Use of an Amplatzer Device for Endoscopic Closure of a Large Bronchopleural Fistula following Lobectomy for a Stage I Squamous Cell Carcinoma
We report on a 68-year-old woman with a history of a diffuse, large, B-cell, non-Hodgkin lymphoma of the thyroid and stomach (stage IV B). She underwent surgery (resection of a thyroidal mass) and was treated with chemotherapy after which complete remission was achieved. At that time, she also underwent tracheal stenting because of recurring aspiration related to a fistula (postoperative) between the oesophagus and the trachea.\nFive years later, she was diagnosed with a squamous lung carcinoma in the right lower lobe – stage IA. She smoked one package of cigarettes a day. A lobectomy was performed and the initial postoperative course was favourable. However, 5 days later, she started suffering from marked dyspnoea. During clinical examination, we noted a subcutaneous emphysema. Developing respiratory insufficiency with extensive bilateral infiltrates visible on chest X-ray prompted intubation and mechanical ventilation. Bronchoscopy revealed a large (approximately 10 mm in diameter) bronchopleural fistula in the middle of the right bronchial stump.\nInitial treatment with antibiotics, chest tube drainage and parenteral feeding failed. Since the patient had a high oxygen need, she was considered inoperable. Due to the size and central location of the fistula, conventional endoscopic treatment did not seem an option either. The tracheal stent was removed and tracheotomy was performed. Unfortunately, the patient remained septic and repeated bronchoscopy was needed to remove extensive, sticky, endobronchial secretions.\nSince no other therapeutic option was available, a 10-mm Amplatzer septal occluder device was eventually placed through the fistula. This device, originally developed for the endovascular closure of cardiac septal defects, consists of two expandable disks, made of nitinol wire mesh, connected by a central waist. The device can be compressed inside a catheter. By placing the catheter inside the defect and then releasing the device from the delivering sheath, the disks can anchor the device on either side of the defect.\nIn our case, a guide wire was introduced through the fistula under direct bronchoscopic visualization. Subsequently, a delivery sheath was pushed over the guide wire beyond the defect. The Amplatzer device was then placed by pulling the delivering sheath back gradually. The distal disk was first extruded and pulled back against the distal side of the defect. The central waist filled the actual defect. Then, the second disk was placed on the proximal side of the defect. Once positioned correctly, the device was released by unscrewing the attached cable.\nThe procedure was successful with almost complete closure of the fistula, but because of a small persistent air leak, BioGlue surgical adhesive was applied after a couple of days to obtain a complete seal of the bronchopleural fistula (fig. ). Within the next week, the patient could be weaned from ventilation. Bronchoscopic reassessment showed granulation tissue developing progressively around the device which caused further closure of the fistula. The patient was eventually discharged from the hospital to a rehabilitation facility several weeks after the insertion of the device. Follow-up 6 months after the insertion of the Amplatzer device was reassuring. There were no remaining symptoms and CT thorax showed a good position of the device and full expansion of the lung tissue without any remaining pleural cavity (fig. ).