Submucosal injection of the silver-human albumin complex for the treatment of bronchopleural fistula

Objective: Postoperative bronchopleural fistula (BPF) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study is to assess the efficacy of the use of the silver-human albumin (SHA) complex injected in the bronchial submucosa for the treatment of BPF. Methods: From January 2005 to March 2008, we treated 11 patients with BPF (seven post-pneumonectomy and four post-lobectomy) by endoscopic injection of the SHA complex into the bronchial submucosa. In all patients a chest drain was positioned and employed for antibiotic pleural irrigation. Simultaneously, the endoscopic treatment including repeated injection of the SHA complex was started. In 10 patients the diameter of the fistulas was equal to or smaller than 5 mm (range: 3-5 mm) and in one it was larger than 5 mm (8 mm). Results: There was no morbidity or mortality related to the procedure. Permanent closure of the fistula was achieved in all 10 patients with a BPF of 3-5 mm. In four of these patients (post-lobectomy fistula), the good general condition allowed early discharge with the Heimlich valve before the completion of treatment. Two other patients with a fistula smaller than 5 mm presented persisting empyema and compromised general conditions after closure of the post-pneumonectomy BPF. These patients underwent fast-track treatment of the empyema achieving definitive cure. In the patient with a BPF larger than 5 mm, the conservative treatment was not sufficient and an omental flap transposition was necessary. Conclusions: The SHA complex submucosal injection is easy, safe and inexpensive. It can be considered a valid therapeutic option in selected patients presenting an early fistula with a size equal to or smaller than 5 mm. Early diagnosis, simultaneous insertion of a chest drain and achievement of a sterile pleural cavity are fundamental conditions for the final success of the procedure.