Bronchopleural fistula is a rare but difficult complication following pulmonary resection. Adequate and prolonged pleural drainage combined with antibiotics continues to be its basic treatment. When this fails, several surgical approaches have been applied with variable rates of success. Successful closure of BPF by endobronchial fibrin glue application through a flexible bronchoscope has recently been reported.
A routine chest x-ray film was performed on a 64-year-old farmer before right hip replacement. A cavitating lesion with an air-fluid level was seen in the right upper lobe. He had received nine months of chemotherapy, two years previously for culture-positive bilateral upper lobe tuberculosis. Lung carcinoma or reactivation of tuberculosis was suspected. Repeated gastric and bronchial aspirates and urine collections showed no AFB on Ziehl-Neelsen staining and cultures. Fiberoptic bronchoscopy and bronchial cytologic studies were normal. Through fluoroscopy, a transthoracic needle aspiration was performed using a Nordenstrom needle. Cytologic studies, AFB smear and culture of the aspirate were negative.
FIGURE 1. Chest radiograph showing the persistent air-fluid level after right upper lobe resection.
A two-month trial of INH and rifampicin followed by six weeks of amoxicillin produced no change in the chest x-ray film. A second bronchoscopy was normal.
A right upper lobe resection was performed. Surprisingly, histologic examination of the resected lobe revealed extensive bronchiectasis of the right upper lobe colonized by Aspergillus fumigatus. One week later, the patient developed high fever, cough and purulent sputum. Postoperatively, the chest drain had bubbled continuously. The chest x-ray film showed an air-fluid level (Fig 1). Bronchoscopy revealed a 2-mm wide fistula on the bronchial stump (Fig 2). Pleural aspirates from the drainage yielded Entewbacter cloacae and Bactewidesfragilis, which are sensitive to cotrimoxazole and penicillin. Despite two successive courses of these antibiotics, accompanied by pleural drainage for six weeks, the patient remained febrile and continued to cough. These problems could be attributed to continuous superinfection of the pleura through the fistula. On three separate occasions, a thin catheter was inserted through a flexible bronchoscope and placed into the orifice of the BPF.
FIGURE 2. Endoscopic view of the orifice of the fistula on the bronchial stump (arrow).
Two milliliters of homogenous fibrin glue (Tissucol Immuno Zurich, containing 500 units/ml of fibrin and 3,500 units/ml of aprotinin, an antifibrinolytic drug) was injected. In two or three minutes, the fibrin plug completely occluded the fistula as confirmed by the cessation of bubbling endobronchial and at the fistula site. To avoid dislodging of the plug, no suction was applied through the pleural drainage or the bronchoscope canal. On two occasions, the BPF remained occluded for three and four days, respectively, with disappearance of productive cough. However, these were only temporarily successful. A thoracotomy was considered again, but because of the patients poor general condition, a right six-first-ribs thoracoplasty was performed. Pleural drainage was maintained for four weeks following this thoracoplasty, but the BPF persisted with fever, productive cough and deterioration of the patients condition. Finally, one more trial of bronchoscope fibrin glue application was performed preceded by gentle touching of the BPF orifice with silver nitrate to try to stimulate its healing by sclerosis. This new endoscopic attempt also failed.
Six weeks after thoracoplasty, thoracoscopy of the right upper thoracic cavity was performed, with the patient under local anesthesia, using a small rigid thoracoscope (7 mm external diameter; Wolf Knittlingen FRG). A pleural recess was visualized with an orifice partly obstructed by several adhesions. Talc (4 ml) was injected into the fistula and into the adjacent pleura forming the recess. Cough and expectoration disappeared. The patient recovered completely and was discharged ten days after thoracoscopy. A two- year follow-up showed that the fistula had not recurred.