Comprehensive treatment of bronchopleural fistulae via fiberoptic bronchoscopy Abstract Objective To introduce the method and experience of treating bronchopleural fistulae at the stump via fiberoptic bronchoscopy. Methods From 1999 to 2007, 6 cases of bronchopleural fistula were treated by fiberoptic bronchoscopy using protein gel sealing method and submucosal sclerotherapy injection method, 3 cases after left upper pneumonectomy, 1 case after right upper pneumonectomy and 2 cases after left lower pneumonectomy. In all cases, the fistula was diagnosed by fiberoptic bronchoscopy, and the fistula was sealed by coagulation of bioprotein glue and cured by submucosal injection of sclerosing agent followed by augmentation and compression of the fistula. The fistula was healed on review of the fistula by fibronectomy. In two cases, the submucosal sclerosing agent was injected on both sides of the fistula, and the fistula was completely closed, and the treatment was successful in one case. in one case, the fistula was about 3 mm, and the first protein glue closure failed, and the fistula was cured after re-injection of sclerosing agent. Conclusion The fibreoptic bronchoscopic sealant method and submucosal sclerosing agent injection method are effective, less invasive, less expensive and safer, and should be the treatment of choice for bronchial stump fistula. Background Bronchopleural fistula is a serious complication after pneumonectomy, and its incidence is less than 1% with the use of disposable tracheal stump closures, but once it occurs and is combined with abscess chest, its mortality rate reaches more than 50%, and the incidence of fistula after total pneumonectomy in the elderly has also been reported to be up to 5%. The main causes are technical defects, stump lesions, post-chemotherapy, diabetes mellitus, anemia, etc. The traditional treatment is closed chest drainage and antibiotic and nutritional support for small fistulas to allow self-healing, and active open-chest secondary surgery to close large fistulas, but most of them fail, and many patients have no chance for secondary surgery due to severe infection in poor physical conditions. With the advancement of technology, endoscopic treatment has become mainstream, and its treatment techniques include OB glue blocking (protein glue blocking method1, trichloroacetic acid procedure, metal endoprosthesis, submucosal injection, etc., which can allow most fistulas to heal. However, a few cases failed to achieve fistula closure after the above methods. The authors have personally treated 6 cases of bronchopleural fistulae with good results via fiberoptic bronchoscopy from 1999 to 2007, and the experience is presented below. Patient data Six cases, male to female ratio 4:2, age 45-73 years, lesion types: 4 cases of lung cancer, 1 case of bronchiectasis, 1 case of tuberculosis, bronchial stump fistula sites: 3 cases after left upper pneumonectomy, 1 case after right upper pneumonectomy, and 2 cases after left lower pneumonectomy. Comorbidities: diabetes mellitus in 2 cases, anemia in 1 case. In all cases, the fistula was diagnosed by fiberoptic bronchoscopy and occurred 10-22 days postoperatively. The main clinical manifestations: postoperative recurrent cough, coughing sputum, rust-colored sputum or pleural fluid, recurrent pleural effusion or liquid pneumothorax, recurrent fever, persistent air leakage from closed chest drainage, long-term intrathoracic abscess, etc. Methods and results 1. Protein gel sealing method: Applicable to those with small fistulas. Routine inhalation of lidocaine tracheal mucosa local anesthesia, bronchial fiberoptic bronchoscopy to confirm the location of the fistula, insert a special thin tube for protein glue through the biopsy hole of the fiberoptic bronchoscope, insert a thin tube into the fistula under direct vision, quickly inject 2-2.5ml of mixed bioprotein glue (Tianxiu medical bioprotein glue, Guangzhou Beixiu Biotechnology Co., Ltd.), microscopically confirm the solidification of protein glue to seal the fistula, and appropriate postoperative cough suppression treatment. This method was successful in one case for each of upper left, upper right and lower left fistulas, and the patient’s body temperature gradually returned to normal after the blockage, and the cough and sputum significantly reduced and disappeared. 2. Subbronchial mucosal injection method: It can be used for large fistulae or for those who have failed in protein gel treatment. Inhale lidocaine for local anesthesia of the tracheal mucosa, confirm the location of the fistula by fiberoptic bronchoscopy, insert the injection needle through the biopsy hole of the fistula, and inject 0.3-0.5 ml of sclerosing agent (1% Aethokysklerol Germany) into the bronchial mucosa on one or both sides of the fistula under direct vision to make the mucosa bulge and press the fistula closed. In two cases, the fistula was completely closed and the persistent air leak in the closed drainage disappeared on the spot, so the one-time treatment was successful and the drainage tube was removed after 1-3 weeks. The fistula was closed immediately, but 1 week later the fistula recurred again, and the review showed that the fistula was significantly smaller than before, and the fistula was cured by re-injection of sclerosing agent and review of bronchoscopy two weeks later. The use of fiberoptic bronchoscopy for the treatment of bronchial stump fistula has been reported in clinical practice, and the success of this group demonstrates the reliability of this treatment. Bioprotein gel is simple, efficient, and economical, and is preferred for small fistulas, as it has the effect of promoting healing in addition to coagulation and physical sealing of the fistula. The submucosal injection method can be used both as a follow-up to the failure of bioprotein gel treatment and as a first choice, especially for larger fistulas, with precise efficacy and uncomplicated operation. The authors summarize their treatment experience through clinical practice as follows: 1. Adequate anti-inflammatory drainage and nutritional support should be provided before fistuloscopic treatment to reduce the edema of the fistula, reduce bleeding during the operation, and prevent accidents such as hemorrhage. The authors have observed one case of failure due to inadequate preoperative preparation. 2. Adequate anesthesia. Fistuloscopic treatment are long, adequate anesthesia is not only to reduce pain and reduce the risk of fistuloscopic operation, but more importantly to make the bioprotein gel can be smoothly coagulated in the fistula position without being coughed out, and there is no accidental injury when the injection needle is punctured. Minimally invasive treatment is the trend in the development of thoracic surgery today, and fiberoptic bronchoscopy should be the treatment of choice for bronchial stump fistula in the future because of its efficacy, minimal trauma, and low cost.