An innovative use of the flexible fibreoptic scope to identify the tracheo-bronchial tree intraoperatively for closure of a bronchopleural fistula.

Sir,

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. It carries a high mortality and morbidity, is associated with prolonged hospital stay and is expensive. We present a case of transsternal closure of BPF where a particularly difficult surgical dissection of the mediastinal structures was aided by illumination provided from a flexible fibreoptic bronchoscope passed into the trachea.

A 28-year-old male underwent left lower lobectomy for bronchiectasis of tubercular origin after a course of antitubercular therapy. He developed a space infection and a persistent bronchopleural fistula. Multiple procedures like open thoracostomy, completion pneumonectomy, bronchial closure with omental flap transposition and thoracoplasty were performed. Yet, healing was not achieved. Cultures for the tuberculous pathogen were negative after subsequent surgeries. The patient presented with persistent cough, malaise and a non-healing lateral thoracotomy wound with a discharging sinus. Bronchoscopy revealed a bronchopleural fistula in the left main bronchus. Hence, it was decided to attempt closure of the BPF via the transsternal approach.

A pre-anaesthetic check-up was done. He had no comorbid conditions. Air entry was absent on the left side and normal vesicular breath sounds were auscultated on the right side. The chest X-ray showed non-homogenous opacity in the left lower zones with air shadow in the left upper zones. Other investigations were unremarkable. General anaesthesia was administered with Inj. fentanyl 2 μg/kg iv, Inj. propofol 2 mg/kg iv and Inj. atracurium 0.8 mg/kg iv. A 39 F right-sided double-lumen endotracheal tube was introduced and its position was confirmed by auscultation. A triple-lumen central venous catheter was introduced into the right internal jugular vein for monitoring the central venous pressure and administration of fluids and blood. The right radial artery was cannulated for beat to beat measurement of blood pressure and to monitor the arterial blood gas. The patient was positioned supine with a roll under the shoulder.

A standard median sternotomy approach was employed to enter the mediastinum. Dense adhesions due to chronic infections had distorted the anatomy and rendered dissection difficult. Intraoperatively, visualization and identification of the carina and main bronchi proved difficult. A pediatric flexible bronchoscope (size 3.7 mm Karl Storz) was introduced into the tracheal lumen of the double-lumen endotracheal tube and guided into the left main bronchial stump. Identification of the trachea and bronchi was thus possible due to the illumination provided by the bronchoscope. The left main bronchial stump was about 1 cm in length with a small bronchopleural fistula. It was resected and resutured; thereby, closure of the bronchopleural fistula was achieved. The infected empyema cavity was debrided and thoracoplasty done to obliterate the pleural space.

In our case, retropericardial dissection could not distinguish between the left main stem bronchus, right main stem bronchus and trachea due to dense adhesions and scar tissue. Dissection had to be performed between the right pulmonary artery, superior vena cava and the aorta to reach the left main stem bronchus. Surgical dissection without identification of the important structures in the mediastinum is fraught with danger and could lead to life-threatening complications. The fibreoptic scope illuminated the left main stem bronchus and made surgical dissection easy. A similar use of the fibreoptic scope to identify the structures intraoperatively could not be found in the literature.

Bronchoscopy has both a diagnostic and a therapeutic role in bronchopleural fistulas.[1] It attempts to localise the fistula, detects the aetiology and allows introduction of sealants into the fistulous tract.[23] The fibreoptic bronchoscope has been successfully used percutaneously to visualise the track of bronchopleural fistulas.[34]

In conclusion, we recommend the use of the fibreoptic bronchoscope intraoperatively to identify the tracheobronchial tree and surrounding structures to aid surgical dissection. The use of this instrument helped not only to reduce surgical time but also prevented catastrophic events that would have occurred had the surgery proceeded without accurate identification of the structures.