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Technical Innovation |
1
Department of Radio-diagnosis, Sanjay Gandhi Post-Graduate Institute of
Medical Sciences, Rae-Barelli Rd., Lucknow 226014, India.
2
Department of Anesthesiology, Sanjay Gandhi Post-Graduate Institute of Medical
Sciences, Lucknow 226014, India.
3
Department of Gastroenterology, Sanjay Gandhi Post-Graduate Institute of
Medical Sciences, Lucknow 226014, India.
Received February 23, 2000;
accepted after revision May 31, 2000.
Address correspondence to S. S. Baijal.
Introduction
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A 12-French Malecot catheter with water-seal drainage was placed in the posterior dependent loculation under sonographic and fluoroscopic guidance, and IV antibiotics were administered. Continuous drainage of pus with leakage of air was observed under water seal. Cavitogram obtained via this catheter revealed a large, irregular, loculated empyema cavity. After 10 days complete resolution of the empyema was seen with a resultant bronchopleural cutaneous fistula. Bronchography was planned to localize the fistula site and embolize the fistula.
After the tracheobronchial tree was topically anesthetized with 5 mL of lidocaine (Xylocaine 2% spray; Astra-Idl, Bangalore, India) administered through a 9-French minitracheotomy channel, a 6-French multipurpose angiography catheter placed over a 0.035-inch hydrophilic guidewire (Terumo, Tokyo, Japan) was used. With limited bronchography and small amounts of nonionic contrast medium, a fistulous tract from one of the subsegmental bronchi of the middle lobe to the loculated pneumothorax cavity was localized (Fig. 1B). With a coaxial microcatheter system (Tracker-18; Target Therapeutics, Fremont, CA), the fistula was embolized with 0.5 mL of N-butyl-2-cyanoacrylate (Nectacryl; Dr. Reddy's Laboratories, Hyderabad, India) mixed with 1.0 mL of iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France). Immediately after embolization, the pneumothorax cavity collapsed. However, 4 hr after the procedure the patient again started having air drainage through the chest tube, and repeated chest radiographs showed reappearance of the pneumothorax.
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A second procedure to embolize the fistulous tract and the involved bronchus as peripherally as possible was performed. Using a 6-French multipurpose catheter, we placed two approximately 2 x 10 mm metallic coils in the fistulous tract. Once the coils were in place, 1.0 mL of N-butyl-2-cyanoacrylate admixed with 2.0 mL of iodized oil (Lipiodol) was injected through a microcatheter; the fistula and the involved subsegmental bronchus were occluded (Fig. 1C). The patient had prompt reduction in the size of the loculated pleural cavity (Fig. 1D), and neither air nor pus discharge was observed through the chest tube over the next few days. The tube was removed after 1 week. Over 6 months of follow-up, the patient had no complaints pertaining to his chest. Sonograms and chest radiographs showed complete resolution of the empyema with healing of the fistula.
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Recently a variety of endobronchial occlusion methods performed with different bronchoscopes and a long list of embolic agents, which includes blood clots, gelatin, gelatin capsule—shaped silicon rubber plugs, machined brass screws, lead fishing sinkers, various sponge materials, tetracyclines, fibrin glue, cyanoacrylate, detachable balloons, and metallic coils, have been tried successfully [1,2,3,4,5,6,7,8]. The site of bronchopleural fistula can be determined with bronchoscopes or guidance of a balloon-tipped catheter into selected airways and inflation of the balloon. If the bronchus contributes to the fistula, balloon occlusion decreases or eliminates the air leak. Instillation of the radioisotopic xenon gas has also been used to locate the bronchial communication to the pleural space [1]. Small amounts of contrast material can also be used to localize the fistula site as was done in our patient.
In 1977, Hartmann and Rausch [2] reported closure of a postoperative peripheral fistula after two bronchoscopic applications of methylcyanoacrylate. Harald et al. [3] occluded bronchopleural fistulas in two patients using tissue glue. Solidification of glue takes approximately 10 sec. Apparently the method works initially by plugging the hole, whereas permanent closure results from an inflammatory process that seals the hole by fibrosis. It has also been shown that repair of fistula occurs by organization of granulation tissue and granulomas caused by foreign bodies. Epithelialization with typical respiratory epithelium has also been reported [3].
However, in 1982 Keller et al. [4] unsuccessfully used two applications of cyanoacrylate for repair of a persistent air leak that occurred after open lung biopsy. In 1987, Lan et al. [5] similarly could only temporarily occlude the fistula using autologous blood clot. However, the addition of doxycycline produced permanent closure, presumably by inducing local mucosal inflammation and edema [5]. In 1991, Walter et al. [1] also obtained fistula closure by instillation of tetracycline into the fistula via a fiberoptic bronchoscope using a balloon catheter and blood clot occlusion technique [1].
Ratliff et al. [6] reported in 1977 control of a bronchopleural fistula using the endoscopic placement of a lead shot after the fistula was localized by bronchoscopic manipulation of a Fogarty catheter. Christopher et al. [7] succeeded in 1990 in controlling a large parenchymal bronchopleural fistula, after surgical treatment had failed, by endobronchially placing angiographic occlusion coils under fluoroscopic guidance and applying fibrin glue.
In almost all the previous reports, bronchoscopes were used to localize the fistula and then to embolize it, with or without angiography catheters. To our knowledge, only one case of temporary balloon catheter occlusion of a bronchopleural fistula with an atrial septostomy catheter that was passed through the patient's endotracheal tube under fluoroscopic guidance without an endoscope has been reported [8]. In our patient, using guidewires and fluoroscopic guidance, we placed simple angiography catheters through a minitracheotomy channel to localize the fistula site and then to occlude it permanently with two indigenously made metallic coils and tissue glue. The minitracheotomy channel allowed better control and maneuverability of the catheters, and fluoroscopic guidance helped, because peripheral placement of embolization material was possible, in preventing complications such as significant collapse and pneumonitis. The first application of tissue glue in the fistulous tract alone achieved only partial closure, whereas the second application of metallic coils with tissue glue in the fistula and the involved subsegmental bronchus provided permanent closure. Closure of the subsegmental bronchus leading to the fistula helped by providing additional time for the fistula to heal, thus suggesting that embolization of both the fistulous tract and the bronchus is needed for a successful closure. The metallic coils presumably acted by providing a matrix for retaining the cyanoacrylate in addition to partially occluding the fistulous tract and possibly inducing local inflammation.
In summary, closure of a bronchopleural fistula can be achieved with angiography catheters under fluoroscopic guidance as a simple and minimally invasive treatment option that requires only topical anesthesia. Closure of an endobronchial fistula thus achieved can save the patient from the complications of surgery and general anesthetics.
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