Multimodality bronchoscopic approach in management of stump dehiscence after pneumonectomy.
Khemasuwan D, Diaz-Mendoza J, and Simoff MJ. Multimodality bronchoscopic approach in management of stump dehiscence after pneumonectomy. Am J Respir Crit Care Med 2015; 191.
Am J Respir Crit Care Med
The occurrence of bronchopleural fistula (BPF) after pneumonectomy is associated with infection and high mortality. Thus, the closure of BPF and chest tube drainage is recommended. Case presentation: A 56 year old male with history of steroid-dependent rheumatoid arthritis and non-small cell lung cancer of the left lung. Patient underwent pneumonectomy. Two months after the surgery, patient developed gradual onset hypoxemic respiratory distress. CT scan of the chest showed bronchopleural fistula (BPF) of left bronchial stump and large air-fluid content in the left hemithorax. Large bore chest tube was placed and broad spectrum antibiotics were started. Patient was found to have persistent air leak from the chest tube. Bronchoscopic evaluation showed a long left main stem stump (54 mm from main carina) with a presence of 4 mm BPF at lateral wall of the stump. Rigid bronchoscopy was performed with the plan for BPF closure. There are three steps in this procedure. Firstly, an allograft bone chip was grinned in a cone shape (4mm) and it was plugged inside the BPF. Secondly, 5 mL of fibrin sealant was instilled into the distal end of the stump. Lastly, a 16 mm Dumon stent with 50 mm length was clipped each side and one end was closed with a nylon suture. An alloderm graft was cut and wrapped around the stent so it covered the end of the stent. After the wrapping, a suture was used to sew the alloderm to the stent. The modified stent was deployed by using the Storz Y-system. Upon completion of the procedure, the air leak had resolved. Then, patient underwent Video assisted thoracoscopic surgery with debridement of chest cavity and insertion of indwelling pleural catheter for management of infection. Patient was discharged home with six-week course of intravenous antibiotics. Discussion: The use of fibrin sealant for a closure of BPF of the central airways is usually not effective as the sealant spills into the pleural space. Fibrin sealant and Alloderm patch have been used for a closure of BPF. However, the alloderm patch is difficult to deploy and to stabilize in the desired location. We used a bone chip to clog the fistula which delayed the spillage of fibrin sealant into pleural cavity. We also report the use of Dumon stent as the splint to hold the alloderm patch in place. This method will allow the granulation tissue to heal and completely close the fistula. (Figure presented).