Zusammenfassung
Bronchopleurale Fisteln (BPF) und Bronchusstumpfinsuffizienzen (BSI) nach Lob- bzw.
Pneumonektomien gelten als gefürchtete Komplikation mit Inzidenzen von bis zu 12 %
und Letalitätsraten bis zu 51 %. Ursachen sind neben der Grunderkrankung Komplikationen
wie Aspirationspneumonien und ARDS, Empyembildung sowie septische Verläufe. Als Mitursachen
gelten Kortikoidbehandlung, hohes Lebensalter, Diabetes mellitus und Zustände nach
Radiatio, aber auch die postoperative mechanische Ventilation (Barotrauma). Nach wie
vor stellt die Bronchusübernähung und plastische Deckung die Methode der Wahl dar,
ist aber bei Hochrisikopatienten oft kontraindiziert. Endoskopische Verfahren mit
Okklusion von Lungenabschnitten z. B. durch das Einbringen von Spongiosa, Coils und/oder
Fibrinkleber sind beschrieben, setzen jedoch die Sondierbarkeit des betreffenden Bronchus
voraus. Die Erfolgsrate ist mit einem Drittel der Fälle nur unbefriedigend. Die retrograde
Instillation von Substanzen mit inflammatorisch-sklerosierender Wirkung wie Doxycyclin
über die Thoraxdrainage führt zu einer Pleurodese durch Verklebung des Restlungenparenchyms
mit der Brustwand und zu einer Verkleinerung der thorakalen Defekthöhle. Bei einer
82-jährigen Patientin mit Zustand nach Mammakarzinom nach Mittellappenresektion bei
Abszedierung und Strahlenulcus nach Radiatio trat eine BPF des rechten 2. Oberlappenbronchus
auf. Wir stellten die Leckage bronchoskopisch durch retrograde Instillation von blauer
Farblösung in die Thoraxhöhle via Drainage dar. Eine Computertomographie nach Gabe
des wasserlöslichen Kontrastmittels Amidotrizoesäure in gleicher Weise bestätigte
den Befund. Der betroffene Segmentbronchus konnte nicht selektiv sondiert werden,
so dass endoskopisch-okkludierende Verfahren bei Intention zum Erhalt der Restbelüftung
des rechten Lungenlappens ausschieden. Mit einem strikten konservativen Therapieregime
(Spontanatmung, retrograde Doxycyclininstillation) gelang die Ausheilung der BPF bei
vollständig belüftetem Unterlappen nach einem Zeitraum von 78 Tagen.
BPF und verbliebene intrathorakale Räume nach Lobektomien stellen ein schwieriges
Problem dar. Die retrograde Darstellung der BPF mit Methylenblau unter bronchoskopischer
Sicht stellt im Einzelfall eine praktikable und kostengünstige diagnostische Methode
dar. Eine konsequente konservative Therapie unter Beatmung mit niedrigem mittleren
Druckniveau und fibrotischer Verklebung der Thoraxhöhle mittels Doxycyclin ist ein
praktikables Verfahren bei inoperablen Risikopatienten.
Abstract
Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies
and pneumonectomies are dreaded complications with incidences of up to 12 % and a
mortality rate of up to 51 %. Apart from the basic illness causes include complications
like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis.
Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as
post-operative mechanical ventilation (barotrauma) are often counted among contributing
causes. Suturing the bronchus and reinforcement by tissue are still the methods of
choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments
with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin
glue have been described. However, they require the respective area to be probable.
With only one third the rate of success is quite unsatisfactory. The retro-graded
instillation of inflammatory-selerotizing substances, like doxycyclin, via a chest
tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to
the thoracic wall and a reduction in size of the residual pleural space. In an 82-year
old female patient a BPF of the second upper lobe bronchus was detected after a middle
lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma.
The leakage was detected on bronchoscopy by retro-graded instillation via the chest
tube of methylene-blue solution into the thoracic cavity. After administering the
water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed
the diagnosis. As the bronchial segment concerned could not be entered selectively,
preservation of the right lung lobe’s residual ventilation by endoscopic-occlussion
procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation,
retro-graded doxycycline instillations) complete healing with a fully ventilated lower
lobe could be achieved over a period of 78 days.
BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem.
Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents
a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy
including short-time low-pressure artificial respiration as well as obliteration by
fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for
inoperable high-risk patients.
Schlüsselwörter
Bronchusfistel - Bronchusstumpfinsuffizienz - Pleurodese - Doxycyclin - Spontanatmung
Key words
Bronchopleural fistula - bronchial stump insufficiency - pleurodesis - doxycycline
- spontaneous breathing
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Dr. med. Thomas Mendel
Klinik für Unfall- und Wiederherstellungschirurgie
BG-Kliniken Bergmannstrost · Merseburger Straße 165 · 06112 Halle (Saale)
Email: thomas.mendel@bergmannstrost.de
