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Significance Of Bronchopleural Fistula In Post Transbronchial Microwave Ablation - Case Series And Unique Insights
Aliss Tsz Ching Chang, Joyce Wing Yan Chan, Rainbow Wing Hung Lau, Calvin Sze Hang Ng.
The Chinese University of Hong Kong, Sha Tin, Hong Kong.
BACKGROUND: Transbronchial microwave ablation is an innovative local therapy for lung malignancies that avoids direct pleural puncture, reducing the risk of pleural-based complications. However, rare cases of bronchopleural fistula (BPF) can still occur. This case series aims to illustrate the potential mechanisms behind BPF formation and discuss possible management options.
METHODS: A single-center retrospective review identified 190 sessions of transbronchial microwave ablation performed under electromagnetic navigation bronchoscopy in a hybrid operating room between March 2019 and November 2024. Four cases of post-ablation BPF were identified during this period. Details about the patients, nodules, and procedures, including intraoperative and postoperative images, were reviewed.
RESULTS: Four cases (2.1%) of BPF were reported among the 190 ablation sessions (250 lesions were ablated). Patient 1 had an intraoperative pneumothorax due to an accidental pleural puncture and tissue contraction during the ablation, resulting in a fistula. It was managed by intraoperative tissue glue injection; no pleural drainage was needed. Patient 2 developed extensive surgical emphysema and a pneumothorax requiring drainage on postoperative day 1. Computed tomography (CT) revealed a ruptured ablation zone, and an endobronchial valve was placed and removed 2 months later. Patient 3 received a subpleural ablation and encountered an inadvertent pleural puncture during instrument exchange, resulting in a large pneumothorax immediately post-procedure that required drainage. Postoperative CT showed a fistula at the site of pleural puncture and was treated with an endobronchial valve. Patient 4 had a delayed pneumothorax on postoperative day 1. During the ablation, tissue contraction occurred and caused the ablation catheter to shift, leading to a tiny fistula being shown on postoperative CT. This patient was managed conservatively with chest drainage.The average length of hospital stay was 12.25 days (range 2-20 days). All cases achieved complete resolution of the air leak, and follow-up CT at three months indicated no delayed complications or recurrent air leaks.
CONCLUSIONS:Although post-transbronchial microwave ablation BPF is rare, it requires careful management due to the potential serious complications. Different mechanisms of fistula formation exist, and management strategies should be tailored to each mechanism to seal the fistula securely while effectively minimizing patient discomfort.
LEGEND: Different mechanisms of bronchopleural fistula formation after transbronchial microwave ablation
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