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Endobronchial Valves for Treatment of Bronchopleural Fistula

2006; Elsevier BV; Volume: 81; Issue: 3 Linguagem: Inglês

10.1016/j.athoracsur.2005.02.074

1552-6259

Kristofer Mitchell, Theresa M. Boley, Stephen R. Hazelrigg,

Airway Management and Intubation Techniques

Endobronchial valves have recently emerged as a possible alternative to lung volume reduction surgery to treat incapacitating emphysema. The early experience with placement of these valves has been shown to be safe, with short-term improvements of quality of life in this patient population. We report a case in which these valves were used to treat a patient with a persistent air leak. Endobronchial valves have recently emerged as a possible alternative to lung volume reduction surgery to treat incapacitating emphysema. The early experience with placement of these valves has been shown to be safe, with short-term improvements of quality of life in this patient population. We report a case in which these valves were used to treat a patient with a persistent air leak. Persistent air leak is a common complication after any pulmonary surgery. The incidence of this complication has been reported to be as great as 46% [1Ciccone A.M. Meyers B.F. Guthrie T.J. et al.Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema.J Thorac Cardiovasc Surg. 2003; 125: 513-525Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar]. The standard methods of treating persistent air leak include continued chest tube suction, Heimlich valves, chemical pleurodesis, and reoperation [2Cerfolio R.J. Advances in thoracostomy tube management.Surg Clin N Am. 2002; : 833-848Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar]. We report an alternative therapy in this case report. A 66-year-old man with a history of asbestos exposure was evaluated for lung volume reduction surgery. He had severe bilateral heterogeneous changes with a residual volume of 228% predicted. A bilateral thoracoscopic lung volume reduction was performed with the finding of several adhesions, especially in the left side. The operation was performed, including stapled resection of the most diseased areas with polytetrafluoroethylene strips to buttress all staple lines. He was postoperatively extubated, but he had large bilateral leaks that developed in the early postoperative period. The right chest tube was removed, but a left tube was required for the next 122 days due to an air leak. The course included the removal of the left tube on postoperative day 41, but the redevelopment of fluid and pneumothorax required replacement of a tube on postoperative day 53. There were several chest tubes replacements made on the left side due to attempts to obtain closure or because of malfunction. Options discussed were pleurodesis, thoracotomy, or placement of endobronchial valves. The large leak that persisted suggested that pleurodesis was unlikely to be successful, and the patient's overall condition did not favor an open thoracotomy. The option of placing endobronchial valves was pursued given that we were fairly certain the leak was coming from the left upper lobe area. The Food and Drug Administration guidelines for compassionate use were followed for the endobronchial valve (Emphasys Medical, Inc, Redwood City, CA) device on this particular patient, and he was taken to the operating room. Through a bronchoscopy, a total of three (two medium and one small) Emphasys endobronchial valves (Emphasys Medical, Inc) were placed in the upper lobe orifice. In the operating room the placement of the valves caused cessation of the air leak, which substantiated treatment of the appropriate lung segment. In the recovery room the patient was noted to have a leak, which was then quite small and allowed the patient to be well controlled with a Heimlich valve. He was discharged home 13 days after valve placement with a Heimlich valve, and the chest tube was removed 1 week later in the office. Lung volume reduction surgery has been shown to be an effective palliative treatment for patients with advanced emphysema [1Ciccone A.M. Meyers B.F. Guthrie T.J. et al.Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema.J Thorac Cardiovasc Surg. 2003; 125: 513-525Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 3Date H. Goto K. Souda R. et al.Bilateral lung volume reduction surgery via median sternotomy for severe pulmonary emphysema.Ann Thorac Surg. 1998; 65: 939-942Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Bousamra 2nd, M. Haasler G.B. Lipchik R.J. et al.Functional and oximetric assessment of patients after lung reduction surgery.J Thorac Cardiovasc Surg. 1997; 113: 675-682Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. It has been well documented that the most common complication associated with lung volume reduction surgery is persistent air leak with a reported incidence as great as 46% [1Ciccone A.M. Meyers B.F. Guthrie T.J. et al.Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema.J Thorac Cardiovasc Surg. 2003; 125: 513-525Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 3Date H. Goto K. Souda R. et al.Bilateral lung volume reduction surgery via median sternotomy for severe pulmonary emphysema.Ann Thorac Surg. 1998; 65: 939-942Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. There have been reports of techniques using Heimlich valves and performing bedside chemical pleurodesis procedures in patients with persistent air leak [2Cerfolio R.J. Advances in thoracostomy tube management.Surg Clin N Am. 2002; : 833-848Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar]. In our patient, we used multiple thoracostomy tubes as well as Heimlich valves. During the prolonged hospital course, additional options to treat the air leak were discussed with the patient as previously described; these options included an experimental endobronchial valve procedure. We believed treating the air leak with pleurodesis was unlikely to be successful, and the option of using an endobronchial valve offered a less invasive option than open thoracotomy. Endobronchial valves have recently emerged as a possible alternative to lung volume reduction surgery to treat incapacitating emphysema (Fig 1). The early experience with placement of these valves has been shown to be safe, with short-term improvements of quality of life in this patient population [5Snell G.I. Holsworth L. Borrill Z.L. et al.The potential for bronchoscopic lung volume reduction using bronchial prostheses a pilot study.Chest. 2003; 124: 1073-1080Crossref PubMed Scopus (188) Google Scholar, 6Yim A.P. Hwong T.M. Lee T.W. et al.Early results of endoscopic lung volume reduction for emphysema.J Thorac Cardiovasc Surg. 2004; 127: 1564-1573Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar]. The mechanism of success of the valves is related to atelectasis in the region of the lung, which is distal to the one-way valve by preventing airflow into this area while allowing outflow of air (Fig 2A,2B). The Emphasys endobronchial valve (Emphasys Medical, Inc) consists of a silicone duckbill, and a one-way valve attached to a nitinol self-expanding stent with silicone seals (Fig 3). We present this case to note that consideration in using these valves may be an option with persistent air leak to prevent airflow into segments of the lung that are responsible for the air leak. This may be valuable in an occasional patient after lung volume reduction surgery.Fig 2(A) The endobronchial valve allows air to escape from the treated lung segment. (B) Air is diverted from the treated segment. Arrows indicate direction of airflow.View Large Image Figure ViewerDownload (PPT)Fig 3The endobronchial valve shown in perspective to a pencil eraser.View Large Image Figure ViewerDownload (PPT)