Bronchoscopic treatment of a giant bronchopleural fistula with autologous platelet-rich plasma

Abstract

Background

Bronchopleural fistula (BPF) is a severe complication observed in patients undergoing lobectomy or pneumonectomy, often resulting in high morbidity and mortality rates.

Case presentation

We present a case of successful treatment of a giant bronchopleural fistula (20 mm *10 mm). The patient underwent a thoracoscopic right lower lobectomy.The approach we used was local injection of autologous frozen platelet-rich plasma (PRP) with bronchoscopic assistance while maintaining digital chest drainage.We chose the treatment of PRP combined with digital drainage for bronchopleural fistula, not only healing of the fistula but also focusing on elimination of the residual cavity in the thoracic cavity.

Conclusion

This highlights the effectiveness of this comprehensive approach in the treatment of bronchopleural fistulae and provides a promising treatment option for future treatment of similarly large bronchopleural fistulae.

Backgroud

Bronchopleural fistula (BPF) is a severe complication observed in patients undergoing lobectomy or pneumonectomy, often resulting in high morbidity and mortality rates [1]. There are no standardized guidelines to determine the gold standard treatment for bronchopleural fistula [2]. According to the available literature, chest drainage plus the application of antimicrobial drugs is the basic treatment, bronchoscopic treatment with stent sealing is favored for small fistulas (< 8 mm), and surgical treatment is favored for larger fistulas (> 8 mm) [3].

We present a case of successful treatment of a giant bronchopleural fistula (20 mm *10 mm). The approach we used was local injection of autologous frozen platelet-rich plasma (PRP) with bronchoscopic assistance while maintaining digital chest drainage.PRP promotes healing of fistula and digital chest drainage device helps prevent the occurrence of pyothorax. Remarkably, the patient achieved complete healing within 28 weeks.

Case presentation

A 57-year-old healthy adult male with a thirty-year smoking history underwent a right lower lobectomy in August 2023 at our hospital after one month of smoking cessation, and the postoperative pathology diagnosed squamous cell carcinoma. On the 27th postoperative day, he was readmitted to the hospital with chest tightness and breathlessness.CT images showed a large amount of fluid in the right pleural cavity, and bronchoscopy confirmed a large fistula (20 mm*10 mm) in the right bronchial trunk. The diagnosis was bronchopleural fistula.

Fig. 1

Throughout the course of treatment, the patient underwent six bronchoscopies and four PRP injections.The amount of PRP used varies according to the healing of the fistula.It lasted 28 weeks, of which 14 weeks were interrupted due to the COVID-19 epidemic

We chose to treat the patient with autologous PRP along with a chest drain connected to a digital suction device, a digital system that helps us detect air leaks and actively drain out fluid from the chest cavity. Auto-PRP is prepared using the double centrifugation method. Initially, about 300 ml of blood was collected from the patient’s antecubital vein into a sodium citrate tube. The PRP was isolated using the Arthrex ACP system (ABS-10014, Arthrex, Inc., USA), a PRP separation device, according to manufacturer’s instructions.

Auto-PRP was injected into the submucosa around the fistula under bronchoscopic observation.

Throughout the course of treatment, the patient underwent six bronchoscopies and four PRP injections (Fig. 1). The first two injections were 30 ml each and the last two injections were 5 ml each.During the period from November 2023 to March 2024, there was no treatment for three months due to the new coronavirus and traditional Chinese festivals.Encouragingly, the last bronchoscopy at 28 weeks showed successful closure of the fistula (Fig. 2).The patient has been continuously followed up since the successful treatment. The patient was reviewed three months after removal of the chest drain and recovered well (Fig. 2F).This highlights the effectiveness of this comprehensive approach in the treatment of bronchopleural fistulae and provides a promising treatment option for future treatment of similarly large bronchopleural fistulae.

Fig. 2

Figure A-E: chestCT and bronchoscopic images from 2023-9 to 2024-4; Figure F: chestCT and bronchoscopic reviewed three months after extubation

Discussion

Amplatzer stent closure is a treatment method that has been reported more frequently in recent years, but the characteristic of easy stent displacement in larger fistulas leads to its failure rate.4 And almost most of the bronchoscopic treatments only emphasise or focus on fistula closure while ignoring the effect of residual fluid pneumoperitoneum or even pyothorax in the pleural cavity. Oren Fruchter reported the results of long-term follow-up of 31 patients after Amplatzer device closure, with a mortality rate of 13% (4/31) due to sepsis within 30 days after surgery, and an additional 6 patients died of sepsis 30 days after stent implantation [4]. So we chose the treatment of PRP combined with digital drainage for bronchopleural fistula not only healing of the fistula but also focusing on elimination of the residual cavity in the thoracic cavity.

PRP is an autologous serum preparation containing high levels of platelets [5]. Upon action on tissue cells it can promote cell growth through the release of tissue factor and PRP is easy to prepare and has been shown to be used in the treatment of conditions including, but not limited to, osteoarthritis, recurrent vesicovaginal fistulae, and enterocutaneous fistulae [6, 7]. Mammoto reported confirming that PRP promotes the proliferation of bronchial disconnected granulation tissue [8].

Wu [9] reported the successful treatment of 3 cases of BPF with PRP, their average treatment time was around 15 weeks, but for the large fistula they opted for PRP combined with a valve.

Ye [10] reported pilot prospective cohort study that revealed a promising poten-tial for PRP therapy in small BPF.Proved the safety and efficacy of PRP treatment. At the same time, it also marks that the role of PRP is being more widely applied and explored.

To the authors’ knowledge, the case we report is the first case of giant bronchopleural fistula (20 mm*10 mm) healed with autologous PRP. Our study provides a new safe and effective way to cure giant BPF.