A 65-year-old man was admitted to our hospital because of hemoptysis. He presented with chronic empyema caused by Aspergillus spp. in the residual thoracic cavity after treatment for tuberculosis. We performed tube thoracostomy, however it failed because the content of the pyothorax developed a very hard. Because he had low lung function and a decreased performance status, completion pneumonectomy was not indicated. Therefore, we performed surgical debridement and open-window thoracotomy. Intraoperative observation revealed that multiple bronchopleural fistulas were located on the surface of the destroyed right lung, while air leakage and purulent sputum flowed out from the fistulas.
Five days after the operation, we attempted endoscopic bronchial occlusion using EWS. He received intubation under local anesthesia and mild sedation with midazolam, and then underwent insertion of a bronchoscope through an endotracheal tube. EWS (7 mm) was placed into the bronchus (right posterior segmental bronchus (B2)) using grasping forceps. Chest CT showed an occluded EWS in the right B2 of the destroyed right lung (Fig. 3A). Although air leakage was not observed just after endoscopic bronchial occlusion using EWS, EWS occluding B2 had fallen into the thoracic cavity because the BPF was larger than 7 mm, and air leakage recurred on postoperative day 8 (Fig. 3B).
We again attempted endoscopic bronchial occlusion under local anesthesia and mild sedation. The bronchoscope was deployed into the right upper lobe bronchus through an endotracheal tube (Fig. 4A). After confirming that the air leakage was localized to the right B2, EWS (7 mm) was again placed in the target bronchus (Fig. 4B). Next, ethyl-2-cyanoacrylate (1.0 ml) was injected through the guide sheath into the space between the bronchial wall and EWS (Fig. 4C). Ethyl-2-cyanoacrylate rapidly hardened and changed to a white color about 60 seconds after injection (Fig. 4D). Air leakage was not observed after this procedure and the postoperative course was uneventful, but the patient died of pneumonia in the left lung three months after the procedure.