach for treatment. A percutaneous coil and glue closure of the right BPF was performed under computed tomographic guidance using the technique previously described. Five days later the right thoracic cavity was irrigated with tissue plasminogen activator (due to septations) and antiseptic solution (cefipime). A xenon ventilation scan showed no leaks. She was discharged the next day after Dakin’s solution irrigation and chest tube removal. Oral linezolid and levofloxacin were prescribed for 2 weeks. One month later the patient is asymptomatic with no change in air and fluid levels. CommentA bronchopleural fistula is defined as “communication between lobar or segmental pulmonary bronchi and the pleural space” with an incidence of 0.5% after lobectomy and 4.5% to 20% after pneumonectomy [1Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula.Semin Thorac Cardiovasc Surg. 2001; 13: 3-7PubMed Scopus (139) Google Scholar]. Darling and colleagues [2Darling G.E. Abdurahman A. Yi Q.L. et al.Risk of a right pneumonectomy: role of bronchopleural fistula.Ann Thorac Surg. 2005; 79: 433-437Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar] reported an incidence of BPF formation after right pneumonectomy of 13.2% and after left pneumonectomy of 5%. Perioperative risk factors for BPF include radiation, chemotherapy, or immunocompromised states. Intraoperative risk factors are surgical inexperience, right pneumonectomy, long stump, stump devascularization, residual cancer, and tension on the bronchial closure. Prolonged ventilation, systemic steroids, and reintubation are postoperative risk factors.A thoracotomy with transposition of muscle flaps or mobilization of omentum to cover the defect, vascularize the tissue, and occupy the empty postpneumonectomy space is recommended for primary closure of a BPF. These open BPF closure techniques have reported a recurrence rate of 25% to 72% [3Asamura H. Kondo H. Goya T. Tsuchiya R. Naruke T. Suemasu K. [Bronchopleural fistulas developing after pulmonary resections for lung cancer predisposing factors, management, and prognosis].Nippon Kyobu Geka Gakkai Zasshi. 1991; 39: 1894-1901PubMed Google Scholar, 4Chichevatov D. Gorshenev A. Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy.Asian Cardiovasc Thorac Ann. 2005; 13: 211-216Crossref PubMed Scopus (15) Google Scholar, 5Michaels B.M. Orgill D.P. Decamp M.M. Pribaz J.J. Eriksson E. Swanson S. Flap closure of postpneumonectomy empyema.Plast Reconstr Surg. 1997; 99: 437-442Crossref PubMed Scopus (26) Google Scholar]. Recently, isolated reports of successful management of BPF with placement of stents, both Dumon Bronchial Stent (Bryan Corp, Woburn, MA) and Ultraflex (Boston Scientific, Watertown, MA) have emerged [6Garcia Franco C.E. Flandes Aldeyturriaga J. Zapatero Gaviria J. Ultraflex expandable metallic stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2005; 79: 386Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 7Madden B.P. Sheth A. Ho T.B. McAnulty G.R. Sayer R.E. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula.Ann Thorac Surg. 2005; 79: 2128-2130Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 8Tayama K. Eriguchi N. Futamata Y. et al.Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2003; 75: 290-292Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Tsukada H. Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula.Ann Thorac Surg. 2005; 80: 1928-1930Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 10Watanabe S. Shimokawa S. Yotsumoto G. Sakasegawa K. The use of a Dumon stent for the treatment of a bronchopleural fistula.Ann Thorac Surg. 2001; 72: 276-278Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar]. The majority of successful BPF closures with intrameatal stents are left-sided postpneumonectomy BPF, with tracheobronchial right-sided size similarity, allowing a seal with a long covered stent. However, we wanted to avoid placing a foreign body into the normal trachea and left main bronchus due to the inherent problems of granulation tissue formation at the stent edges, inefficient clearance of secretions across the stented segment, and the lumen differential. Use of endobronchial closure techniques has gained popularity as a minimally invasive option for small BPFs or in poor surgical candidates [11Salmon C.J. Ponn R.B. Westcott J.L. Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula.Chest. 1990; 98: 233-234Crossref PubMed Scopus (23) Google Scholar]. Hollaus and colleagues [12Hollaus P.H. Lax F. Janakiev D. et al.Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.Ann Thorac Surg. 1998; 66: 923-927Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] have reported use of endobronchial closure using submucosal injected fibrin glue with a closure rate of 51%, although some still required a chronic drainage system. Ponn and colleagues [13Ponn R.B. D’Agostino R.S. Stern H. Westcott J.L. Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils.Ann Thorac Surg. 1993; 56: 1343-1347Abstract Full Text PDF PubMed Scopus (29) Google Scholar] have reported the use of vascular occlusion coils placed endobronchially using fluoroscopic guidance to successfully close parenchymal BPFs after failed surgical and sealant management. The endobronchial approach requires several repeat procedures in most patients to achieve adequate closure.In this report, we describe the evolution of an image-guided technique utilizing transthoracic placement of coils and cyanoacrylate glue. In contrast to endobronchial techniques, our technique combines vascular occlusion coils as scaffolding and a sealant that potentially decreases the number of procedures and even successfully closes a major bronchial stump leak. Transthoracic needle biopsy of mediastinal and hilar lesions is a well-established technique with a low incidence of serious complications (ie, namely, a 0% to 34% reported incidence of pneumothorax and a hemoptysis rate of 0% to 10%) [14Protopapas Z. Westcott J.L. Transthoracic hilar and mediastinal biopsy.Radiol Clin North Am. 2000; 38: 281-291Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. However, due to the presence of a postpneumonectomy space in our patients, the chance of either of these complications was low to nonexistent. The hilar vessels can be avoided with careful technique, computed tomographic fluoroscopy imaging, and a tangential approach.Our technique successfully managed two recalcitrant postpneumonectomy BPFs. Image guidance allows insertion of coils transversely through the BPF into the tissues adjacent to the fistula tract while avoiding major vessels. The coils serve as scaffolding to which the injected cyanoacrylate glue adheres, providing anchorage to aid fistula closure. This is superior to prior reports in which glue plugs were placed directly into the lumen of a BPF and were then subsequently dislodged [15Walser E.M. Gomez G. Zwischenberger J.B. et al.Combined transthoracic and transtracheal closure of large bronchopleural fistulae.J Laparoendosc Adv Surg Tech A. 2004; 14: 97-101Crossref PubMed Scopus (7) Google Scholar]. Although further experience is needed to validate this approach, our image-guided technique for BPF closure provides a sound basis for less invasive management of postpneumonectomy BPF. A bronchopleural fistula is defined as “communication between lobar or segmental pulmonary bronchi and the pleural space” with an incidence of 0.5% after lobectomy and 4.5% to 20% after pneumonectomy [1Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula.Semin Thorac Cardiovasc Surg. 2001; 13: 3-7PubMed Scopus (139) Google Scholar]. Darling and colleagues [2Darling G.E. Abdurahman A. Yi Q.L. et al.Risk of a right pneumonectomy: role of bronchopleural fistula.Ann Thorac Surg. 2005; 79: 433-437Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar] reported an incidence of BPF formation after right pneumonectomy of 13.2% and after left pneumonectomy of 5%. Perioperative risk factors for BPF include radiation, chemotherapy, or immunocompromised states. Intraoperative risk factors are surgical inexperience, right pneumonectomy, long stump, stump devascularization, residual cancer, and tension on the bronchial closure. Prolonged ventilation, systemic steroids, and reintubation are postoperative risk factors. A thoracotomy with transposition of muscle flaps or mobilization of omentum to cover the defect, vascularize the tissue, and occupy the empty postpneumonectomy space is recommended for primary closure of a BPF. These open BPF closure techniques have reported a recurrence rate of 25% to 72% [3Asamura H. Kondo H. Goya T. Tsuchiya R. Naruke T. Suemasu K. [Bronchopleural fistulas developing after pulmonary resections for lung cancer predisposing factors, management, and prognosis].Nippon Kyobu Geka Gakkai Zasshi. 1991; 39: 1894-1901PubMed Google Scholar, 4Chichevatov D. Gorshenev A. Omentoplasty in treatment of early bronchopleural fistulas after pneumonectomy.Asian Cardiovasc Thorac Ann. 2005; 13: 211-216Crossref PubMed Scopus (15) Google Scholar, 5Michaels B.M. Orgill D.P. Decamp M.M. Pribaz J.J. Eriksson E. Swanson S. Flap closure of postpneumonectomy empyema.Plast Reconstr Surg. 1997; 99: 437-442Crossref PubMed Scopus (26) Google Scholar]. Recently, isolated reports of successful management of BPF with placement of stents, both Dumon Bronchial Stent (Bryan Corp, Woburn, MA) and Ultraflex (Boston Scientific, Watertown, MA) have emerged [6Garcia Franco C.E. Flandes Aldeyturriaga J. Zapatero Gaviria J. Ultraflex expandable metallic stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2005; 79: 386Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 7Madden B.P. Sheth A. Ho T.B. McAnulty G.R. Sayer R.E. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula.Ann Thorac Surg. 2005; 79: 2128-2130Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 8Tayama K. Eriguchi N. Futamata Y. et al.Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy.Ann Thorac Surg. 2003; 75: 290-292Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Tsukada H. Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula.Ann Thorac Surg. 2005; 80: 1928-1930Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 10Watanabe S. Shimokawa S. Yotsumoto G. Sakasegawa K. The use of a Dumon stent for the treatment of a bronchopleural fistula.Ann Thorac Surg. 2001; 72: 276-278Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar]. The majority of successful BPF closures with intrameatal stents are left-sided postpneumonectomy BPF, with tracheobronchial right-sided size similarity, allowing a seal with a long covered stent. However, we wanted to avoid placing a foreign body into the normal trachea and left main bronchus due to the inherent problems of granulation tissue formation at the stent edges, inefficient clearance of secretions across the stented segment, and the lumen differential. Use of endobronchial closure techniques has gained popularity as a minimally invasive option for small BPFs or in poor surgical candidates [11Salmon C.J. Ponn R.B. Westcott J.L. Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula.Chest. 1990; 98: 233-234Crossref PubMed Scopus (23) Google Scholar]. Hollaus and colleagues [12Hollaus P.H. Lax F. Janakiev D. et al.Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.Ann Thorac Surg. 1998; 66: 923-927Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] have reported use of endobronchial closure using submucosal injected fibrin glue with a closure rate of 51%, although some still required a chronic drainage system. Ponn and colleagues [13Ponn R.B. D’Agostino R.S. Stern H. Westcott J.L. Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils.Ann Thorac Surg. 1993; 56: 1343-1347Abstract Full Text PDF PubMed Scopus (29) Google Scholar] have reported the use of vascular occlusion coils placed endobronchially using fluoroscopic guidance to successfully close parenchymal BPFs after failed surgical and sealant management. The endobronchial approach requires several repeat procedures in most patients to achieve adequate closure. In this report, we describe the evolution of an image-guided technique utilizing transthoracic placement of coils and cyanoacrylate glue. In contrast to endobronchial techniques, our technique combines vascular occlusion coils as scaffolding and a sealant that potentially decreases the number of procedures and even successfully closes a major bronchial stump leak. Transthoracic needle biopsy of mediastinal and hilar lesions is a well-established technique with a low incidence of serious complications (ie, namely, a 0% to 34% reported incidence of pneumothorax and a hemoptysis rate of 0% to 10%) [14Protopapas Z. Westcott J.L. Transthoracic hilar and mediastinal biopsy.Radiol Clin North Am. 2000; 38: 281-291Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. However, due to the presence of a postpneumonectomy space in our patients, the chance of either of these complications was low to nonexistent. The hilar vessels can be avoided with careful technique, computed tomographic fluoroscopy imaging, and a tangential approach. Our technique successfully managed two recalcitrant postpneumonectomy BPFs. Image guidance allows insertion of coils transversely through the BPF into the tissues adjacent to the fistula tract while avoiding major vessels. The coils serve as scaffolding to which the injected cyanoacrylate glue adheres, providing anchorage to aid fistula closure. This is superior to prior reports in which glue plugs were placed directly into the lumen of a BPF and were then subsequently dislodged [15Walser E.M. Gomez G. Zwischenberger J.B. et al.Combined transthoracic and transtracheal closure of large bronchopleural fistulae.J Laparoendosc Adv Surg Tech A. 2004; 14: 97-101Crossref PubMed Scopus (7) Google Scholar]. Although further experience is needed to validate this approach, our image-guided technique for BPF closure provides a sound basis for less invasive management of postpneumonectomy BPF." @default.
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• W2079074523 title "Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate" @default.
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