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J Thorac Cardiovasc Surg 2007;134:531-533
© 2007 The American Association for Thoracic Surgery

Brief Communication

Interventional closure of postpneumonectomy bronchial pleural fistula with a self-expandable double umbrella–shaped occluder knitted with nitinol shape memory alloy

Jianhua Zhang, MD, PhDa,*, Shengshou Hu, MD, PhDb,*, Bingren Gao, MD, PhDa, Debin Liu, MD, PhDb, Feixue Song, MDa, Bin Li, MDa, Yongzhu Yang, MDa, Shenjun Zhu, MD, PhDc, Zhiping Wang, MD, PhDa

a Department of Thoracic and Cardiovascular Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
b Department of Surgery, Cardiovascular Institute and Fuwai Hospital, Beijing, China
c The Medical College of Tsinghua University, Beijing, China.

Received for publication January 9, 2007; revisions received March 14, 2007; accepted for publication March 16, 2007.

* Address for reprint: Jian-hua Zhang, MD, PhD, Department of Thoracic and Cardiovascular Surgery, The Second Hospital of Lanzhou University, Lanzhou 730030, China. (Email: Zhangjianhua68{at}yahoo.com.cn; huss{at}163bj.com).

* Address for reprint: Sheng-shou Hu, MD, PhD, Department of Cardiovascular Surgery, Cardiovascular Institute and Fu-Wai Hospital, Beijing 100037, China. (Email: Zhangjianhua68{at}yahoo.com.cn; huss{at}163bj.com).


Figure 1
Dr Zhang


Postpneumonectomy bronchial pleural fistula (PBPF) is one of the most serious complications in cardiac surgery.1Go Surgical repair of PBPF would be of high risk. The interventional procedures available have limited effects on fistulas with larger orifices. We designed a double-umbrella occluder and used it in 6 patients from April 2002 through November 2006. The results are as follows.

Clinical Summary

A total of 6 patients (4 male and 2 female patients; age range, approximately 34–74 years) were included in this study. Patients had tuberculous thick walled cavity (n = 1), tuberculosis-destroyed lungs (n = 2), chronic lung abscess (n = 1), and central-type lung cancer (n = 2). One patient had preoperative radiotherapy, 1 patient had diabetes mellitus and an older age (74 years), and 1 patient had concomitant dyscrasia. A left entire pneumonectomy was performed in 4 patients, and a right entire pnemuonectomy was performed in 2 patients. The bronchial stump was closed by using manual suturing in 4 patients and a suture stapler in 2 patients. Fistulas and empyema occurred on postoperative days 7 to 21.

The occluder consists of a proximal umbrella, distal umbrella, proximal metal marker, distal metal marker, waist, and proximal nut (Figure 1, A). The internal filler was layers of polyester fabric, and the tectorial membrane was polyurethane. A Shape Memory Alloy Co Ltd manufactured the products.


Figure 1
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  		Figure 1. The preoperative preparation of PBPF. A, The bronchoscopic view of PBPF with a 5-mm diameter fistula orifice at the end of the left main bronchus. B, The designed draft of the double umbrella-shaped occlusive device and the pushing wire rope. PBPF, Postpneumonectomy bronchial pleural fistula.

 
A fibrobronchoscope was delivered, and then a guide wire was delivered into the orifice of the fistula. The fibrobronchoscope was extracted, with the guide wire left behind. The delivery sheath was delivered, and then the guide wire was extracted. The occluder was pushed in through the delivery sheath with a pusher. Subsequently, the distal umbrella, waist, and proximal umbrella were released. The delivery sheath was withdrawn, with the pusher left in place. The inflation examination was performed to make sure there was no air leakage through the chest tube. After the shape of the double umbrella was determined to be satisfactory by means of fluoroscopy, the pusher was screwed out. Because 1 patient could not tolerate general anesthesia, the procedure was done through an existing chest tube and succeeded.

All patients went back to the ward with chest tubes. Pleural space irrigation was performed with solution containing antibiotic and chymotrypsin. The follow-up included clinical examination, radiography, and fibrobronchoscopy in the first, second, and fourth weeks and every 3 months thereafter.

The duration of the operation ranged from 20 to 50 minutes. The operation was performed successfully once in 4 patients and twice in 2 patients to exchange larger occluders. During the procedure, the occluder expanded into a dumbbell shape (Figure 1, B) and the typical double-umbrella shape. The air leakage ceased within 24 hours in 3 patients and 1 week in others. The occluder was covered by a mucous membrane at 30 days (Figure 2). Complete healing of the empyema ranged from 2 to 5 months. No major operation-related complications occurred. No bronchial pleural fistula reoccurred. No patients died because of the recurrence of bronchial pleural fistula. One patient died 2 years after the operation because of the recurrence of lung cancer, and 1 died of dyscrasia 3 months later. The follow-up rate was 100%.


Figure 2
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  		Figure 2. The bronchoscopic view of the PBPF showing that the mucous membrane covered the occlusive device at 1-month follow-up. PBPF, Postpneumonectomy bronchial pleural fistula.

 
Discussion

Surgical repair of the bronchial stump of PBPF is restricted because of high risks, serious injury,2Go and a low success rate.

Some interventional techniques available, including endoscopic burning with a laser or chemistry materials, sclerosing agent injection, fibrin sealant injection, and covered stent placement, have been used because of their convenience, safety, and effectiveness. But they have difficulties in occluding orifice fistulas larger than 3 mm in diameter.3,4Go

Animal experiments5Go and our own clinical experiments have shown that interventional occlusion of a PBPF with a specifically designed double-umbrella occluder is a convenient, minimally invasive, economic, and time-saving technique. The occluder has good effect, especially on orifice fistulae of larger than 3 mm in diameter, and can be localized easily because of its special shape without stenosis and shifting. It neither produces sputum retention and abnormal flavor nor induces severe cough. The occluder is small in size, with a definite occluding effect and good histocompatibility. Although the procedure reported here might violate the principle of keeping prosthetic material away from an infected field, this compromise might be appropriate in selected patients. This kind of procedure could be especially useful in the treatment of main bronchus pleural fistulas because it is not easy to shift contrast with a stent. Placement of the occluder through an existing chest tube tract might be developed as a better route because there is no need for general anesthesia and an endotracheal procedure.

Conclusion

Interventional closure of the PBPF with a specially designed double-umbrella occluder is a safe, effective, and feasible approach. Because the number of cases is very limited, further studies are needed.

References

  1. Vester SR, Faber LP, Kirtle CF. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:1253-1257.[Abstract/Free Full Text]
  2. Javadpour H, Sidhu P, Luke DA. Bronchopleural fistula after pneumonectomy. Ir J Med Sci 2003;172:13-15.[Medline]
  3. Kiriyama M, Fujii Y, Yamakawa Y, et al. Endobronchial neodymium-yttrium-aluminum garnet laser for noninvasive closure of small proximal bronchopleural fistula after lung resection. Ann Thorac Surg 2002;73:945-948.[Abstract/Free Full Text]
  4. Hirata T, Ogawa E, Takenaka K, et al. Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate. Ann Thorac Surg 2002;74:2174.[Abstract/Free Full Text]
  5. Li Qiang, Yang Xiaoming, Gong Shanshi, et al. Development of bronchial occlusive device made of NiTi memory alloy and its application for bronchial closure in dogs. Acad J Second Milit Med University 2004;25:697-700.




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