Colonic interposition for oesophageal replacement surgery in a patient with left broncho-oesophageal fistula: anaesthetic management

Management of an uncorrected broncho-oesophageal fistula in the perioperative period is a challenge for the anaesthesiologist. Positive pressure ventilation which is inevitable during surgery will lead to gastric insufflation and there is a high risk of aspiration of gastric contents. In this case report, we discuss how we used a double lumen tube to occlude a pericarinal broncho-oesophageal fistula. This method was quite effective as it obviated the need for isolating the lung as well as ensured smooth delivery of positive pressure ventilation during the surgery.

[Successful Negative Pressure Wound Therapy for Pleural Empyema by Closing Bronchopleural Fistula with Cyanoacrylate Products]

A 69-year-old man had experienced right upper lobectomy for inflammatory granuloma. Three months after surgery, he was diagnosed with pleural empyema due to bronchopleural fistula and open window thoracostomy was performed. Since we could not decrease the dead space and the amount of pleural effusion, we introduced negative pressure wound therapy (NPWT). Before applying, we closed the fistula with suturing and cyanoacrylate products. Four weeks later, we performed an operation to close the open window with muscle transposition. NPWT is reported to be useful to treat pleural empyema, but control the air leakage from fistulas is essential to introduce this treatment. We think cyanoacrylate products may be useful in closing fistulas temporarily to introduce NPWT.

Bronchobiliary fistula: a clinical and surgical challenge. Presentation of a pediatric case

INTRODUCTION

Congenital bronchobiliary fistula is an extremely rare malformation with high morbidity and mortality rates. Up to 2016, 36 cases had been reported worldwide.

CLINICAL CASE

11-year-old male patient with history of chronic lung disease and respiratory insufficiency, bile ptyalism and 66-80% arterial saturation, jaundice, asymmetric thorax, finger clubbing, and disseminated crackling rales. He was diagnosed through fibrobronchoscopy and CT-scan. After fistula closure and right pneumonectomy, recurrence occurred due to bile duct hypoplasia as evidenced by endoscopic retrograde cholangiopancreatography. Left lateral hepatic segmentectomy and fistula closure from the abdomen were carried out. Bronchopleural fistula persisted following intensive nutritional and antibiotic treatment. It was surgically closed using a bovine pericardial patch. Six months later, the patient had no symptoms.

DISCUSSION

Given how extremely rare this malformation is, cross-disciplinary treatment and a high grade of suspicion are needed. The presence of bile duct hypoplasia is to be considered, since it requires a thoracoabdominal approach.

Prophylactic Bronchial Stump Support With Intrathoracic Muscle Flap Transposition

BACKGROUND

Bronchopleural fistula (BPF) is a dreaded complication of pulmonary resection. For high-risk patients, bronchial stump coverage with vascularized tissue has been recommended. The goal of this study was to report our experience with intrathoracic muscle transposition for bronchial stump coverage.

METHODS

A retrospective review of all patients who underwent intrathoracic muscle flap transposition as a prophylactic measure at our institution between 1990 and 2010 was conducted. Demographics, surgical characteristics, and complication rates were abstracted and analyzed.

RESULTS

A total of 160 patients were identified. The most common lung resections performed were pneumonectomy (n = 69, 43%) and lobectomy (n = 60, 38%). A total of 168 flaps were used where serratus anterior was the most common flap (n = 136, 81%), followed by intercostal (n = 14, 8%), and latissimus dorsi (n = 12, 7%). Ten patients (6%) developed BPF, and empyema occurred in 13 patients (8%). Median survival was 20 months, and operative mortality occurred in 7 patients (4%).

CONCLUSIONS

Reinforcement of the bronchial closure with vascularized muscle is a viable option for potentially decreasing the incidence of BPF in high-risk patients. Further randomized studies are needed to determine the efficacy of this technique for BPF prevention.

[Successful Conservative Management of Bronchopleural Fistula after Intraoperative Bronchial Injury]

A 64-year-old woman diagnosed as primary lung cancer was admitted for surgery. Right lower lobectomy and ND2a-1 nodal dissection was performed under video-assisted thoracic surgery( VATS). The membranous portion of intermediate bronchus was injured about length of 5 mm while dissecting subcarinal lymph nodes. The fistula was closed by knotted suture using 4-0 polydioxanone (PDS) and covered with pericardial fat pad. Although the postoperative course was uneventful and discharged at postoperative day (POD) nine, bloody sputum appeared and right pneumothorax developed at POD 11. Bronchoscopy revealed a slit-like bronchopleural fistula at intermediate bronchus. By continuous thoracic drainage, the fistula successfully closed at POD 13.

[Esophagotracheal and esophagobronchial fistulas]

Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.

Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report

RATIONALE

An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited.

PATIENT CONCERNS

A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close.

DIAGNOSES

Intractable esophago-bronchial fistula associated with esophageal surgery.

INTERVENTIONS AND OUTCOMES

On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case.

LESSONS

We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: a clinical observation of 17 cases

BACKGROUND

Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula.

METHODS

Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed.

RESULTS

Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5-431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure).

CONCLUSIONS

The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

Successful repair of a tuberculous bronchial lymphatic fistula with pericardial fat pad patch. A case report

This study reported a rare case of mediastinal abscess scrofula. The patient was found to have a large left main bronchial orificium fistula (approximately 1.5x1.5cm in size) after clearing a mediastinal lymph node abscess via the right thoracotomy approach. The adjacent tissue was empty and could not be directly repaired. Therefore, the research team cut out an appropriately sized right pericardial fat pad patch during the operation for repairing and then covered it with a biological patch (Neoveil) for reinforcement. The mediastinal pleura was treated by embedding and the postoperative recovery was good. KEY WORDS: Abscess, Fistula, Pericardial fat patch, Tuberculous bronchial lymphatic, Tuberculosis bacillus, Type mediastinal lymphatic tuberculosis.

[Completion Pneumonectomy for the Recurrence of Lung Cancer]

INTRODUCTIONS

The morbidity and mortality after completion pneumonectomy (CP) are reportedly high. We, herein, report the outcomes of CP at our institution.

SUBJECTS

Nine consecutive patients [7 men and 2 women, average age of 72 years(range 44~84 years)] who underwent CP for recurrence of lung cancer during 2012~2018 were retrospectively reviewed.

RESULTS

Right-sided sleeve CP was performed in two cases and left-sided CP in seven cases. The indications for surgery were lymph node metastasis of the cancer, pulmonary metastasis, and bronchial stump recurrence in 4, 3, and 2 cases, respectively. Postoperative complications occurred in six patients. One of the patients who underwent right sleeve pneumonectomy developed bronchopleural fistula and died 68 days after the surgery. The mean follow-up period was 33 months, and four patients died during follow-up. Of the 5 patients still alive, 4 had no recurrence and 1 had recurrence in the stump of the main bronchus. The five-year overall survival rate was 78%.

CONCLUSIONS

Although only few cases were assessed, the prognosis after CP at our institution was relatively good.

Postpneumonectomy MRSA empyema treated with vacuum therapy - case report and literature review

INTRODUCTION

Postpneumonectomy empyema is one of serious complications with high mortality and lethality. In this paper, the authors describe the treatment of methicillin-resistant Staphylococcus aureus-induced postpneumonectomy empyema by vacuum therapy in a patient operated on for malignant pleural mesothelioma.

CASE REPORT

A 64-year-old patient was operated on at our clinic for epithelioid mesothelioma of the right pleural cavity. We performed extrapleural pneumonectomy with intraoperative hyperthermic intrathoracic chemotherapy. Seven weeks after surgery the patient was readmitted for right pleural cavity empyema caused by methicillin-resistant Staphylococcus aureus (MRSA). Following pleural cavity debridement and mesh explantation we applied vacuum therapy. In total, we performed 4 dressing changes with final application of an antibiotic solution into the pleural cavity and wound closure. The patient showed no evidence of recurrent empyema during subsequent 12-month follow-up and underwent chemotherapy.

CONCLUSION

Vacuum therapy is an effective treatment of postpneumonectomy empyema in patients without a bronchopleural fistula; nevertheless, specific postpneumonectomy patient care is required.

Successful repair of a tuberculous bronchial lymphatic fistula with pericardial fat pad patch. A case report

This study reported a rare case of mediastinal abscess scrofula. The patient was found to have a large left main bronchial orificium fistula (approximately 1.5x1.5cm in size) after clearing a mediastinal lymph node abscess via the right thoracotomy approach. The adjacent tissue was empty and could not be directly repaired. Therefore, the research team cut out an appropriately sized right pericardial fat pad patch during the operation for repairing and then covered it with a biological patch (Neoveil) for reinforcement. The mediastinal pleura was treated by embedding and the postoperative recovery was good. KEY WORDS: Abscess, Fistula, Pericardial fat patch, Tuberculous bronchial lymphatic, Tuberculosis bacillus, Type mediastinal lymphatic tuberculosis.

Pulmonary mucormycosis: a case of pulmonary arterial hypertension, Westermark sign, and bronchopleural fistula

We herein describe a patient with pulmonary mucormycosis and acute myelogenous leukemia. Computed tomography showed a widened pulmonary artery, a bronchopleural fistula, and the Westermark sign. Despite worsening hemoptysis, the operation was delayed for 6 months. The operation was very complicated and difficult. A thorough preoperative examination, adequate preoperative preparation, appropriate surgical timing, and rich clinical and surgical experience were the keys to successful surgery in this case.

Effective treatment of bronchopleural fistula with empyema by pedicled latissimus dorsi muscle flap transfer: Two case report

RATIONALE

Bronchopleural fistula (BPF) is a dreaded complication after lobectomy or pneumonectomy and is associated with high morbidity and mortality. Successful management remains challenging when this condition is combined with empyema, and the initial treatment is usually conservative and endoscopic, but operative intervention may be required in refractory cases.

PATIENT CONCERNS

Two patients diagnosed with BPF with empyema were selected to undergo surgery in our hospital because they could not be cured by conservative and endoscopic therapy for 1 or more years. One was a 70-year-old man who had a 1-year history of fever and cough after he received a minimally invasive right lower lobectomy for intermediate lung adenocarcinoma and chemotherapy 2 years ago; the other was a 73-year-old man who had a 2-year history of cough and fever after he underwent a minimally invasive right upper lobectomy for early lung adenocarcinoma 3 years earlier.

DIAGNOSIS

Both patients were diagnosed with BPF with empyema.

INTERVENTIONS

After receiving conservative and endoscopic therapies, both patients underwent pedicled latissimus dorsi muscle flap transfers for complete filling of the empyema cavity.

OUTCOMES

The patients recovered very well, with no recurrence of BPF and empyema during postoperative follow-up.

LESSONS

It is crucial to not only completely control infection and occlude BPFs, but also obliterate the empyema cavity. Thus, pedicled latissimus dorsi muscle flap transfer associated with conservative and endoscopic therapies for BPF with empyema is a useful treatment option, offering feasible and efficient management with promising results.

[Aspergillus Empyema with Bronchopleural Fistula due to Destroyed Lung after Postoperative Radiotherapy for Thymoma]

A 35-year-old man underwent adjuvant chemoradiation therapy to the surgical margin of the thymoma. Five years after the therapy, an area of the right upper lung lobe, which was included in the irradiation field, developed destroyed lung, resulting in Aspergillus empyema with bronchopleural fistula. To control the infection, an open window thoracostomy was performed. As the bronchopleural fistula resulted in pneumonia, bronchial embolization was performed with an Endobronchial Watanabe Spigot. After the empyema cavity was cleaned, the empyema space was closed with omental and muscular flap, thoracoplasty. Negative pressure wound therapy was carried out because of poor wound healing. The patient is doing well without relapse 15 months after the thoracoplasty.

Rare broncho-pulmonary arterial fistula in a healthy 9-year-old girl

A 9-year-old previously well girl presented with multiple episodes of large volume haemoptysis and right sided consolidation. She continued to have haemoptysis despite intravenous antibiotics. CT chest suggested a right mainstem endobronchial lesion; this was not seen on bronchoscopy where an extensive blood clot was removed. Distal flexible bronchoscopy could not identify the source of bleeding. CT angiogram revealed a broncho-pulmonary arterial fistula, a rare cause of haemoptysis in children. Endovascular embolisation resulted in short-term symptom resolution; however, haemoptysis recurred months later, leading to re-embolisation. This case highlights a stepwise approach to the workup of large volume haemoptysis.

Clinical Evaluation of Endoscopic Bronchial Occlusion with an Endobronchial Watanabe Spigot for the Management of Intractable Pneumothorax, Pyothorax with Bronchial Fistula, and Postoperative Air Leakage

Objective The present study aimed to evaluate the clinical effectiveness of endoscopic bronchial occlusion (EBO) with endobronchial Watanabe spigots (EWSs) for the management of prolonged pulmonary air leaks, such as intractable pneumothorax, pyothorax with bronchial fistula, and postoperative air leakage. Methods This was a retrospective study. Between April 2005 and March 2018, we recruited 21 patients with intractable pneumothorax (10 cases), pyothorax with bronchial fistula (7 cases), and postsurgical pulmonary fistula (4 cases) in whom appropriate drainage for 2 weeks had been unsuccessful and who were unsuitable for surgery. An EWS was inserted using a flexible bronchoscope via an endotracheal or a tracheostomy tube. Results The mean number of sessions with EWS procedures was 1.94, and the mean number of inserted EWS per patient was 6.5. In addition to EWS procedures, pleural washing and pleural adhesion therapy were performed in all cases with pyothorax, whereas pleural adhesion therapy was performed in three patients with pneumothorax. The successful treatment rate was 85.7%. Reduction of air leakage was observed in 19/21 patients. The mean duration of reduction of air leaks was 4.1 days (median, 1; range, 0-24 days) following EWS procedures. The mean duration from tube insertion to chest tube removal was 43.4 days (median, 29; range, 16-105 days). Complications included spigot migration and infection (aspergillosis); no complications caused significant mortality. Conclusion Performing EBO using an EWS appears to be a reasonable option for the management of intractable pneumothorax, pyothorax with pulmonary fistula, and postoperative air leakage.

Muscle Flap Transposition for the Management of Intrathoracic Fistulas

BACKGROUND

Intrathoracic fistulas pose unique challenges for thoracic and reconstructive surgeons. To decrease the incidence of fistula recurrence, pedicled flaps have been suggested to buttress the repair site. The authors aimed to report their experience with muscle flap transposition for the management of intrathoracic fistulas.

METHODS

A retrospective review of all patients who underwent intrathoracic muscle flap transposition for the management of intrathoracic fistulas from 1990 to 2010 was conducted. Patient demographics, surgical characteristics, and complication rates were abstracted and analyzed.

RESULTS

A total of 198 patients were identified. Bronchopleural fistula was present in 156 of the patients (79 percent), and 48 had esophageal fistula (24 percent). A total of 238 flaps were used, constituting an average of 1.2 flaps per patient. After the initial fistula repair, bronchopleural fistula complicated the course of 34 patients (17 percent), and esophageal fistula occurred in 13 patients (7 percent). Partial flap loss was identified in 11 flaps (6 percent), and total flap loss occurred in four flaps (2 percent). Median follow-up was 27 months. At the last follow-up, 182 of the patients (92 percent) had no evidence of fistula, 175 (89 percent) achieved successful chest closure, and 164 (83 percent) had successful treatment. Preoperative radiation therapy and American Society of Anesthesiologists score of 4 or greater were identified as risk factors for unsuccessful treatment.

CONCLUSIONS

Intrathoracic fistulas remain a source of major morbidity and mortality. Reinforcement of the fistula closure with vascularized muscle flaps is a viable option for preventing dehiscence of the repair site and can be potentially life-saving.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Omental Flap for Bronchopleural Fistula After Pneumonectomy and Aorta Replacement

Bronchopleural fistula (BPF) is a fatal complication after lung cancer surgery. We report the case of a 56-year-old man treated with omental flap for BPF after pneumonectomy along with descending aorta replacement. He underwent left pneumonectomy with combined resection of the descending aorta, followed by replacement with prosthetic graft after the diagnosis of lung cancer, cT4 N1 M0 stage IIIA. He had BPF postoperatively and underwent an omental flap plombage after unsuccessful repair using the latissimus dorsi muscle. He did not have BPF recurrence or aortic graft infection. An omental flap is a useful option for treating BPF with an intrathoracic prosthetic graft.

Anesthetic management for a patient with bronchobiliary fistula after pancreaticoduodenectomy: A case report

RATIONALE

Perioperative management of patients with bronchobiliary fistula (BBF) is an anesthetic challenge because they typically exhibit poor lung function preoperatively, require meticulous lung isolation intraoperatively and need postoperative respiratory support.

PATIENT CONCERNS

A 44-year-old man with a past surgical history of pancreaticoduodenectomy presented fluctuating fever, jaundice, dyspnea and yellowish sputum. Despite intravenous antibiotic treatment and repeated percutaneous drainage, patient showed gradual deterioration with hypoxemia, and uncontrolled pneumonia.

DIAGNOSES

The patient was diagnosed with BBF based on the clinical manifestation such as biloptysis with pneumonia, and imaging studies.

INTERVENTIONS

Resection of the fistula and bilobectomy was performed under general anesthesia. Avoidance of positive pressure ventilation before lung isolation and precise lung isolation are essential for patients with BBF to protect the unaffected lung. Therefore, rapid sequence induction was performed. Left-sided double-lumen tube was inserted for lung isolation and position of the tube was confirmed by visualization with fiberoptic bronchoscopy. Bile-stained secretion was repeatedly suctioned in trachea and both bronchi during surgery.

OUTCOMES

In spite of decrease in SpO2 with institution of one-lung ventilation, the patient's oxygenation was gradually improved as surgery progressed without hemodynamic instability. At the end of surgery, the double-lumen tube was replaced with a single-lumen endotracheal tube for postoperative mechanical ventilation.

LESSONS

Absolute lung isolation using double-lumen tube for one-lung ventilation and bronchial toilet during surgery and replacement of single-lumen tube for postoperative respiratory support at the end of surgery are effective to improve oxygenation in patients with BBF.

Combined Y-Shaped Covered Metallic Stents for Gastrobronchial Fistulas Involving the Right Intermediate Bronchus

Gastrobronchial fistula that involves the right intermediate bronchus is an extremely rare complication of esophagectomy. In this report, two patients with gastrobronchial fistulas around the secondary right carina were treated by combined Y-shaped covered metallic stents. Four covered stents were inserted successfully at the first attempt with no complications. The gastrobronchial fistula was fully sealed in each patient, and they were able to eat without coughing.

[Aorto-esophago-bronchial and aorto-pulmonary fistulas in a patient with aortic aneurysm]

Aorto-esophageal and aorto-bronchial fistulas are rare and life-threatening diseases if emergency treatment is absent. The most of publications devoted to this problem are case reports describing successful treatment of patients with aorto-esophageal and aorto-bronchial fistulas by using of endovascular or open transthoracic surgery. However, we did not find reports of several aortic fistulas in a patient after previous aortic stenting. It is presented case report of patient with aorto-esophago-bronchial and aorto-pulmonary fistulas in postoperative period after thoracic endovascular aortic repair (TEVAR).

Distal duodenectomy: a new option of surgical treatment for duodenal tumors

OBJECTIVE

To assess severity, safety and functional advisability of distal pancreatectomy using original surgical technique developed in the Blokhin National Medical Research Centre of Oncology.

MATERIAL AND METHODS

There were 10 patients with duodenal malignancies who have undergone distal pancreatectomy in the Blokhin National Medical Research Centre of Oncology for the period 2006-2018. Distal pancreatectomy for primary duodenal tumors was performed in 8 patients, 2 patients underwent surgery for external invasion of the duodenum.

RESULTS

Postoperative complications Clavien-Dindo grade 1 and 2 occurred in 4 (40%) patients. Surgical complication grade 2 occurred in 1 (10%) patient (pancreatic fistula with effective conservative management). There were no cases of leakage of duodenal stump and duodenojejunostomy, impaired bile flow and stenosis of anastomosis with delayed stomach emptying.

CONCLUSION

Distal duodenectomyis associated with low postoperative morbidity, good functionality and quality of life. This procedure is preferred for non-epithelial and neuroendocrine tumors, as well as with secondary malignant duodenal invasion.