Duodenobronchial fistula

Duodenobronchial fistulas are an extremely rare subgroup of abdominobronchial fistulas, which include bronchobiliary, gastrobronchial, enterobronchial, colobronchial, and splenobronchial fistulas. Only one case of a duodenobronchial fistula has been previously reported. Duodenobronchial fistulas occur as a complication of a duodenal injury. The characteristic symptoms are a cough that produces copious bilious secretions, shortness of breath, and fever. The diagnosis is made by contrast gastrointestinal studies. Treatment requires an abdominal approach with interruption of the fistula at its duodenal origin and control of the inciting inflammatory process. With prompt diagnosis and treatment, thoracic drainage or pulmonary resection should not be needed.

Management of malignant air leak in a child with a neonatal high-frequency oscillatory ventilator

A 10-year-old, 36-kg child with a malignant air leak who failed conventional mechanical ventilation and high-frequency jet ventilation was successfully treated with a neonatal high-frequency oscillatory ventilator for 31 days. Since the air leak resolved with minimal hemodynamic compromise, this technique may have application in the management of respiratory failure and air leak in the older and larger child for prolonged periods of time.

[The use of human fibrin glue in fistulous pathology of the lung]

Currently, bronchopleural fistulas present a decreasing complication rate in thoracic surgery, especially since surgical management of tubercular infections is no longer needed. The introduction of non-reacting suture materials and the technological advances have also lowered the incidence of such complication. Although fistulas tend to be chronic, their treatment is possible. Today, in fact, the use of human fibrin glue gives positive results which depend on the extent of the fistula as well as the adherence of the glue to the bronchial wall. The authors report their experience in two cases treated with human fibrin glue.

A new endoscopic method for treatment of malignant oesophagobronchial fistulas

A short malignant oesophagobronchial fistula which could not be sealed using adhesive agents was successfully treated using a new endoscopic technique. The procedure provided good palliation and the results withstood the test of time in the patient. The method, which is described in detail, provides a useful modification to existing methods.

Closure of a bronchopleural fistula with bronchoscopic instillation of tetracycline

Persistent bronchopleural fistulas (BPF) due to infection, trauma, or thoracic surgical procedures are often difficult to manage. We report a patient with fulminant Staphylococcus aureus pneumonia complicated by chronic BPF formation which prevented weaning from mechanical ventilation due to severe air leak. Fistula closure was obtained by instillation of tetracycline into the fistula via a fiberoptic bronchoscope using a balloon catheter and blood clot occlusion technique. This closed the BPF and allowed successful weaning from mechanical ventilation.

The management of malignant esophago-respiratory fistulas with a cuffed prosthesis

Peroral intubation with a standard prosthesis fails to occlude inoperable malignant esophago-respiratory fistulas located above the narrowed segment, or when there is little or no stricture at all. Ten patients with malignant esophago-respiratory fistulas were intubated perorally with a prosthesis surrounded by a foam ruber cuff contained in a silicone sheath, in which a vacuum can be created. The type of fistula was esophago-bronchial in 6 patients, esophago-tracheal in 3 patients, and gastro-tracheal in 1 patient. The fistula was located above the stricture in 8 patients and in a malignancy without a stricture in 2 patients. The diameter of the opening of the fistula ranged between 1 and 3 cm. Complications with the cuffed tube were recurrent leakage after a period of 30 days in situ in 1 patient, and compression of the trachea immediately after intubation in 1 patient. Adequate palliation, that is, no symptoms related to the fistula, good transit of food and discharge from hospital within a few days was achieved in 9 patients for an average period of 37.2 days (10-84 days). The cuffed esophageal prosthesis can improve the quality of life in patients with malignant esophago-respiratory fistulas that do not respond to conventional intubation.

Positive end expiratory pressure and critical oxygenation during transport in ventilated patients

Transportation of patients critically dependent on positive end expiratory pressure (PEEP) can be problematic, as a patient of ours with adult respiratory distress syndrome (ARDS) and bilateral broncho-pleural fistulae demonstrated. He required intermittent positive pressure ventilation (IPPV) (Siemens 900C) with 100% O2 and PEEP of 2 kPa to maintain his arterial O2 saturation (SaO2) greater than 90%. Severe hypoxemia (SaO2 less than 75%) occurred on change to a portable ventilator (Oxylog, Dräger) with a PEEP value (Ambu 20) at its expiratory port, despite adjusting the valve to 2 kPa, continuing use of 100% O2, and varying the ventilatory pattern. The problem appeared due to loss of PEEP because of gas leak from the lungs via his intercostal catheters. It was solved by introducing a continuous O2 flow of 5 l/min into the circuit between the Oxylog non-rebreathing valve and endotracheal tube. We used a model lung to investigate the effect of a gas leak from the lungs or circuit on the performance of the Oxylog IPPV/PEEP system. Lung compliance and ventilatory pattern were adjusted so that tidal volume (VT) = 0.61, peak inspiratory Airway pressure (PIP) = 5 kPa, PEEP = 1.5 kPa, and respiratory rate = 10/min. A small leak was introduced from the lung resulting in a decrease in PIP, VT, and PEEP. Adjustment of ventilator minute volume to restore PIP to 5 kPa failed to restore PEEP, airway pressure continuing to fall throughout the expiratory pause. PEEP was restored by providing a compensatory flow of O2 of 5 l/min to the system between the Oxylog non-rebreathing valve and the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula

Angiographic occlusion coils placed endobronchially under fluoroscopic guidance succeeded in controlling a large parenchymal bronchopleural fistula after failure of surgical treatment and transbronchoscopic fibrin glue application.

Endoscopic palliative intubation of the esophagus invaded by lung cancer

Thirty-two patients with esophageal involvement by lung cancer were managed by endoscopic intubation. In 22 patients with extrinsic esophageal strictures, the success rate of intubation was 91%, and 82% were discharged with their dysphagia relieved and esophageal patency restored. The mean survival rate was 4.4 months. In 10 patients with esophago-bronchial fistulas, 3 had the fistulous tract obliterated and lived a mean of 5 months. This low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor-associated stenosis. The overall morbidity rate was 28.1% (18.8% perforation, 6.3% hemorrhage, and 3.1% tracheal obstruction). The overall mortality rate was 18.8%. Although complications were more frequent than in primary esophageal tumors, endoscopic intubation was the only way to palliate this desperate condition and provided 66.6% of patients with relief of symptoms, nutritional improvement, and a mean survival time of 4.5 months.

A new device that allows synchronous intermittent inspiratory chest tube occlusion with any mechanical ventilator

Controlling a massively leaking bronchopleural fistula (BPF) can prove difficult. In combination with acute respiratory failure (ARF), BPF results in a mortality of 81 percent. Intermittent inspiratory chest tube occlusion (IICTO) is recognized as effective in controlling even the largest BPF; however, IICTO, as previously described, is difficult to use for a variety of reasons. We report two cases of BPF in association with ARF managed with a simple new device that allows the application of IICTO with virtually any mechanical ventilator. The effectiveness of the device and associated technique in controlling BPF leaks is clearly demonstrated and may have played a role in the eventual recovery of a patient with BPF. Further study of the technique is warranted.

Endoscopic diagnosis and treatment of postoperative bronchopleural fistula

The diagnosis and closure of small postresection bronchopleural fistulae can be accomplished with selective bronchography and placement of fibrin sealant through the flexible fiberoptic bronchoscope. This method of diagnosis and closure of the bronchopleural fistula avoids both general anesthesia and a thoracotomy. This technique is successful in small bronchopleural fistulae and patients with multiple postresection bronchial stumps.

Successful closure of chronic BPF by thoracoscopy after failure of endoscopic fibrin glue application and thoracoplasty

We report a case of chronic debilitating BPF following right upper lobe resection. Despite several endobronchial applications of fibrin glue, we could not close it. Since the patient was extremely debilitated by symptoms due to the BPF, a thoracoplasty was attempted but was not successful. Finally, the BPF was definitely closed by instillation of talc into the pleura through thoracoscopy. To our knowledge, this is the first reported case of chemical closure of a recalcitrant BPF by the route of thoracoscopy. It also shows the failure of endoscopic fibrin glue application in such a condition.

The use of endoscopy to treat bronchobiliary fistula caused by choledocholithiasis

Bronchobiliary fistula is a rare disorder consisting of the formation of a passageway between the biliary ducts and the bronchial tree. We describe an 87-yr-old woman who had a bronchobiliary fistula secondary to obstruction caused by multiple common bile duct stones. The diagnosis was confirmed by the presence of bile in the sputum and transhepatic cholangiography. Successful stone extraction with balloon and basket techniques and endoscopic sphincterotomy decompressed the biliary tract and was followed by healing of the bronchobiliary fistula without surgical intervention, which has heretofore been considered the only successful means of treatment.

Bronchoscopy in severe blunt chest trauma

Extended lesions of the lung parenchyma are often seen in association with blunt chest trauma. Blood aspiration, atelectasis and the formation of bronchopleural fistulae can lead to early respiratory deterioration and the development of severe post-traumatic complications (pneumonia, acute respiratory distress syndrome). Diagnostic and therapeutic bronchoscopy is essential on admission. This procedure helps to estimate the severity and extent of parenchymal lesions even before chest X-ray signs are noted. Bronchoalveolar lavage is needed for removal of aspirates. In our study bronchoalveolar lavage on admission reduced bacterial contamination and pneumonia in comparison to patients not lavaged. A new method for closure of bronchopleural fistulae is described. Fibrin instillation after balloon catheter occlusion leads to a significant reduction of tidal volume loss (greater than 50% in average).

Self adjusting stent in the management of malignant tracheo-oesophageal fistula

The development of a malignant oesophago-respiratory fistula is a distressing situation which often leads to an early death. Dissatisfaction with the high levels of mortality and morbidity associated with the surgical bypass procedures, coupled with the failure of many of the oesophageal tubes, to completely occlude the fistula, has led to the development of a new cuffed tube (Wilson Cooke tube). This tube has the potential to not only relieve dysphagia but also to occlude the fistula without risk of pressure necrosis.

Successful closure of bronchopleural fistula with adhesive tissue. Case report

Surgical closure of a bronchopleural fistula following right pneumonectomy for squamous cell carcinoma was achieved with monomeric n-butyl-2-cyanoacrylate. Previous attempts at closure by conservative and endoscopic means were unsuccessful. Tissue adhesives are useful in the surgical or endoscopic management of bronchopleural fistula.

An esophagobronchopleural fistula successfully treated by a surgical procedure combined with conservative therapy after resection for lung cancer

The patient was a 43-year-old woman, who had undergone a right middle and lower lobectomy for adenocarcinoma of the lung. An esophagobronchopleural fistula developed two months after the operation. It was treated by a combined procedure consisting of pedicle flap closure of the fistula and thoracoplasty. The esophagobronchopleural fistula recurred two days later, however, and another pedicle flap closure with fenestration of the chest wall were performed in a third operation. A bronchopleural fistula then recurred, after which it was treated by conservative therapy including intravenous hyperalimentation, frequent dressing changes and systemic administration of appropriate antibiotics. It closed spontaneously 23 days after surgery, in spite of this being a very rare but serious complication very difficult to treat and cure. From our experience with this particular case, we recommend, for treating esophagobronchopleural fistulas, proper drainage, antibiotic therapy, intravenous hyperalimentation and packing of the empyema space, together with closure of the fistula using a muscle or pleural flap.

[Conservative treatment of postoperative defects of the bronchial stump and of bronchoalveolar fistulae]

Based on their experience with the treatment of 65 patients the authors consider that choice of the method of treatment depends on the bronchus calibre and the fistula size. Good results were obtained when using different variants of bronchus obturation with the application of glue.