Commentary: An innovative, minimally-invasive approach to post-pneumonectomy bronchopleural fistula.

Irmina A. Elliott, MD, Harmeet S. Bedi, MD, and Natalie S. Lui, MD

Creative bronchoscopic techniques, such as occlusion with an Amplatzer vascular plug, should be considered in the management of postoperative bronchopleural fistula in carefully selected patients.

See Article page 345.

In this issue of the Journal, Menezes and colleagues present a case of a bronchopleural fistula (BPF) in a patient presenting 2 months after left pneumonectomy with a chronic cough without signs of infection and an air-fluid level in the left chest. The patient had previously received immunotherapy (but not radiation), and the bronchial stump had been buttressed with an intercostal muscle flap intraoperatively. The BPF was successfully closed bronchoscopically using an Amplatzer vascular plug II (AVP).

The AVP is a braided nitinol mesh plug first designed for atrial septal closure and now often used in interventional radiology for embolization of bleeding; the device costs on the order of $1000. The available diameters, lengths, and small guide catheters used to deploy the plug are well suited to bronchoscopic use. Use of the AVP is among a host of minimally invasive techniques that have been successfully used to treat postoperative BPFs. These include application of products or use of devices such as fibrin glue, coils, valves, and even carbolic acid., Covered stent placement spanning the trachea to the contralateral mainstem bronchus to exclude the bronchial stump is also an option, although seating the stent can be challenging. Because this complication is rare, data to support any specific approach will likely remain limited to case series.

One concern about any technique requiring insertion of a device through the BPF is further injury or expansion of the fistula. This is especially concerning for smaller BPFs that might be difficult to visualize and access. For this reason, we urge caution when considering this technique and advise collaborating with an interventionalist with the AVP experience to assist in the case.

It also should be noted that foreign bodies in the airway can cause significant granulation tissue. The production of granulation tissue is unpredictable and very patient-specific; some patients can develop bulky granulation tissue within 4 weeks, whereas others never do. For this reason, the length of the bronchial stump should be taken into consideration when planning bronchoscopic intervention. In a patient with a very short left mainstem stump, any granulation tissue could easily lead to right mainstem obstruction, in the same way that patients can develop mainstem obstruction from granulation originating from a stent located in the contralateral mainstem bronchus. If this were to occur in a patient with a BPF, removing the plug might not be an option.

Collaboration with an interventionalist experienced in use of the chosen device, as well as careful consideration of the anatomy, including size of the fistula, stump length, and relation to the trachea and contralateral bronchus, are critical for planning minimally invasive management of BPFs. Patients with a postoperative BPF and signs of sepsis who are reasonable surgical candidates are probably still best managed with aggressive surgical debridement, closure, and tissue flap coverage. However, in patients with a more indolent clinical presentation, or those who are too deconditioned to undergo surgery, creative minimally invasive approaches should be considered to minimize the morbidity associated with reoperation.

We congratulate the authors on an innovative and successful solution to a difficult clinical problem.