Bronchopleural fistula after robotic-assisted pulmonary lobectomy

Bronchopleural fistula (BPF) is defined as a communication between a lobar or segmental pulmonary bronchi and the pleural space. It can be a late as well as early postlobectomy or postpneumonectomy complication. The incidence of BPF is 0.5% postlobectomy and can be up to 28% post pneumonectomy. It is more frequent on the right side (13.2%) compared with the left (5%) [McManigle et al. 1990; Cerfolio, 2001; Darling et al. 2005]. Moreover, the mortality is higher on the right (44%) compared with the left side (33%) [Darling et al. 2005]. The risk factors for BPF include right-sided pneumonectomy, infectious complications, radiation or chemotherapy, leaving residual tumor, long stump and surgeon inexperience, among others [Darling et al. 2005, Sato et al. 1989]. The clinical presentation ranges from acute dyspnea, fever and cough to hemoptysis, subcutaneous emphysema and persistent air leak. In some instances, BPF can lead to life threatening tension pneumothorax with cardiovascular collapse and death. In some cases, patients with BPF can present chronically with wasting, malaise and relapsing fever [Lois and Noppen, 2005]. The diagnosis of BPF is usually suggested with persistent leak through the chest tube. Chest radiographs frequently demonstrate a new or multiple air–liquid levels in the postpneumonectomy space, or a change in a preexisting air–liquid level. BPF can be confirmed by bronchoscopy; however it can be falsely negative in cases of small distal fistulas and the use of various bronchoscopic techniques such as bronchography, methylene blue instillation, capnography and balloon-tipped catheter reliably make the diagnosis [Sarkar et al. 2010]. If the location of the BPF remains in doubt, ventilation scintigraphy can be performed with high sensitivity and specificity [Raja et al. 1999].

The initial step in managing patients with BPF is hemodynamic stabilization, such as insertion of a chest tube in the presence of tension pneumothorax or drainage of an infected pleural space. The next step is the closure of the BPF, which can be done surgically as well as bronchoscopically. Surgical options are usually successful (95%) and consist of direct stump closure with or without intercostal muscle reinforcement, omental flap, thoracoplasty and chronic open drainage [Stamatis et al. 1994]. Bronchoscopically, different sealing compounds can be applied, such as tissue glue, lead shot, ethanol, water-soluble polyethylene glycol-based gel, cyanoacrylate glue, fibrin glue, albumin-glutaraldehyde tissue adhesive, gel foam, coils, balloon catheter occlusion, stent and others.

In our practice, we had a 67-year-old man who underwent bilobectomy for bronchogenic carcinoma affecting the right middle and lower lobes. The DaVinci surgical robot was used to dissect the bronchus intermedius, which was stapled with an Endo-GIA-60 stapler, thereby isolating and preserving the upper lobe.

The right chest tube was removed 3 days postoperatively with no signs of pneumothorax and with full right upper lobe expansion. The patient developed worsening shortness of breath 24 h later and was found to have large right pneumothorax, and therefore, a large bore chest tube was reinserted. Two days later, flexible bronchoscopy was performed for persistent leak, in an effort to locate and possibly seal the BPF. With the bronchoscopy at the distal part of the right main stem bronchus, the surgical stump was found to be open with direct clear visualization of the heart beating (Figures 1 and 2). As a result, thoracoscopy was performed over and the bronchopleural fistula was closed using interrupted 5-0 polypropylene sutures. The patient did well and was discharged a week later.

Figure 1.

Bronchoscopic view at the level of the main stem bronchus showing a large bronchopleural fistula.

Figure 2.

Closer view directly visualizing the heart through the bronchopleural fistula.