Healing of bronchopleural fistula using a modified Dumon stent: a case report
© Ferraroli et al; licensee BioMed Central Ltd. 2006
Received: 02 May 2006
Accepted: 23 June 2006
Published: 23 June 2006
Brochopleural fistula following lung resection is a therapeuric challenge for thoracic surgeons.
We describe a case of late bronchopleural fistula after right extrapleural pneumonectomy for malignant mesothelioma. Bronchoscopic attempts to repair it were unsuccessful.
The use of a modified Y Dumon stent associated with glue apposition on the bronchial stump allowed us to close the fistula without the need of any surgical repair.
The appearance of a bronchopleural fistula is a well-known and frightening complication of pulmonary surgery. Different methods have been used to solve this problem conservatively, from bronchial gluing  to stent placement. The latter includes the self-expandable stent  or classic Dumon stent . In this case we used a modified Y Dumon stent in an attempt to close a bronchopleural fistula which appeared 10 months after a right extrapleural pneumonectomy for malignant mesothelioma.
A 64-year old man was referred to our department for right recurrent pleural effusion. A CT scan showed thickened right parietal pleura with a minimal pleural effusion, but no pulmonary nodules or lymphadenopathies or distant metastases. Because of negative cytology malignancy, the patient underwent a thoracoscopic pleural biopsy on December 2004 that showed an epithelioid monophasic pleural mesothelioma, followed by talc pleurodesis at the end of the procedure.
Three weeks later the patient underwent a right extrapleural pneumonectomy with coverage of the bronchial stump with a flap of thymic tissue. The pathological examination confirmed a monophasic epithelioid pleural mesothelioma, with lung and pericardial fat infiltration, but no invasion of the diaphragm or pericardium (pT3 N0 M0). The postoperative period was uneventful.
The negative cultures from the pleural fluid allowed us to remove the chest drain and to discharge the patient on the 3rd postoperative day. The patient was uneventful (no empyema or pneumonitis verified) until he died 4 months later for pulmonary emboli. The post-mortem examination showed a massive pulmonary thrombus in the left main pulmonary artery which explain the sudden respiratory insufficiency and death at home and an initial relapse of mesothelioma in the posterior part of chest wall, without signs of infections.
Biologic glue has been used to treat bronchopleural fistulas, and its efficacy has been demonstrated . When no results are obtained with the biological glue, the Dumon stent is an acceptable option to exclude the bronchial stump from ventilation and to prevent the fistula from staying open, because of the positive pressure exerted on it during breathing, as well as to avoid aspiration pneumonia and the maintenance of empyema .
Usually, it is more difficult to treat a fistula on a main bronchus, both for the presence of a single lung and the challenge of inserting the appropriate stent for the changed anatomy following a pneumonectomy. A self-expandable covered tracheobronchial stent could solve this problem for its ability to adequately fit the tracheal and bronchial size as well described in a previous report .
The use of a modified Y Dumon stent has some other advantages. First, it can be removed when the patient does not tolerate a foreign body in the bronchial tree; second, it does not give frightening complications such as erosion of the mucosa, with the possibility of perforation and/or severe bleeding.
The only points for careful consideration in this kind of stent are to adequately evaluate the size of the trachea and bronchus, to avoid air or fluid filtration and then the possibility to keep the fistula patent. This has already been well described in other papers where the same kind of modified Dumon stent was used [4, 5]. We used the stent as a first choice, closing the fistula immediately after its appearance without any previous surgical procedure as in the case reported by Tsukada and coll. .
It is our opinion that this kind of procedure could be useful in the treatment of main bronchus pleural fistulas, and it could be even used in larger ones, eventually associated with apposition of several devices (glue, atoxysclerol, TachoSil, etc.). We also believe that this stent could be performed as a first choice when the fistula appears, thereby avoiding any surgical procedure.
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