[Closure of bronchopleural fistula by video-assisted mediastinal surgery after pneumonectomy]

Disruption of a mainstream bronchus is a rare but dreaded complication of pneumonectomy. When the bronchial tump measures at least 15 mm, the conventional therapeutic strategy is to drain the pleural cavity followed by closure of the fistula via trans-mediastinal sternotomy. After an experimental study on cadavers to test the technical feasibility of main bronchus closure via a cervical approach using a video-mediastinoscope, we used video-assisted mediastinal surgery successfully in a patient with a left main bronchus fistula.

[A successful case of surgical treatment for the bronchogastric tube fistula originated in the reconstructed gastric tube after operation for esophageal cancer]

A successful case of surgical treatment for a bronchogastric tube fistula after resection for esophageal cancer are reported herein. The patient was a 67-year-old male who had undergone blunt total esophagectomy with reconstruction of a whole gastric tube pulled up through the posterior mediastinum and laryngopharyngectomy with a permanent end-tracheostomy in February, 1983. After the operation, he was irradiated prophylactically to the both neck and upper mediastinum with a total dose of 50 Gy. He showed no sign of recurrence. But 11 years after the operation, he complained excretion of food from his tracheostomy. Endoscopical examination on admission revealed an ulcer in the anterior wall of the reconstructed gastric tube penetrating to the right main bronchus. He was treated conservatively, but endoscopy didn't reveal the ulcer in healing. So we performed an operation. At first the gastric tube and the right main bronchus were divided. Then we attempted to close each fistula. We could suture the gastric tube wall tightly. The membranous wall of bronchus around the fistula was weak, but we could close that fistula without air leak by using the azygos vein flap. His postoperative course was uneventful. We consider that postoperative irradiation, administration of antibiotics, and bile reflux etc. might play significant role in development of the penetrating ulcer.

[A case report of a left bronchial stump fistula from which the wrapped omentum was removed, because of rupture of the anastomotic aneurysm of the descending thoracic aorta--functions of the wrapped omentum in the early phase and extended phase after surgery]

The omental wrapping is a method of the choice for empyema with bronchopleural fistula. A 71-year-old woman, who had undergone graft replacement for the aneurysm of the descending thoracic aorta, underwent left pneumonectomy for lung abscess. Two months after surgery, the bronchopleural fistula in the stump was presented and successfully repaired by omentopexy. When anastomotic aneurysm rupture of the graft was presented one year later, the management was successful because mortal bleeding was prevented by the omental pedicle flap in the left thoracic cavity. Though we removed the omental flap with hematoma, the fistula didn't recurred. The omentum facilitates the healing of bronchopleural fistula in the early phase after surgery, but the healing course in the extended phase had not have any trouble without omental vascularization.

Closure of a postpneumonectomy main bronchus fistula using video-assisted mediastinal surgery

Disruption of a mainstem bronchus is a rare but dreaded complication of pneumonectomy. After an anatomic study on cadavers, we successfully used a video mediastinoscope to close a postpneumonectomy main bronchus fistula via a cervical incision.

[A successful surgical case of descending necrotizing mediastinitis with fistula formation to the right main bronchus]

Descending necrotizing mediastinitis (DNM) is extremely rare and one of the most lethal forms of mediastinitis, even in the era of antibiotics. We have recently treated a 65-year-old man who was diagnosed as having a fistula to the right main bronchus caused by DNM secondary to a peritonsillar abscess. Surgical treatment consisted in closing the right bronchial fistula and covering it with the latissimus dorsi muscle flap and mediastinal drainage through thoracotomy. Postoperative course was uneventful. This is the second known reported case of a successful operation for DNM with bronchial fistula.

Thoracobiliary fistula

Thoracobiliary communications in the form of either pleurobiliary or bronchobiliary fistulas are reported complications of many diseases. A strong suspicion in the appropriate clinical setting is necessary to recognize this problem. Bilioptysis is the sine qua non of a bronchobiliary fistula. Diagnostic imaging studies are useful to identify the communication and to delineate its location. Although surgery is the optimal intervention, percutaneous drainage and intravenous antimicrobial therapy may offer the best therapeutic option in patients with metastatic cancer and limited physiologic reserve. We report a unique case of bronchobiliary fistula complicating a uterine leiomyosarcoma with hepatic metastases. Long-term palliation was achieved with percutaneous drainage and appropriate fluid and electrolyte replacement therapy.

Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy

Between 1972 and 1993, 19 patients (15 males and 4 females) with bronchopleural fistulae and pleural empyema after pneumonectomy were treated with transsternal transpericardial operations and closure of the fistula. The underlying malignant disease was a non-small cell carcinoma in 12, a malignant epithelial mesothelioma in two, and an atypical carcinoid tumor in one case. One patient each presented with tuberculosis, chest trauma, and lung destroyed by bronchiectasis. Fistulas affected the right bronchial stump in 17, and the left in 2, cases after pneumonectomy. The time between pneumonectomy and transsternal transpericardial operation ranged between 1 month and 4 years. All patients were submitted to drainage and irrigation of the empyema cavity (2-4 weeks). In 16 patients a long bronchial stump was sutured or stapled, in three cases resection of a short stump with the distal trachea was followed by anastomosis of the trachea and left main stem bronchus. Irrigation of the pneumonectomy cavity was continued in all patients for 2 weeks. Transsternal transpericardial operation was successful in 15 patients. Two patients died in the first 30 days, of renal or respiratory failure without fistula recurrence. In two cases the fistula recurred; definitive healing was achieved using a great omentum flap and endoscopic application of fibrin glue and bone spongiosa. Transsternal transpericardial management of bronchus stump fistula after pneumonectomy is highly effective and offers advantages over the direct approach through the infected empyema cavity.

Prosthetic graft infection in the descending thoracic aorta treated by extra-anatomic rerouting

Prosthetic aortic graft infection is a dreaded complication associated with high mortality. Some of the best results have been achieved with removal of the infected prosthesis, although this is not always possible in the case of the thoracic aorta. A patient with an infected coarctation graft managed by aortic rerouting is described here.

Giant bronchoesophageal fistula: a rare complication of bronchial artery embolization

Bronchoesophageal fistulas after bronchial artery embolization are rare. In the previous literature only 2 cases were recorded. Here we report treatment of a giant bronchoesophageal fistula on both the left and right bronchus. Our surgical treatment included fistula exclusion by esophageal diversion, and esophageal reconstruction was made by retrosternal stomach. The result was good, and the patient made a satisfactory recovery.

Endoscopic (-ERC) fibrin sealing and histoacryl sealing of an abscess induced bilio-hepatico-cutaneous and a bilio-hepatico-phrenico-bronchial fistulous system

We report the case of a female patient with persisting bilio-bronchial and bilio-cutaneous fistulae originating in the right liver lobe. The causative factor was a subphrenic liver abscess which had been adequately and successfully treated. No biliary obstruction was detectable on admission. Because of her previous medical history the patient was considered to be a high surgical risk. Therefore the described endoscopic (ERC) approach was chosen. Here we describe the first successful attempt to close such a fistulous system by repeated fibrin and histoacryl-sealing through an endoscopically guided catheter. The success of this innovative procedure may be helpful, in the management of similar cases in the future.

Aortobronchial fistula after correction of congenital cardiovascular abnormalities

Aortobronchial fistula (ABF) is a rare but highly lethal condition. Four patients with ABF, 10-25 years after surgical repair of a congenital cardiovascular abnormality are reported. All patients presented with haemoptysis. Computed tomographic (CT) scan and aortography were inconclusive in two, diagnostic in one and not performed in another. Three patients underwent operation: all survived and are free of symptoms with a follow-up of 2-8 yrs. The fourth patient died before operation due to massive haemorrhage into the lung. In all patients, the fistula was secondary to aortic interposition of patch grafts.

Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps

In the past, several methods for closure of postpneumonectomy bronchopleural fistula have been proposed. Herein we describe a technique to close a bronchopleural fistula using a mobilized diaphragmatic flap sutured directly to the fistula edges. This maneuver improves the blood supply to the bronchial stump and may reduce residual pleural cavity. To prevent bacterial contamination of the pleural space, the procedure should be performed immediately after the diagnosis.

Esophagocardioplasty for achalasia in closure of a complicated esophagobronchial fistula

We report a rare case of benign esophagobronchial fistula associated with achalasia. The fistula healed spontaneously after esophagocardioplasty with a gastric patch, suggesting the utility of this procedure.

[New techniques in thoracic surgery. II]

The surgical approach to affections of the chest wall and pleura, still the predominant indications for thoracic surgery, has greatly changed since the advent of thoracoscopic procedures, and is emphasized in this second part of a two-part review, together with other indications for mediastinal tumours. Indicated after lung exeresis or emergency chest surgery, protective chest wall reconstruction with muscular flaps is no longer an exceptional operation. Inversely, thoracic surgery for infectious complications have become less frequent, unusually limited to well established procedures for tuberculosis surgery, treatment of bronchial fistula or mediastinal supperations. The chest cavity is well adapted to new techniques of thoracoscopy and video-assisted thoracic surgery both for diagnosis and treatment. Indications for pleuroscopy have taken on a completely new aspect since 1989. These techniques are used for pericardial fenestration, thoracic sympathectomy for dyshidrosis, vagotomy, splanchnicectomy, chylothorax, spinal affections, empyema and trauma surgery. These new techniques have also had an impact on treatment of spontaneous pneumothorax. For tumour surgery, thoracoscopy has made possible a more adapted strategy currently based on an initial needle biopsy, with limited thoracoscopic exeresis and ultimate treatment depending upon the pathology report. Immediate thoracoscopy without prior biopsy appears excessive. Video-assisted thoracosurgery is also used for most malignant mediastinal tumour which, due to advances in chemotherapy surgery have transformed the prognosis of a large number of mediastinal tumours.

Congenital bronchoesophageal fistulas in adult patients

BACKGROUND

Congenital bronchoesophageal fistulas have rarely been reported. Presented here is the 14-year experience of our hospital with this lesion.

METHODS

The study comprises 13 patients; 9 had a Braimbridge type II fistula; 2, a type I fistula; and 2, a type IV fistula. The most frequent site of communication was between the middle esophagus and the right lower lobe of the lung, especially the superior segment. A fistulectomy, with or without pulmonary resection, was performed on each patient.

RESULTS

All patients had complete relief of symptoms. No operative complications were observed.

CONCLUSIONS

Congenital bronchoesophageal fistulas in adults are usually diagnosed by an esophagography. Symptoms are often nonspecific, and the possibility of a congenital bronchoesophageal fistula should be considered in patients who complain of long-standing unexplainable respiratory symptoms such as coughing and frequent pulmonary infections. The surgical intervention is relatively simple. In many cases, a fistulectomy with simple closure of the openings in both the esophagus and the bronchus is all that is required. Pulmonary resection is needed in some patients with severe bronchiectasis and recurrent pneumonitis.

Role of covered esophageal stents in malignant esophagorespiratory fistula

Malignant esophagorespiratory fistulas are distressing for patients who already have a limited prognosis. Palliative treatment by surgical bypass is often unjustified, and although the use of esophageal stents is more appropriate, their results are variable due to their inability to provide a tight seal. We have managed 2 patients with self-expanding covered esophageal stents, which appear to offer excellent prospects for palliation.

Intrathoracic transposition of the musculocutaneous flap in treating empyema

Intrathoracic transposition of the musculocutaneous (MC) flaps of the latissimus dorsi and rectus abdominis was performed after open-drainage thoracotomy in 6 patients with empyema. The MC flaps were designed in such a way that the muscle-bearing skin paddle was extended well beyond the distal muscle borders. The MC flaps thus provided substantially larger pieces compared to muscle flaps. With the exception of one patient with persistent bronchopleural fistula whose empyema recurred due to the reopening of the fistula, the thoracic closure was successful in all patients. Postoperative magnetic resonance imaging revealed a well-preserved volume of subcutaneous tissue in the flaps, while the muscle portions of the flaps had atrophied. In conclusion, compared to muscle flaps, MC flaps have the advantages that (1) larger empyema cavities can be obliterated, and (2) the deformity of the thoracic wall can be minimized because of the small range of resected rib segments and well-preserved volume of subcutaneous tissue in the flap long after the transposition. The use of MC flaps is thus indicated for the empyema cavity remaining when a cavity is cleaned up of granulatous tissue with eradication of bronchopleural fistula.

Pedicled jejunal seromuscular flap for bronchocutaneous fistula

We report the successful closure of a complicated bronchocutaneous fistula using a pedicled jejunal flap. The fistula, secondary to tuberculosis and irradiation, previously had been closed with a latissimus dorsi musculocutaneous flap. This initial repair failed. The recurrent fistulas were closed again using a jejunal seromuscular flap, and the chest wall defect was reconstructed with a rectus abdominis musculocutaneous flap.

Heart transplantation for chyloptysis after Fontan operation

Chyloptysis is a rare clinical problem, fewer than 10 patients having been reported in the literature. We report a patient with intractable chyloptysis associated with a Fontan procedure, who was palliated by heart transplantation.

Treatment strategies for bronchopleural fistula

Successful management of chronic postoperative bronchopleural fistula remains a challenge for thoracic surgeons. Forty-two patients (33 referred from other institutions) were treated for major postoperative bronchopleural fistula since 1978. Factors associated with bronchopleural fistula included right pneumonectomy (n = 23), left pneumonectomy (n = 8), long bronchial stump (n = 16), pneumonia (n = 13), radiation therapy (n = 12), stapled bronchial closure (n = 8), prolonged mechanical ventilation (n = 7), recurrent carcinoma (n = 6), and tuberculosis (n = 2). Patients had undergone an average of 3.3 surgical procedures to correct their bronchopleural fistulas during a mean interval of 24 months before our treatment. Bronchopleural fistulas were located in the right main bronchial stump (n = 23), left main bronchial stump (n = 8), right lobar bronchial stumps (n = 10), and tracheobronchial anastomosis (n = 1). Thirty-five patients were treated by suture closure of the bronchial stump, buttressed with vascularized pedicle flaps of omentum (n = 19), muscle (n = 13), or pleura (n = 2). In seven cases, direct suture closure was not possible, and omental (n = 6) or muscle (n = 1) flaps were sutured over the bronchopleural fistula. Suture closure without pedicle coverage was performed successfully in one case. Initial repair of the fistula was successful in 23 of 25 patients treated with omentum, in nine of 14 patients treated with muscle and in neither of two patients treated with pleural flaps. In nine patients with persistent or recurrent bronchopleural fistula after our initial repair, four underwent a second procedure (three successful) and five were managed with drainage only. The fistula was successfully closed in 11 of 12 patients who had received high-dose radiation therapy (nine with omentum). Overall, successful closure of bronchopleural fistula was achieved in 36 of 42 patients (86%). Four in-hospital deaths resulted from pneumonia and sepsis, two in patients with recurrent bronchopleural fistula after pleural flap closure. In 16 patients the empyema cavity was obliterated during definitive repair of the fistula. The cavity resolved with drainage in four others, nine had draining cavities at follow-up, and one was lost to follow-up. Ten patients required a total of 17 Clagett procedures and one had a delayed myoplasty. Direct surgical repair of chronic bronchopleural fistula may be achieved in most patients after adequate pleural drainage by suture closure and aggressive transposition of vascularized pedicle flaps. Omentum is particularly effective in buttressing the closure of bronchopleural fistulas.

[Bronchoesophageal fistula and broncholithiasis]

Bronchoesophageal fistulas (BEF) in an adult, whether acquired or congenital, are uncommon but bronchoesophageal perforation secondary to broncholithiasis caused by calcified mediastinal adenopathy and leading to the formation of a fistulous tract is extremely rare. We present a case of acquired BEF in a 57-years-old women who presented cough with expectoration of broncholiths, hemoptysis and cough after swallowing liquid or solid hemoptysis and cough after swallowing liquid or solid foods. The chest film and computed tomographic scan showed calcified mediastinal adenopathy. Endoscopic examination of the esophagus revealed no mucosal abnormality. A bronchial esophageal fistula was identified at the level of the 1/3 midesophagus just below the carina in the esophagogram. The bronchoscopy showed a polypoid area located in the medial side of the right main bronchus. There was no evidence of neoplasm. The patient underwent excision of fistula and interposition of pleural bundle after completing a right posterolateral thoracotomy. The postoperative course was uneventful and the patient has been doing well on follow-up.