eComment. Post-pneumonectomy empyema with bronchopleural fistula

In this article by Andreetti and colleagues [1], the authors described a modification in the implantation of a tracheobronchial stent to exclude a bronchopleural fistula (PBF) by anchoring it to the tracheal mucosal surface using titanium helical fasteners.

The conical-shaped, fully-covered and self-expandable stent (Tracheobronxane Silmet, Novatech SA, France) was successfully used in six patients with post-pneumonectomy BPF. Early identification of the BPF and urgent (within few hours of fistula occurrence) endoscopic implantation and anchoring of the Silmet stent ensured excellent results in all patients without distal migration of the stent.

What is remarkable in their report is that none of their patients presented with empyema. We would like to ask the authors if they are disposed to implanting the Silmet stent in patients with post-pneumonectomy empyema?

Traditionally in the case of post-pneumonectomy empyema, the BPF must be debrided and the bronchial stump closed and reinforced by an intrathoracic transposition of omentum or muscle flaps [2]. However, isolation of the hilar element and identification of the fistula could be difficult due to mediastinal edema and fibrosis. In the latter case, surgical management consists of an open window thoracotomy and involves daily changes of the intracavitary wound dressings over a long period of time.

Negative pressure wound therapy (NPWT) such as the vacuum assisted closure (VAC) therapy device (KCI Inc, San Antonio, TX) has been adopted as an alternative method to classic wound dressings, owing to the accelerated wound healing process [3]. VAC promotes healing through the enhancement of granulation tissue formation, the removal of exudates and oedema, increased tissue perfusion and oxygenation, and wound volume reduction [4]. One major drawback in the application of VAC therapy in the thoracic cavity is the presence of air leaks. To ensure adequate functioning of the VAC system placed inside the chest, the deployment of the Silmet stent in case of a large fistula is an appropriate technique to stop air leaks.

Passera et al. [5] recently published a case report concerning a patient with a large bronchopleural fistula and empyema. The surgical strategy consisted of an open window thoracostomy, surgical debridement of the bronchial stump and the deployment of an Amplatzer septal occluder device (AGA Medical Corp, Plymouth, MN) to close the BPF. Thereafter, the thoracostomy rapidly and spontaneously closed with VAC therapy.

The combination of endoscopic occlusion of the PBF in the setting of post-pneumonectomy empyema (by using the Silmet stent plus anchoring system or Amplatzer septal occluder device) and application of VAC therapy through the open window thoracotomy seems not only to be safe and effective but also appears to accelerate the healing process and reduce the hospital stay. Future studies with larger numbers of patients will be required to validate the efficacy of the procedure and to draw definitive conclusions.

Conflict of Interest: None declared