Endobronchial Valve as Salvage Lung-Sparing Treatment of Prolonged Air Leak Following Laser Assisted Metastasectomy

In the recent years employment of LASER for resection of lung metastasis demonstrated to be a valid surgical option to avoid major anatomical lung resections. First experimental studies performed in the swine model [1] showed that at histological evaluation in the 0.5-cm quadrants laying distant from the “center” of the LASER application, the tissue presented with cell vacuolization and membrane destruction, while not signs of thermal damage was observed at 1-cm quadrants. These data have several implications for daily clinical application; firstly, lung areas that are distant more than 1 cm apart do not entail the risk of heat accumulation; secondly, while resecting lung metastases that are closer than 1 cm to each other, the surgeon should either wait 3 to 5 minutes for spontaneous tissue cooling before resecting the next metastasis to avoid applying the second LASER shot on a surface of pulmonary parenchyma already interested and potentially damaged by the first application; finally, the microscopic (not detectable) residual neoplastic cells (spreading from the metastatic lesion to the adjacent “healthy” parenchyma) could potentially be eradicated until 1 cm far from resected area. Therefore, LASER resection are considered radical even when a closer margin of resection (< 1 mm) is found at histological examination of specimen. Moreover, through the high temperature reached in the tissue (>700°C), LASER has an excellent sealing ability of small vessels and bronchi until 3-4 mm, minimizing the risk of intraoperative and postoperative bleeding and air leakage. Conversely, when such complications occur, especially delayed air leakage from bronchopleural fistula (BPF), treatments may be very challenging since scar tissue could prevent healing. Therefore, surgical intervention, pleurodesis, and prolonged chest tube drainage have several disadvantages in these patients. Many attempts have been made to treat BPF through flexible bronchoscopy by submucosal injection of acrilic glue. Endobronchial one-way valves (EBV), originally designed for lung volume reduction in pulmonary emphysema, represent an emerging option for treatment of BPF. Insertion of EBV have less trauma, relatively short operation time, better safety than surgical intervention and is more likely to be accepted by patients. In this paper we describe two case of delayed and prolonged air leak after LASER resection which finally received a successful treatment through placement of endobronchial valves.