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Overview of Bronchopleural Fistula Management, with a Focus on Bronchoscopic Treatment

  • Interventional Pulmonology (SA Arias, Section Editor)
  • Published:
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Abstract

Purpose of Review

This review presents an overview of the management of bronchopleural fistula with a special focus on bronchoscopic treatment.

Recent Findings

Bronchopleural fistula is a common complication of lung resection. Once this complication occurs, morbidity and mortality are significant. Surgical repair leads to definitive management; however, most patients with bronchopleural fistula who underwent resection are too frail to undergo a second surgical procedure. In patients who are poor surgical candidates, bronchoscopic treatment has emerged as an excellent treatment option. Bronchoscopy allows for the instillation of sclerosing agents, glues or placement of various devices to seal the airway defect such as endobronchial valves and stents. Success rates of bronchoscopic management have been high; however, few studies have been published.

Summary

Bronchoscopic techniques for the management of bronchopleural fistulas have gained ground for transient or even definitive fistula closure. Endobronchial valves and stents are useful alternatives, especially for patients for whom surgery is a high-risk procedure.

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References

  1. Berkowitz DM. Endoscopic Management of Bronchopleural Fistulas. In: Ernst A, Herth FJF, editors. Principles and Practice of Interventional Pulmonology. New York, NY: Springer New York; 2013. p. 435–48.

  2. Secasanu V, Keshishyan S, Revelo AE. Evaluation and endoscopic management of persistent air leaks. Shanghai Chest. 2019;4.

  3. Nagahiro I, Aoe M, Sano Y, Date H, Andou A, Shimizu N. Bronchopleural fistula after lobectomy for lung cancer. Asian Cardiovasc Thorac Ann. 2007;15(1):45–8.

    Article  PubMed  Google Scholar 

  4. Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. The Journal of thoracic and cardiovascular surgery. 1992;104(5):1456–64.

  5. Alpert JB, Godoy MC, Degroot PM, Truong MT, Ko JP. Imaging the post-thoracotomy patient: anatomic changes and postoperative complications. Radiol Clin North Am. 2014;52(1):85–103.

    Article  PubMed  Google Scholar 

  6. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128(6):3955–65.

    Article  PubMed  Google Scholar 

  7. Liberman M, Muzikansky A, Wright CD, Wain JC, Donahue DM, Allan JS, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. The Annals of thoracic surgery. 2010;89(3):891–7; discussion 7–8.

  8. Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 2001;7(6):330–6.

    CAS  Google Scholar 

  9. Mao R, Ying PQ, Xie D, Dai CY, Zha JY, Chen T, et al. Conservative management of empyema-complicated post-lobectomy bronchopleural fistulas: experience of consecutive 13 cases in 9 years. J Thorac Dis. 2016;8(7):1577–86.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent air leaks. Chest. 2017;152(2):417–23.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Mehta RH, Hoag J, Borah A, Abramian E. Closure of a bronchopleural fistula complicating cryoprobe biopsy of the lung. Respirology case reports. 2018;6(5):e00319.

  12. Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii61–76.

  13. Lazarus DR, Casal RF. Persistent air leaks: a review with an emphasis on bronchoscopic management. J Thorac Dis. 2017;9(11):4660–70.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zanotti G, Mitchell JD. Bronchopleural Fistula and Empyema After Anatomic Lung Resection. Thorac Cardiovasc Surg. 2015;25(4):421–7.

    Google Scholar 

  15. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65 Suppl 2:ii18–31.

  16. Leuzzi G, Facciolo F, Pastorino U, Rocco G. Methods for the postoperative management of the thoracic oncology patients: lessons from the clinic. Expert Rev Respir Med. 2015;9(6):751–67.

    Article  CAS  PubMed  Google Scholar 

  17. Cerfolio RJ. Recent advances in the treatment of air leaks. Curr Opin Pulm Med. 2005;11(4):319–23.

    Article  PubMed  Google Scholar 

  18. Cerfolio RJ, Varela G, Brunelli A. Digital and smart chest drainage systems to monitor air leaks: the birth of a new era? Thorac Cardiovasc Surg. 2010;20(3):413–20.

    Google Scholar 

  19. Kim EA, Lee KS, Shim YM, Kim J, Kim K, Kim TS, et al. Radiographic and CT findings in complications following pulmonary resection. Radiographics: a review publication of the Radiological Society of North America, Inc. 2002;22(1):67–86.

  20. Ricci ZJ, Haramati LB, Rosenbaum AT, Liebling MS. Role of computed tomography in guiding the management of peripheral bronchopleural fistula. J Thorac Imaging. 2002;17(3):214–8.

    Article  PubMed  Google Scholar 

  21. Gaur P, Dunne R, Colson YL, Gill RR. Bronchopleural fistula and the role of contemporary imaging. J Thorac Cardiovasc Surg. 2014;148(1):341–7.

    Article  PubMed  Google Scholar 

  22. Keshishyan S, Revelo AE, Epelbaum O. Bronchoscopic management of prolonged air leak. J Thorac Dis. 2017;9(Suppl 10):S1034–46.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Sakata KK, Nasim F, Schiavo DN, Nelson DR, Kern RM, Mullon JJ. Methylene blue for bronchopleural fistula localization. J Bronchol Interv Pulmonol. 2018;25(1):63–6.

    Article  Google Scholar 

  24. Hirata T, Ogawa E, Takenaka K, Uwokawa R, Fujisawa I. Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate. Ann Thorac Surg. 2002;74(6):2174–6.

    Article  PubMed  Google Scholar 

  25. Tian Q, Qi F, An Y, Liu XC, Chen LA. Using the Chartis system to selectively target a lung segment with a persistent air leak. Eur Respir J. 2013;41(6):1461–3.

    Article  PubMed  Google Scholar 

  26. Zeng YM, Chen YF, Lin HH, Zhang XB. Use of endo-bronchial end-tidal CO(2) test for location of the pleural air leakage in patients with intractable pneumothorax. Ther Adv Respir Dis. 2018;12:1753465818756564.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Mark JB, McDougall IR. Diagnosis and localization of bronchopulmonary air leaks using ventilation scintigraphy. Chest. 1997;111(2):286–9.

    Article  CAS  PubMed  Google Scholar 

  28. Sarkar P, Patel N, Chusid J, Shah R, Talwar A. The role of computed tomography bronchography in the management of bronchopleural fistulas. J Thorac Imaging. 2010;25(1):W10–3.

    Article  PubMed  Google Scholar 

  29. Rahman NM, Maskell NA, Davies CW, Hedley EL, Nunn AJ, Gleeson FV, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536–43.

    Article  PubMed  Google Scholar 

  30. Piccolo F, Pitman N, Bhatnagar R, Popowicz N, Smith NA, Brockway B, et al. Intrapleural tissue plasminogen activator and deoxyribonuclease for pleural infection. An effective and safe alternative to surgery. Annals of the American Thoracic Society. 2014;11(9):1419–25.

  31. Leiter N, Pickering EM, Sangwan YS, Burrows WM, Friedberg JS, Sachdeva A. Intrapleural therapy for empyema in the setting of a bronchopleural fistula: a novel use of an intrabronchial valve. Ann Thorac Surg. 2018;106(3):e111–3.

    Article  PubMed  Google Scholar 

  32. Hooper CE, Edey AJ, Wallis A, Clive AO, Morley A, White P, et al. Pleural irrigation trial (PIT): a randomised controlled trial of pleural irrigation with normal saline versus standard care in patients with pleural infection. Eur Respir J. 2015;46(2):456–63.

    Article  PubMed  Google Scholar 

  33. Chawla RK, Madan A, Bhardwaj PK, Chawla K. Bronchoscopic management of bronchopleural fistula with intrabronchial instillation of glue (N-butyl cyanoacrylate). Lung India: official organ of Indian Chest Society. 2012;29(1):11–4.

    Article  Google Scholar 

  34. Cepeda S, Pajares V, Trujillo-Reyes JC, Torrego A. A new cyanoacrylate used as bronchial sealant in the endoscopic treatment of bronchopleural fistual. Arch Bronconeumol. 2017;53(3):168–9.

    Article  PubMed  Google Scholar 

  35. Scappaticci E, Ardissone F, Ruffini E, Baldi S, Revello F, Coni F. As originally published in 1994: Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Updated in 2000. The Annals of thoracic surgery. 2000;69(5):1629–30.

  36. Battistoni P, Caterino U, Batzella S, Dello Iacono R, Lucantoni G, Galluccio G. The use of polyvinyl alcohol sponge and cyanoacrylate glue in the treatment of large and chronic bronchopleural fistulae following lung cancer resection. Respiration; international review of thoracic diseases. 2017;94(1):58–61.

    Article  CAS  PubMed  Google Scholar 

  37. Potaris K, Mihos P, Gakidis I. Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery. Medical science monitor: international medical journal of experimental and clinical research. 2003;9(7):Pi79–83.

  38. Ranu H, Gatheral T, Sheth A, Smith EE, Madden BP. Successful endobronchial seal of surgical bronchopleural fistulas using BioGlue. Ann Thorac Surg. 2009;88(5):1691–2.

    Article  PubMed  Google Scholar 

  39. Katoch CD, Chandran VM, Bhattacharyya D, Barthwal MS. Closure of bronchopleural fistula by interventional bronchoscopy using sealants and endobronchial devices. Medical journal, Armed Forces India. 2013;69(4):326–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Glover W, Chavis TV, Daniel TM, Kron IL, Spotnitz WD. Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas. J Thorac Cardiovasc Surg. 1987;93(3):470–2.

    Article  CAS  PubMed  Google Scholar 

  41. York EL, Lewall DB, Hirji M, Gelfand ET, Modry DL. Endoscopic diagnosis and treatment of postoperative bronchopleural fistula. Chest. 1990;97(6):1390–2.

    Article  CAS  PubMed  Google Scholar 

  42. Hollaus PH, Lax F, Janakiev D, Lucciarini P, Katz E, Kreuzer A, et al. Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases. Ann Thorac Surg. 1998;66(3):923–7.

    Article  CAS  PubMed  Google Scholar 

  43. Mehta HJ, Malhotra P, Begnaud A, Penley AM, Jantz MA. Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel. Chest. 2015;147(3):695–9.

    Article  PubMed  Google Scholar 

  44. Jones DP, David I. Gelfoam occlusion of peripheral bronchopleural fistulas. Ann Thorac Surg. 1986;42(3):334–5.

    Article  CAS  PubMed  Google Scholar 

  45. Akgül AG, Özbay S, Mehmetoğlu SS, Liman ŞT, Sezer HF, Topçu S. Simple and economical management of a prolonged air leak. Journal of bronchology & interventional pulmonology. 2013;20(4):355–6.

    Article  Google Scholar 

  46. Aynaci E, Kocatürk CI, Yildiz P, Bedirhan MA. Argon plasma coagulation as an alternative treatment for bronchopleural fistulas developed after sleeve pneumonectomy. Interact Cardiovasc Thorac Surg. 2012;14(6):912–4.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Kiriyama M, Fujii Y, Yamakawa Y, Fukai I, Yano M, Kaji M, et al. Endobronchial neodymium:yttrium-aluminum garnet laser for noninvasive closure of small proximal bronchopleural fistula after lung resection. The Annals of thoracic surgery. 2002;73(3):945–8; discussion 8–9.

  48. Mahajan AK, Doeing DC, Hogarth DK. Isolation of persistent air leaks and placement of intrabronchial valves. J Thorac Cardiovasc Surg. 2013;145(3):626–30.

    Article  PubMed  Google Scholar 

  49. Kovitz KL, French KD. Endobronchial valve placement and balloon occlusion for persistent air leak: procedure overview and new current procedural terminology codes for 2013. Chest. 2013;144(2):661–5.

    Article  PubMed  Google Scholar 

  50. Reed MF, Gilbert CR, Taylor MD, Toth JW. Endobronchial valves for challenging air leaks. Ann Thorac Surg. 2015;100(4):1181–6.

    Article  PubMed  Google Scholar 

  51. Firlinger I, Stubenberger E, Müller MR, Burghuber OC, Valipour A. Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring. Ann Thorac Surg. 2013;95(4):1243–9.

    Article  PubMed  Google Scholar 

  52. Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, et al. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011;91(1):270–3.

    Article  PubMed  Google Scholar 

  53. Travaline JM, McKenna RJ Jr, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009;136(2):355–60.

    Article  PubMed  Google Scholar 

  54. Gilbert CR, Casal RF, Lee HJ, Feller-Kopman D, Frimpong B, Dincer HE, et al. Use of one-way intrabronchial valves in air leak management after tube thoracostomy drainage. Ann Thorac Surg. 2016;101(5):1891–6.

    Article  PubMed  Google Scholar 

  55. Majid A, Kheir F, Sierra-Ruiz M, Ghattas C, Parikh M, Channick C, et al. Assessment of fissure integrity in patients with intrabronchial valves for treatment of prolonged air leak. Ann Thorac Surg. 2019;107(2):407–11.

    Article  PubMed  Google Scholar 

  56. Watanabe S, Watanabe T, Urayama H. Endobronchial occlusion method of bronchopleural fistula with metallic coils and glue. Thorac Cardiovasc Surg. 2003;51(2):106–8.

    Article  CAS  PubMed  Google Scholar 

  57. Fruchter O, Kramer MR, Dagan T, Raviv Y, Abdel-Rahman N, Saute M, et al. Endobronchial closure of bronchopleural fistulae using amplatzer devices: our experience and literature review. Chest. 2011;139(3):682–7.

    Article  PubMed  Google Scholar 

  58. Klotz LV, Gesierich W, Schott-Hildebrand S, Hatz RA, Lindner M. Endobronchial closure of bronchopleural fistula using Amplatzer device. J Thorac Dis. 2015;7(8):1478–82.

    PubMed  PubMed Central  Google Scholar 

  59. Fruchter O, Bruckheimer E, Raviv Y, Rosengarten D, Saute M, Kramer MR. Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug. European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery. 2012;41(1):46–9.

    Google Scholar 

  60. Dutau H, Palot A, Haas A, Decamps I, Durieux O. Endobronchial embolization with a silicone spigot as a temporary treatment for massive hemoptysis: a new bronchoscopic approach of the disease. Respiration; international review of thoracic diseases. 2006;73(6):830–2.

    Article  PubMed  Google Scholar 

  61. Watanabe Y, Matsuo K, Tamaoki A, Komoto R, Hiraki S. Bronchial occlusion with endobronchial Watanabe Spigot. Journal of bronchology & interventional pulmonology. 2003;10(4):264–7.

    Google Scholar 

  62. Himeji D, Tanaka GI, Fukuyama C, Shiiba R, Yamanaka A, Beppu K. Clinical evaluation of endoscopic bronchial occlusion with an endobronchial Watanabe Spigot for the management of intractable pneumothorax, pyothorax with bronchial fistula, and postoperative air leakage. Internal medicine (Tokyo, Japan). 2020;59(15):1835–9.

    Article  Google Scholar 

  63. Mizumori Y, Nakahara Y, Hirata N, Hiraoka R, Kominami R, Hirano K, et al. Toward easy and rapid bronchial occlusion with an endobronchial Watanabe Spigot: a new technique using a guide sheath and curette. J Bronchol Interv Pulmonol. 2020;27(2):122–7.

    Article  Google Scholar 

  64. Watanabe 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(1):276–8.

    Article  CAS  PubMed  Google Scholar 

  65. Tsukada H, Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula. Ann Thorac Surg. 2005;80(5):1928–30.

    Article  PubMed  Google Scholar 

  66. Cusumano G, Terminella A, Vasta I, Riscica Lizzio C, Bellofiore S, Saita S. Endoscopic stenting for double bronco-pleural fistula after lobectomy. Asian Cardiovasc Thorac Ann. 2015;23(8):995–7.

    Article  PubMed  Google Scholar 

  67. Bellato V, Ferraroli GM, De Caria D, Infante MV, Cariboni U, Spoto MR, et al. Management of postoperative bronchopleural fistula with a tracheobronchial stent in a patient requiring mechanical ventilation. Intensive Care Med. 2010;36(4):721–2.

    Article  PubMed  Google Scholar 

  68. Ferraroli GM, Testori A, Cioffi U, De Simone M, Alloisio M, Galliera M, et al. Healing of bronchopleural fistula using a modified Dumon stent: a case report. J Cardiothorac Surg. 2006;1:16.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Dutau H, Breen DP, Gomez C, Thomas PA, Vergnon JM. The integrated place of tracheobronchial stents in the multidisciplinary management of large post-pneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2011;39(2):185–9.

    Article  Google Scholar 

  70. Cao M, Zhu Q, Wang W, Zhang TX, Jiang MZ, Zang Q. Clinical application of fully covered self-expandable metal stents in the treatment of bronchial fistula. Thorac Cardiovasc Surg. 2016;64(6):533–9.

    Article  PubMed  Google Scholar 

  71. Han X, Yin M, Li L, Zhu M, Ren K, Qi Y, et al. Customized airway stenting for bronchopleural fistula after pulmonary resection by interventional technique: single-center study of 148 consecutive patients. Surg Endosc. 2018;32(10):4116–24.

    Article  PubMed  Google Scholar 

  72. Freitag L, Gördes M, Zarogoulidis P, Darwiche K, Franzen D, Funke F, et al. Towards individualized tracheobronchial stents: technical, practical and legal considerations. Respiration; international review of thoracic diseases. 2017;94(5):442–56.

    Article  CAS  PubMed  Google Scholar 

  73. Huang W, Shan Q, Wu Z, Li H, Zhou M, Ding X, et al. Retrievable covered metallic segmented Y airway stent for gastrorespiratory fistula of carina or main bronchi. J Thorac Cardiovasc Surg. 2021;161(5):1664-71.e2.

    Article  PubMed  Google Scholar 

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Aliaga, F., Grosu, H.B. & Vial, M.R. Overview of Bronchopleural Fistula Management, with a Focus on Bronchoscopic Treatment. Curr Pulmonol Rep 11, 65–73 (2022). https://doi.org/10.1007/s13665-022-00289-3

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