Congenital bronchoesophageal fistula in the adult

Congenital bronchoesophageal fistula is a rare clinical entity in adult patients. This anomaly may cause various symptoms such as respiratory infections, coughing bouts when eating or drinking, and even hemoptysis. We present a report on 9 patients with bronchoesophageal fistulas who were treated in our hospital during the last 30 years. One patient died of pulmonary complications before definitive treatment of the fistula. Other patients recovered from surgical closure of the fistula without complications. Based on our experience, these patients should be treated surgically without delay. Observation may result in fatal pulmonary complications.

Results of surgical management of tuberculosis: experience in 206 patients undergoing operation

Between January 1978 and December 1990, 206 operations for pulmonary tuberculosis were performed at our institution, a former sanatorium located in northern Italy. Patients with tuberculoma and pleural tuberculous disease were excluded from this series. Cavitary sequelae, bronchiectases, and hemoptysis were the most common indications for resection. Scar cancer and mycetoma were associated diseases in more than 60% of the patients. Healing was achieved in 90% of the patients. Operative mortality was 3%. Overall morbidity was 29.1%. Patient stratification showed that sputum-positive patients had a higher morbidity (30%) and a lower healing rate (86.2%). Before operation, an accurate assessment of both the performance status and the functional reserve of the surgical candidates is emphasized. Despite a high complication rate, aggressive surgical treatment of drug-resistant tuberculosis or its stabilized sequelae is warranted to achieve anatomobiological eradication of the disease, thus avoiding long-term troublesome complications.

[A case of chronic empyema due to tuberculosis with bronchopleural fistulae treated successfully by extraperiosteal air plombage thoracoplasty and omentoplasty]

A 63-year-old man, who had undergone induction of artificial pneumothorax at 20 years of age as a treatment for right tuberculosis, developed fever and cough. A chest X-ray film showed marked pleural effusion in the right chest. Examination of sputum and the pleural effusion revealed tubercle bacillus, and right tuberculous empyema was diagnosed. At surgery, the right thoracic cavity was occupied by empyema, and multiple bronchopleural fistulae were observed. Because of the presence of tubercle bacilli in the empyema cavity, extraperiosteal air plombage thoracoplasty was insufficient for control of the empyema. Therefore, omentoplasty was added. Two months after the operation, the patient was discharged in good condition. He has been doing well without any sign of recurrence of empyema for the last two years. Although extraperiosteal air plombage thoracoplasty is a considerably effective therapy for empyema, its curability rate is lower in cases like the present one in which bronchopleural fistulae and bacteria are present in empyema cavity, such as our case. We consider that our method, extrapriosteal air plombage thoracoplasty with omentoplasty, is a reliable one for control of empyema, in patient with high risk factors for recurrence, such as bronchopleural fistulae and bacteria in the cavity.

Video-assisted thoracoscopy for closure of a bronchial stump fistula

It is thought that thoracoscopic closure of a bronchial stump fistula is beyond the capabilities of current thoracoscopic techniques. We describe the successful use of thoracoscopy in the therapy of a late right main bronchial stump dehiscence after pneumonectomy and chemotherapy of a stage IIIA adenocarcinoma. We clipped the fistula with a Multifire Endo Hernia Stapler (Auto Suture) and we obtained intraoperative airtight closure of the fistula.

[The diagnosis and treatment of benign esophagotracheo-bronchial fistula: a report of 26 cases]

Twenty six patients with esophagotracheal fistula or esophagobronchial fistula were treated from 1960 to 1991. There were 18 males and 8 females with age ranging from 19 to 69. Trauma and complication of esophageal diverticulum were the main causes of fistula. Among 23 patients surgically treated, 10 underwent direct repair, and 13 either closure of esophageal defect or tracheal or bronchial defect. The concomitant procedures were permanent tracheostomy, tracheal resection and reconstruction, pulmonary resection, thoracoplasty esophagectomy, and esophagogastric anastomosis. All patients resumed normal eating. Complications included paralysis of recurrent nerves, empyema, injury and ligation of subclavian artery, dehiscence of tracheal anastomosis, and contralateral pneumohydrothorax in each patient. Prognosis of 3 nonsurgical treatments of fistulas was poor. Surgical intervention should be done as soon as the diagnosis is established in order to minimize pulmonary complication.

Laser patch welding: experimental study for application to endoscopic closure of bronchopleural fistula, a preliminary report

BACKGROUND AND OBJECTIVE

Postoperative bronchopleural fistula is a serious complication following pulmonary resection. To close the bronchopleural fistula, we developed a new method of endoscopic patch welding using laser tissue welding between bronchial tissue and a patch.

STUDY DESIGN/MATERIALS AND METHODS

The feasibility of the laser patch welding was examined by in vitro and in vivo animal experiments. A newly developed carbon monoxide (CO) laser and an Argon ion laser were evaluated. Various tissue membranes and artificial membranes were evaluated as patch materials.

RESULTS

We found that the combination of expanded polytetrafluoroethylene (e-PTFE; 200 microns in thickness) and the CO laser with contact irradiation method offered the strongest laser patch welding. Using this combination, the irradiation at 400 W/cm2 for 10 seconds resulted in 16-18 g of measured traction strength at the welding spot (2 mm in diameter). The welded e-PTFE patch at bronchial stump remained for 5 weeks.

CONCLUSION

Our results encourage use of this novel laser patch technique for clinical applications.

Bronchopleural fistula after pneumonectomy for lung cancer

Bronchopleural fistula (BPF) after pneumonectomy is a life-threatening complication. Over a period of 14 years (January 1980 to November 1993), 471 pneumonectomies were performed byone surgical team using a uniform suture technique for primary lung cancer. Non-small cell lung cancer accounted for 451 cases and 20 cases were small cell cancer. All operations were performed using a uniform hand suture technique. There were seven cases of BPF giving an incidence of 1.5%. All fistulas occurred within 15 days postoperatively and there were no late fistulas. The bronchial stump was free of tumor in all cases. No fistula occurred in the 24 (5.1%) completion pneumonectomies. The experience of the surgeon was important as the senior author performed 374 pneumonectomies with two fistulas (0.5%) while other surgeons in training performed 97 pneumonectomies with five fistulas (5.1%). Bronchial dehiscence was confirmed by bronchoscopy in all cases and an attempt at resuturing the stump through the same thoracotomy incision was made within 2 days of the diagnosis. Closure was successful in five patients, while the other two developed fatal complications. We conclude that suture closure to the bronchial stump after pneumonectomy provides a cheap and reliable technique, it is applicable in all situations and can be taught to surgeons in training with an acceptable risk.

[Tuberculous adenopathies of the mediastinum: surgical experience in adults]

Fifty eight patients were treated for mediastinal tuberculous adenopathies in the thoracic surgery department from 1986 to 1992. Surgery was diagnostic in 49: mediastinoscopy n = 42, left anterior mediastinotomy n = 3, thoracotomy n = 3 and video assisted surgery n = 1. Surgery was in view of cure in 9: bronchial fistula despite medical treatment n = 6, recurrence under medical treatment n = 3. Mediastinal tuberculous adenopathies rarely complicate in adults. Surgical treatment is quickly effective in prolonging and complicating cases under medical treatment and also probably diminishes the risk of bronchial and pulmonary sequellaes.

[Endoscopic treatment of bronchopleural fistula using fibrin biological adhesive]

Three cases are reported of bronchopleural fistula successfully resolved by using biological adhesives through the intrabronchial way. In the three cases the rigid bronchoscope was used to prepare the field and the passage of the adhesive material. The results obtained allow the consideration of this procedure as useful for small fistulas and as a initial therapeutical approach for other fistulas due to the small morbidity rate associated with this procedure compared with others.

Aortobronchial fistula 13 years following repair of aortic transection

We describe a 56-year-old man with the new onset of hemoptysis, increasing in frequency and magnitude, initially diagnosed and treated as pulmonary embolism. Bronchoscopy, computed tomography, and thoracic aortography were performed twice before the diagnosis was made. Thirteen years previously, the patient underwent thoracic aortic interposition graft placement for aortic laceration as a result of a motor vehicle accident. The second aortogram demonstrated a small pseudoaneurysm at the expected proximal graft suture line. Aortobronchial fistula, a rare cause of hemoptysis, was diagnosed. The patient underwent successful resection of the graft and placement of a new dacron interposition graft. All cultures, including blood, sputum, and operative specimen cultures, were negative. The patient is alive and well 1 year following surgery.

Management of postpneumonectomy bronchopleural fistulae. A review

The management of postpneumonectomy bronchopleural fistulae continues to constitute a major therapeutic challenge. Refinements of surgical techniques have reduced the incidence of this dreaded complication although it cannot be totally prevented. Management remains controversial. We report our recent experience of three patients with bronchopleural fistulae following a right pneumonectomy, two for bronchogenic carcinoma and another for non-tuberculous, suppurative lung disease. Our treatment of choice for these patients is, immediate pleural drainage together with parenteral broad spectrum antibiotics followed by endoscopic closure of the fistula with monomeric n-butyl-2-cyanoacrylate glue (Histoacryl blue, B Braun, Melsungen, Germany). The pleural space is then irrigated with Povidone Iodine to sterility following which the closed bronchial stump is reinforced following which the closed bronchial stump is reinforced and the pleural space obliterated by decortication, omentopexy and by a tailored thoracoplasty. This cosmetically acceptable treatment produces minimal functional disability and is achieved with minimal morbidity and mortality in these critically ill patients.

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

A 52-year-old man had been having cough on drinking water since 30 years. He coughed out blood 20 years ago. Chest roentgenogram showed the infiltrating shadow in the right lower lung field and the left hilum. Chest computed tomogram in the left atrium level showed fistulous communication between the bronchus and the esophagus and cavity lesion. Esophagogram showed fistulous communication between the bronchus (rt. B7) and the middle third of the esophagus. Bronchogram showed the stenotic lesion of the right B7a and B*. And abnormal bronchus was revealed and fistula was suspected. The orifice of the fistula was seen by esophageal endoscopy. Through the right posterolateral thoracotomy, fistelectomy and covering with pleural flap over the esophageal suturing site were performed. Histologic finding of the resected specimen revealed fistula's wall composing of smooth muscle lined with squamous cell layer. This case is categorized as Braimbridge type II. The postoperative course was uneventful and the patient is now in free of complaints at the 6th month's P.O.D.

Bronchobiliary fistula secondary to biliary lithiasis. Treatment by endoscopic sphincterotomy

Bronchobiliary fistula is a rare condition, defined by the presence of a passage between the biliary tract and the bronchial tree. Many conditions can give rise to the development of such a communication. Biliary lithiasis is one of those and is perhaps the one most amenable to endoscopic management. We describe a case of bronchobiliary fistula secondary to the development of choledocholithiasis in a cholecystectomized patient. The clinical suspicion was raised by the presence of bilioptosis (bile-stained sputum), and the diagnosis established by endoscopic retrograde cholangiopancreatography. The patient was submitted to endoscopic sphincterotomy and stone extraction, achieving frank clinical alleviation. This case gives us the chance to review bronchobiliary fistulas secondary to biliary lithiasis, placing particular emphasis on the opportunities of endoscopic management.

[Surgically successful treatment of pleural empyema with multiple bronchial fistulae--a case report]

A 62-year-old man who had undergone left lingual segmentectomy for pulmonary tuberculosis developed left chronic localized pleural empyema with multiple bronchial fistulae in the region of surgical gauze left in the thoracic cavity. We surgically removed the gauze and fenestrated the empyema. After disinfection of the region of suppuration, small fistulae which were less than 2 mm in diameter were closed by fibrin-glue-packing and consolidation of the orifices using 40% silver nitrate solution. Two and one-half months later a second operation was performed. Residual large fistulae were closed by fibrin-glue-packing and suturing of their orifices, and the empyema space was then obliterated by muscle flap plombage. The patient's postoperative course was good and the empyema was completely cured with this treatment.

Gastrobronchial fistula: an unusual complication of esophagectomy

Gastrobronchial fistula is an extremely rare condition. A case of gastrobronchial fistula secondary to a benign gastric ulcer 9 years after esophagectomy and gastric pull-up for treatment of esophageal carcinoma is described. A review of the literature is provided.

Aortobronchial Fistula following Aortic Valve Surgery

We report the case of a 54-year-old man with an aortobronchial fistula following aortic valve replacement for prosthetic endocarditis. He presented with massive haemoptysis and the diagnosis was made following computerized tomography of the chest. Effective treatment was achieved by adhering to the basic principles of fistula management. The patient remains well at 1 year follow-up.

Omentopexy and muscle transposition: two alternative methods in the treatment of pleural empyema and mediastinitis

From March 1987 to March 1993, 64 patients with chronic empyema and mediastinitis were treated with omentum and thoracic muscle transposition. There were 36 male and 28 female patients, age range 29 to 76 years. 31 patients suffered from chronic empyema and bronchopleural fistula after lung surgery, 18 patients had chronic empyema after pulmonary inflammatory disease, and 15 patients developed a mediastinitis with or without pleural empyema after cardiac surgery or irradiation of the chest wall. The pedicled omentum was used in 33, the thoracic muscles latissimus dorsi, pectoralis major, serratus anterior, and trapezius either alone or combined in 31 cases. There were no perioperative deaths. Bronchopleural fistulas and infected spaces were successfully closed in 61 patients (95.3%). Postoperative CT scan, angiography, bronchoscopy, and lung function tests demonstrate the efficacy of both surgical methods. Omentum pedicle and thoracic muscle flaps supply excellent vascularised tissue to fill infected pleural space and mediastinum, particularly in patients with limited cardiopulmonary function.

Empyema following pulmonary resection

Empyema after lung resection is an uncommon, but serious, complication. Its reported incidence varies from 1% to 5%, and it is frequently associated with a bronchopleural fistula. This article covers the prevention and treatment of empyema. Treatment requires the use of appropriate antibiotics, adequate drainage, obliteration of the pleural space, and closure of the fistula in order to achieve a long-term successful outcome.

[Amebic liver abscess with hepatobronchial fistula]

Four weeks after a holiday in Kenya a 57-year-old woman developed a fever up to 40 degrees C, right upper abdominal pain, icteric sclerae, nausea and vomiting. Laboratory tests revealed leukocytosis (24,400/microliters), markedly accelerated erythrocyte sedimentation rate (123 mm/h) and moderately increased activity of liver enzymes in serum. The liver was unremarkable on ultrasound. Four days after hospitalization the patient complained of dyspnoea and pleuritic pain. Ultrasound examination and computed tomography showed an abscess in the right lobe of the liver. Amoebic abscess of the liver being the most likely diagnosis, although the relevant serological tests were unremarkable and a titre increase occurred only later, treatment was started with metronidazole (four times 500 mg daily intravenously) and paromomycin (three times 10 mg/kg daily). Her condition significantly improved within a day. Two weeks later, however, she developed chest pain, dyspnoea and cough productive of large amounts of white-yellow sputum, even though antibiotic treatment was continuing. A transdiaphragmatic rupture of the abscess with formation of a hepatobronchial fistula proved to be the cause of these symptoms. The patient was treated surgically by drainage and suturing-over of the extensive diaphragmatic defect and after 2 weeks she was discharged symptom-free on a maintenance dose of diloxanide furoate (three times 500 mg/d orally).

[Benign esophago-bronchial fistula in a 52-year-old woman]

The case of a 52-year-old woman with an oesophagobronchial fistula is presented. The diagnosis was not made preoperatively. The patient was operated twice, with resection of a diverticulum of the oesophagus at the last operation. The congenital or acquired origin of the fistula is discussed.

A new composite gastric seromuscular and omental pedicle flap

OBJECTIVE

The authors performed a study to see if gastric seromuscular patch elevation is anatomically feasible and to estimate the maximum size of the patch relative to its blood supply.

SUMMARY BACKGROUND DATA

A flap composed of greater omentum and a full-thickness segment of the greater curvature of the stomach, based on the right gastroepiploic artery, was first described in 1977. Elevation of the greater omentum along with a seromuscular patch of stomach has not been reported previously.

METHODS

Angiography was performed via the right gastroepiploic artery in a stomach obtained from ten patients who underwent gastrectomy, then india ink was injected. The stomach was then fixed in 10% formalin, and histochemical examination was performed to determine if seromuscular patch elevation was possible.

RESULT

Results of the angiography and injection experiment of india ink indicated that the territory of a single gastric ramus was approximately 5 cm x 5 cm in both anterior and posterior walls of the stomach. Histology revealed that the gastric rami lay between the muscular layer and the mucosa.

CONCLUSION

The authors believed that a composite gastric seromuscular patch and omental pedicle flap would be clinically applicable. The authors also believed that the maximum size of the patch was 10 cm x 10 cm. They used this flap to successfully treat three patients with chronic soft-tissue defects--two bronchopleural fistulae and a radiation ulcer.