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J Thorac Cardiovasc Surg 2009;138:603-607
© 2009 The American Association for Thoracic Surgery

General Thoracic Surgery

Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae

^a Critical Care and Respiratory Division, University of Athens, Athens, Greece
^b Pulmonary Diseases Unit, Department of Internal Medicine, Immunoallergic and Respiratory diseases, "Ospedali Riuniti," Ancona, Italy
^c Thoracic Surgery Department, "Evaggelismos" Hospital, Athens, Greece
^d Anesthesiology Department, "Evaggelismos" Hospital, Athens, Greece

Received for publication July 17, 2008; revisions received September 20, 2008; accepted for publication October 26, 2008.

^_* Address for reprints: Charalambos Zisis, MD, FETCS, Department of Thoracic Surgery, "Evangelismos" Hospital 45-47, Ipsilantou St, 106 75 Athens, Greece. (Email: chzisis{at}hol.gr).

Objective: Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways.

Methods: Consecutive patients with small (5 mm) bronchopleural fistulae in proximal airways were included in the study. After measurement of bronchopleural fistula size through a flexible videobronchoscopy, a standard bronchoscopic cytology brush covered with silver nitrate was passed through the working channel of the scope and was rubbed against the fistula's orifice producing blanching and edema on the mucosa. This procedure was repeated until closure of the fistula's orifice (treatment success) or absence of any tissue response after 2 bronchoscopic sessions (treatment failure).

Results: Of 16 patients referred, 5 were excluded from treatment because of large (>5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2–5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8% success rate) after a median of 2.5 (range 1–10) applications of silver nitrate. After 11 (0.5–24) months of follow-up, no relapse was observed among successfully treated fistulae.

Conclusion: The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases.