[A case of empyema with a bronchopleural fistula treated by a pedicle muscle flap with the thick parietal pleura]

A 65-year-old male with a bronchopleural fistula of 10 mm in diameter underwent thoracoplasty combined with a pedicle muscle flap following open thoracic window. He had been treated by gastrectomy and right upper lobectomy because of gastric perforation and lung tuberculosis before empyema. Sterilization for the empyema cavity through the thoracic window was done for 255 days, obliteration of the empyema cavity was achieved by a muscle flap with the thick parietal pleura. The parietal pleura which was not separated from the intercostal pleura which was not separated from the intercostal muscle was used for reinforcement of the muscle flap against the high intra-tracheal pressure. There was no postoperative relapse of empyema for 9 months.

[Spontaneous cutaneous cysto-hepato-bronchial fistula caused by a hydatid cyst. Apropos of a case]

We report a case liver hydatid cyst which fistulized simultaneously and spontaneously to the skin and in the bronchia observed in a 70-years-old woman. Outcome was favorable after surgical intervention. It is an extremely rare and original case.

Repair of aortobronchial fistula using extraanatomic grafts and hypothermic arrest

Aortobronchial fistula is a rare complication of thoracic aortic operations that is fatal if not promptly diagnosed and repaired. The case of a 23-year-old woman who presented with an aortobronchial fistula after three previous left thoracotomies for thoracic aortic procedures is described.

[The treatment of bronchopleural fistulae due to bronchial dehiscence by chest wall interventions. The authors' personal experience]

The authors present their personal experience of three cases of bronchial fistulae post pneumonectomy or lobectomy. Surgical treatment was not done directly on the bronchial stump but by thoracoplasty. This approach to the thoracic chest gets good results on condition that stabilization in reexpansion of residual parenchyma and drainage of bronchial secretions is carried out.

Treatment of long-standing thoracostoma and bronchopleural fistula without pulmonary resection in high risk patients

A chronic bronchopleural fistula and a fibrotic postthoracotomy space in a patient with poor functional respiratory reserve is a difficult problem. The classic management of bronchopleural cutaneous fistulas has been with further pulmonary resection to healthy bronchus, repair of the bronchus directly, and a thoracoplasty or myoplasty technique to obliterate the cavity. In a high risk patient, further pulmonary resection and thoracoplasty may be contraindicated. Myoplasty techniques alone without control of the fistula have limited success. In the last 4 years, we have treated six patients with right-sided thoracostomas after a primary open drainage procedure for bronchopleural fistula and empyema. The air leak was controlled with inversion of the sinus tract, fibrin glue, and muscle flap cavity obliteration. An average of two muscle flaps per patient were used, including the contralateral latissimus dorsi muscle. An 83 percent success rate has been achieved with this procedure in patients who otherwise would not be considered surgical candidates. Attention to the details described, including direct suture closure of the bronchial sinus, obliteration of the cavity by local muscle flaps, and avoidance of mechanical positive pressure ventilation, will make extended thoracotomy, pulmonary resection, and thoracoplasty unnecessary in these high risk patients.

Treatment of empyema by transposition of contralateral lower trapezius flap

We report the successful treatment of bronchopleural fistula and empyema using transposition of a contralateral lower trapezius musclocutaneous flap, which provided immediate obliteration of the middle-back empyema cavity. This technique is easy to perform without any intraoperative change of position and with little postoperative impairment of the back and shoulder movement.

[An experience with omentopexy for the repair of postoperative bronchopleural fistula]

Postoperative bronchopleural fistula has been the most troublesome complications in the thoracic surgery. In this report, we presented a case of bronchopleural fistula successfully closed by omentopexy. A 51-year-old man had undergone left upper lobectomy and S6 segmentectomy for primary lung cancer. Bronchopleural fistula due to postoperative pneumonia was developed and completion pneumonectomy with the intercostal-musclo-pexy was performed. Post-re-operative course was unsuccessful, bronchopleural fistula remained, so we tried re-closure of the bronchial stump by omentopexy without thoracoplasty or muscle flap plombage. About a half year after 3rd operation, he relapsed into bronchopleural fistula. Then fibrin gluing was performed via a flexible fiberoptic bronchoscope without hospitalization, and the omental flap was fixed completely to the bronchial stump. We believe the omentopexy a useful procedure for treating postoperative bronchopleural fistula which can't make any chest-wall deformation.

Postpneumonectomy stump fistula in a ventilated patient

The development of a postpneumonectomy stump fistula in a ventilated patient is a feared and frequently fatal event. Furthermore, the necessity of a pneumonectomy from sequelae of blunt trauma is rare. We describe the salvage of a young patient with a combination of the above events. The method involves the use of a simple intravenous bag "plombage" in combination with a regional thoracoplasty to buttress a resutured bronchial stump.

Video-assisted thoracoscopic closure of postpneumonectomy bronchopleural fistulas

Despite improved surgical techniques and advances in medical-surgical treatment, postpneumonectomy bronchopleural fistulas remain an important cause of morbidity and a therapeutic challenge. Video-assisted thoracoscopic closure of these fistulas reinforced by transposition of bulky chest wall muscles or omentum to obliterate the residual space may lessen risks and complications of repeated thoracotomy in these often frail, debilitated, and compromised patients. We report our initial experience with video-assisted thoracoscopic debridement of the empyema cavity and closure of the postpneumonectomy bronchopleural fistula by transposing an entire pectoralis major muscle in one patient and by transposing a pedicled omentum in another patient.

Permissive hypercapnia with high-frequency oscillatory ventilation and one-lung isolation for intraoperative management of lung resection in a patient with multiple bronchopleural fistulae

We report the use of high-frequency oscillatory ventilation in the operating room during repair of multiple bronchopleural fistulae in a 9-year-old boy. In addition, we used principles of permissive hypercapnia to further minimize barotrauma. There were no cardiovascular consequences due to either the high-frequency ventilation or the permissive hypercapnia. Our goals in employing this strategy were to minimize barotrauma, minimize gas flow through the fistulae, and optimize the surgical results.

[Surgical emergency induced by chest tumors]

Mechanisms and therapeutic procedures for emergencies induced by chest tumors are reviewed. 1) Carcinomatous pleuritis is the most frequently encountered situation for clinicians. At first, pleural effusion should be punctured for diagnosis and chest drainage should be performed consequently. Intrathoracic chemotherapy and pleurodasis (OK-432 is usually used) are then used if necessary. 2) Airway stenosis is the most critical state. Conventionally, violent incubation throughout the stenotic portion of the airway has been used with poor results. Recently, however, irradiation of Nd:YAG laser can be utilized, and the prognosis of the airway stenosis is much improved. Another effective procedure is the insertion of several kinds of airway stent. Silicon stents like T-tube, Dumon tube and Dynamic stent or metallic stents like EMS (Expandable Metallic Stent) are generally used. The advantages of EMS are easy installation and little disturbance of sputum excretion. The disadvantages of EMS are difficult removal and re-stenosis of the airway. On the other hand, silicon tubes are easy to be removed, re-insertion is possible and re-stenosis is rare, but the insertion should be performed under general anesthesia and sputum excretion may pose problems. A case of laser irradiation and two cases of stent insertion are presented. 3) Airway bleeding is also emergent. Bronchofiberscopic ethanol injection (BEI) is effective against continuous bleeding of the central airway. We performed BEI for 33 lung cancer cases, and the method was effective for all cases. 4) Cardiac tamponade, SVC syndrome, esophago-bronchial fistula, bronchial stump fistula are also important emergencies induced by chest tumors. Standard therapeutic procedures are explained for all oncology surgeons and physicians.

[Congenital broncho-esophageal fistula manifesting in adult age]

Congenital bronchoesophageal fistula manifesting in adulthood is an infrequent disorder. Presenting a successfully treated case, the authors review the clinicopathological features of the disease regarding the data of literature. The long-standing, non-specific respiratory symptoms recurring in the same pulmonary location call the attention to the fistula, which should be verified by esophagography and endoscopy. The adequate treatment consisting of fistulectomy and resection of the destroyed lung parenchyma lead to prompt recovery.

False left ventricular aneurysm with ventriculo-bronchial fistula and massive haemoptysis

An intravenous drug user presented with bacteraemia and massive hemoptysis 10 years after a penetrating cardiac injury. He was found to have false left ventricular aneurysm with ventriculo-bronchial fistula. The clinical course suggests that the aneurysm became infected and that the inflammatory process weakened the aneurysmal sac and led to the development of fistula. Prompt recognition of the aneurysm with appropriate surgical repair resulted in a successful outcome.

Open window thoracostomy in the treatment of esophageal or bronchopleural fistula with advanced mediastinitis and septic shock

Mediastinitis and septic shock following esophageal or bronchopleural fistula are rare but serious conditions with a high mortality rate. Six patients were treated with open window thoracostomy (OWT) after primary suture repair and closed tube drainage had failed to cure the patient's condition. In all cases the clinical condition improved immediately. Two patients died later because of unrelated diseases. OWT should be considered in critically ill patients with broncho- or esophagopleural fistula when primary therapy fails to control the septic focus.

[Respiratory management after closure of a bronchial-fistula with an omental pedicled gastric flap]

A 56-year-old female, after closure of a bronchial-fistula with an omental pedicle gastric flap, underwent controlled ventilation for two weeks in order to stabilize the flap. We suspended the administration of vecuronium once a day and examined the plasma concentration of vecuronium when a twitch response appeared. During the two weeks of ventilation, plasma concentration of vecuronium was maintained at low doses by adjusting the daily dose of vecuronium infusion. However, the suspended period of vecuronium infusion was prolonged gradually and the patient care such as tracheal suction and position changing became restricted. In addition, we have to care for the infection and a mental injury.

Bronchobiliary fistula. A rare complication of chronic pancreatitis

CONCLUSIONS

Bronchobiliary fistula is an in frequent manifestation of common bile duct obstruction. The slowly progressive narrowing of the common duct by the fibrosis of chronic pancreatitis is an even more rare mechanism of such fistula formation with only two cases having been reported previously. A third case of bronchobiliary fistula caused by chronic pancreatitis is presented and its successful management is discussed.

BACKGROUND

A 54-yr-old male with known chronic pancreatitis presented with a cough productive of copious amounts of bile and with pulmonary infiltrates.

METHODS

Diagnosis of bronchobiliary fistula was made based on HIDA scan and confirmed by operative cholangiogram.

RESULTS

Successful correction of this fistula was accomplished by operative closure of the fistulous tract and diversion of the narrowed bile duct by hepaticojejunal bypass.

[Congenital esophago-bronchial fistula in the adult: a case report]

A 45-year-old female with congenital esophago-bronchial fistula was reported. She had suffered from common cold and recurrent bouts of coughing during meals since infancy. An esophago-bronchial fistula was detected by esophagography accidentally. The fistula was connected with right lower lobe bronchus (B6). CT scan showed the cystic change of the right lower lobe. The fistula was surgically removed and right lower lobe lobectomy was carried out. The adhesion of the lower lobe to the chest wall was recognized, but there were no inflammatory signs around the fistula. The isolation of the fistula was very easy. The postoperative course was uneventful.

[Repair of the gastric tube-right main bronchus fistula after operation for esophageal cancer--treatment by transposition of pedicled pectoralis major muscle flap]

We have experienced a case who showed the gastric tube-right main bronchus fistula. A 51-year-old male complained cough and vomiting suddenly. He underwent esophagectomy and radio-chemotherapy for advanced esophageal cancer 19 months ago. Chest X-ray showed severe pneumonia, and gastroscopy, bronchoscopy and CT scan showed the fistula between the whole stomach esophageal substitute and right main bronchus. After recovery from the pneumonia with the treatment by continuous suction through the naso-gastric tube, operation was performed. The fistula was repaired with transposition of a pedicled pectralis major muscle successfully. After the operation, respiration was performed independently with two ventilators for right and left lung to avoid increasing air way pressure. His postoperative course was uneventful, and he discharged on the 66th postoperative day. The cause of the fistula was considered to be a peptic ulcer due to residual secretion of gastric acid.

Endoscopic management of a bronchobiliary fistula

A bronchobiliary fistula is a rare entity that manifests as bilioptysis. We report a 73-year-old woman with a hepato-cellular carcinoma who developed a bronchobiliary fistula. Endoscopic biliary sphincterotomy and insertion of a prosthesis led to successful resolution of symptoms and restoration of normal bile flow. We review the pertinent literature and the basis for management.

Massive hemoptysis as a manifestation of fistulized thoracic aortic aneurysms into the bronchial tree

Aortobronchial fistulas are an uncommon and serious cause of hemoptysis. We present three cases of aortobronchial fistulas that were diagnosed and treated at our hospital. They were presented as massive hemoptysis. The clinical suspicion of a leaking thoracic aortic aneurysm into the bronchial tree should prompt the correct diagnostic procedures since early surgery is the only way to manage this condition.

Management of microfistula following pulmonary resection

The symptoms and signs of cough and changes in the air-fluid pattern on chest radiograph are critical as warning signs of bronchopleural fistula. Drainage of the pleural space is a critical first step for all patients to limit endobronchial contamination and prevent drowing. Once nutritional status is optimized and treatment for infection is established, suture reclosure of the bronchial stump with vascularized flap coverage is curative for the acutely presenting fistula, usually fewer than 2 weeks after surgery. Patients who present with bronchopleural fistula at times more remote from resection are unlikely to have direct reclosure of their fistula. These patients may have closure of their fistula by either an anterior, transpericardial approach, thoracotomy with muscle flap to fill the pleural space, or muscle flap coverage of the fistula with a limited thoracoplasty to obliterate the pleural space. Patients who cannot undergo operations of this magnitude may be treated with endoscopically placed tissue adhesives to seal the fistula. These various treatment options are successful in 75% to 100% of cases, and have been responsible for significantly reducing the morbidity and mortality from bronchopleural fistula.

Bronchoesophagopleural fistula after photodynamic therapy for malignant mesothelioma

A 66-year-old woman presented with a bronchoesophagopleural fistula 10 weeks after thoracic photodynamic therapy for malignant mesothelioma. This is the third reported case of an esophagopleural fistula developing subsequent to photodynamic therapy for mesothelioma. We review the literature on this topic and report our successful management of this complication.