A 39-year-old man, who worked as a tunnel worker for a decade, was diagnosed with bilateral pulmonary tuberculosis and lung destruction. Unfortunately, owing to work constraints, the patient received only partial treatment. Years later, he visited Chung Shan Medical University Hospital and presented with hemoptysis. Two years prior, he underwent transcatheter arterial embolization for severe hemoptysis. However, the intermittent hemoptysis persisted, leading to several admissions during which he received conservative treatment.
Contrast-enhanced chest tomography revealed pleural thickening with heterogeneous consolidations over the right upper and middle lobes, indicative of destructive lung damage and bronchiectasis (Fig. 1A-B). His preoperative lung function showed poor forced expiratory volume in one second (FEV1 = 47% prediction) and forced vital capacity (FVC = 36% prediction), consistent with obstructive lung disease. Given the recurrent hemoptysis and failure of conservative treatment, lobectomies of the right upper and middle lobes were recommended.
The patient underwent thoracoscopic bilobectomy of the lungs. During surgery, severe adhesions and calcification of the chest wall and lung parenchyma were observed. The entire hilar structure was calcified, presenting challenges for dissection, despite the assistance of energy devices. Identification of the tortuous pulmonary artery and bronchus led to the division of the right upper and middle lobes, using endovascular gastrointestinal anastomosis stapler (Endo GIA; Medtronic, Minneapolis, MN, USA) and linear stapler (DST Series™ TA™ 60 mm, Medtronic, Minneapolis, MN, USA) assist.
Postoperatively, small air leaks developed through the parenchyma and stump side that required repair using 6 − 0 PDS sutures. Unfortunately, one week later, the patient's chest tube revealed a worsened air leak, and a follow-up film indicated severe right lower lobe collapse, indicative of BPF formation. A second surgical procedure revealed a fistula, measuring 8 mm, over the right upper lobe stump. An intercostal muscle flap was created to repair the BPF; however, large volume air leakage persisted.
To address the issue, two abdominal subcutaneous fat pads were retrieved for treatment (Fig. 2A-B). The patient was positioned in the right decubitus position, and the was noted over the apical segment of the right upper lobe (8 mm in size, Fig. 3A). The bronchial stumps were removed using electrocauterization. The obtained subcutaneous fat pads were applied to the lesion and covered with platelet-rich plasma (PRP) and Neoveil™ (Gunze Ltd., Japan) (Fig. 3B-D). Following surgery, sedation was maintained, and the right decubitus position was maintained for three days. Follow-up bronchoscopy on (7-days post-surgery) revealed that the fat pad was firm and steady with no fistula formation (Fig. 4A). The patient was weaned off his ventilator on Day 15 post-surgery and later transferred to the general ward. Follow-up bronchoscopy (60-days post-surgery) revealed shrinkage of the fat pad and resolution of the outside Neoveil coverage with no fistula formation (Fig. 4B). Although a follow-up video recording revealed a persistent dead space over the right chest wall, considering the relatively stable condition, the patient was discharged with a chest tube-free drain (Fig. 4C).