Interact CardioVasc Thorac Surg 2009;8:697-698. doi:10.1510/icvts.2008.201814
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Thoracic oncologic |
Management of a complicated pulmonary fistula caused by lung cancer using a fibrin glue-soaked polyglycolic acid sheet covered with an intercostal muscle flap
Tomohiro Maniwa*,
Hiroyuki Kaneda and
Yukihito Saito
Department of Thoracic Cardiovascular Surgery, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shinmachi, Hrakata, Osaka, Japan
Received 31 December 2008;
received in revised form 19 February 2009;
accepted 20 February 2009
*Corresponding author. Tel.: +81-72-804-0101; fax: +81-6-6994-7022.
E-mail address: maniwat{at}hirakata.kmu.ac.jp (T. Maniwa).
 |
Abstract
|
|---|
Pulmonary fistulas caused by tumours are very fragile and difficult to suture directly. It is impossible to close pulmonary fistulas with tissue sealants when massive air leakage occurs in the low pressure of the respiratory tract. A 73-year-old man with a pneumothorax caused by lung cancer had suffered a persistent massive air leakage for more than one month. We used a fibrin glue-soaked polyglycolic acid (PGA) sheet for sealing the complicated fistula. In addition, the visceral pleura of the fistula was wrapped with the pedicle of an intercostal muscle (ICM) flap to prevent massive air leakage. The pneumothorax did not reappear after surgery. Thus, a fibrin glue-soaked PGA sheet covered with an ICM flap was effective for sealing an intractable air-leaking fistula caused by lung cancer.
Key Words: Lung cancer; Pneumothorax; Intercostal muscle flap
|
1. Introduction
|
|---|
Direct suturing cannot control pulmonary fistulas caused by malignant tumours. We often use tissue sealants such as fibrin glue, a fibrin sheet or a fibrin glue-soaked polyglycolic (PGA) sheet for such cases [1–3]. However, when massive air leaks occur in the low-pressure environment of the respiratory tract, we cannot control them simply with tissue sealants. On the other hand, intercostal muscle (ICM) flaps have been used successfully for reinforcing bronchial stumps or bronchial fistulas [4–6]. Here, we used a fibrin glue-soaked PGA sheet covered with ICM for sealing an intractable air leak caused by lung cancer.
|
2. Case report
|
|---|
A 73-year-old man was referred to Kansai Medical University Hospital for treatment of a persistent massive air leakage that had lasted for more than one month. Chest computed tomography scans revealed a mass measuring 4.8x4.0 cm in the right upper lung lobe (Fig. 1a), multiple small nodules on the pleura and a deflated right lung (Fig. 1b). The patient's white blood cell count was 9.6x109/l and his C-reactive protein level was 2.46 mg/dl. Positron emission tomography using 18F-fluorodeoxyglucose uptake showed multiple lung and adrenal tumours (Fig. 1c). All cultures of pleural effusions taken from a chest tube before surgery were negative.
View larger version (125K):
[in this window]
[in a new window]
|
Fig. 1. (a) Chest computed tomography (CT) revealed a mass measuring 4.8x4.0 cm in the right upper lobe. (b) CT revealed multiple small nodules on the pleura and deflating right lung. (c) Positron emission tomography revealed 18F-fluorodeoxyglucose uptake in multiple lung tumours and in the adrenal gland.
|
|
We considered this to be a fistula caused by ruptured lung cancer based on these findings. Thoracoscopy revealed a pulmonary fistula associated with a large lung tumour of the right upper lobe (Fig. 2a). This barely invaded the right lower lobe. Histopathology of a tumour on intercostal pleura biopsy showed a poorly differentiated adenocarcinoma of the lung by thoracoscopy. All lobes showed severe emphysema. It was impossible to perform right upper lobectomy and suture this complicated pulmonary fistula directly. We decided that the patient needed to undergo an axillary thoracotomy, harvesting an ICM flap to cover this complicated pulmonary fistula. The length of incision was 10 cm using a video thoracoscope. The fourth ICM was harvested from the inferior edge of the fourth rib using cautery (setting 40) and then applied to cover the fistula. First, we used a fibrin glue-soaked (Bolheal, the Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan) PGA sheet (Neoveil, Gunze Ltd, Kyoto, Japan) (Fig. 2b, c). In addition, we covered the visceral pleura of the fistula with the pedicled ICM flap to prevent massive air leakage (Fig. 2d). The patient's postoperative course has been good. The patient and his family did not desire chemotherapy, and he was discharged 23 days postoperatively. There has been no recurrence of the pneumothorax for ten months.
View larger version (124K):
[in this window]
[in a new window]
|
Fig. 2. (a) Thoracoscopy revealed a pulmonary fistula of large lung tumour of the right upper lobe. (b, c) We used a fibrin glue-soaked polyglycolic acid sheet for covering the pulmonary fistula. (d) We covered the visceral pleura of the fistula with a pedicled intercostal muscle flap to prevent massive air leakage.
|
|
|
3. Discussion
|
|---|
Pulmonary fistulas caused by lung tumours, with accompanying emphysema, cannot be controlled by direct suturing, but fibrin glue-soaked PGA sheets have been used [1]. However, such approaches are ineffective when massive air leaks occur in the respiratory system, and the leaks are likely to recur. Mizuno et al. [2] reported that they used PGA sheets and fibrin glue for uncontrollable air leaks in 90 cases, including three patients with infectious diseases. Nakamura et al. [3] used PGA sheets and fibrin glue for patients with infectious thoracopathies such as emphysema and lung abscesses, and the air leaks were controlled successfully. The patients had no complications caused by infections in either study. Thus, there is no evidence for an interrelationship between the use of fibrin glue-soaked PGA sheet and postoperative infections. On the other hand, it was reported that PGA sheets promoted fibroblast infiltration from the tissue and caused thickening of the pleura [7].
Harvesting an ICM flap is easy, and this muscle has a good blood flow. Therefore, pedicled ICM flaps have often been used for treating bronchial fistulas or for reinforcing bronchial stumps [4–6]. It takes between 45 s and 12 min to harvest an ICM flap [5, 8, 9]. Cerfolio et al. [8, 9] reported that the use of an ICM flap reduces the pain of thoracotomy, as it avoids damage to the intercostal nerves from the retractor. We also examined harvesting the ICM, and found that this procedure did not seem to increase the blood loss during surgery, or pain or chest-tube volume after surgery [5, 6]. Covering with a wide ICM graft helps to prevent re-leakage. Therefore, we conclude that harvesting ICM is not excessive surgery, and in this case grafting associated with a fibrin glue-soaked PGA sheet helped to close a complicated pulmonary fistula caused by lung cancer.
|
References
|
|---|
- Miyamoto H, Futagawa T, Wang Z, Yamazaki A, Morio A, Sonobe S, Izumi H, Hosoda Y, Hata E. Fibrin glue and bioabsorbable felt patch for intraoperative intractable air leaks. Jpn J Thorac Cardiovasc Surg 2003;51:232–236.[CrossRef][Medline]
- Mizuno H, Hitomi S, Nakamura T, Shimizu Y. Clinical experience of the combined use of polyglycolide non-woven felt with fibrin glue to prevent postoperative pulmonary fistula. [Article in Japanese] Nippon Kyobu Geka Gakkai Zasshi 1995;43:1559–1564.
- Nakamura T, Shimizu Y, Watanabe S, Hitomi S, Kitano M, Tamada J, Matsunobe S. New bioabsorbable pledgets and non-woven fabrics made from polyglycolide (PGA) for pulmonary surgery: clinical experience. Thorac Cardiovasc Surg 1990;38:81–85.[CrossRef][Medline]
- Hollaus PH, Huber M, Lax F, Peter N, Bohm W, Nestor S, Pridum. Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap. Eur J Cardiothorac Surg 1999;16:181–186.[Abstract/Free Full Text]
- Maniwa T, Saito Y, Kaneda H, Imamura H. Bronchial stump reinforcement with the intercostal muscle flap without adverse effects. Eur J Cardiothorac Surg 2006;30:652–656.[Abstract/Free Full Text]
- Maniwa T, Saito Y, Kaneda H. Intercostal muscle flap without increase of pain and blood loss after lung surgery. J Thorac Cardiovasc Surg 2006;131:1422–1423; authors' reply 1423–1424.[Free Full Text]
- Gika M, Kawamura M, Izumi Y, Kobayashi K. The short-term efficacy of fibrin glue combined with absorptive sheet material in visceral pleural defect repair. Interact Cardiovasc Thorac Surg 2007;6:12–15.[Abstract/Free Full Text]
- Cerfolio RJ, Bryant AS, Patel B, Bartolucci AA. Intercostal muscle flap reduces the pain of thoracotomy: a prospective randomized trial. J Thorac Cardiovasc Surg 2005;130:987–993.[Abstract/Free Full Text]
- Cerfolio RJ, Bryant AS, Maniscalco LM. A non-divided intercostal muscle flap further reduces pain of thoracotomy: a prospective randomized trial. Ann Thorac Surg 2008;85:1901–1906.[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction