[Clinical characteristics and therapeutic experience of case of severe highly pathogenic A/H5N1 avian influenza with bronchopleural fistula]

OBJECTIVE

To summarize the clinical characteristics and therapeutic experience of A/H5N1 infected patient with intractable bronchopleural fistula.

METHOD

The data of a patient with A/H5N1 infection complicated with bronchopleural fistula was collected and analyzed.

RESULTS

A 44-year-old woman with pneuminian was diagnosed as A/H5N1 infection by reverse-transcription polymerase chain reaction (RT-PCR) in laboratory from the sample of secretion of respiratory tracts. She had exposed to sick or dead poultry 3 days before development of illness. She developed acute respiratory distress syndrome 7 days after onset of sickness. After comprehensive management with antiviral agents, antibiotics, convalescent serum and invasive ventilation, her clinical condition improved and turned to stable. However, 16 days after onset of illness, her clinical situation deteriorated due to ventilator-associated pneumonia, bilateral pneumothorax and persistent right bronchopleural fistula. After partly failure of beside assist thoracoscopy to fix the pleural fistula, transbronchoscopic bronchial occlusion by autoblood was explored and the air leakage stopped soon after occlusion. Three days after the autoblood clot was expectorated out and air leak recurred. Then, bronchopleural fistula on the surface of visceral pleura was successfully blocked by biogel and OB gel through pleural cavity by fibrobronchoscopy. The patient was discharged from the hospital 99 days after onset of illness (at the 94th hospital day).

CONCLUSION

Bronchopleural fistula was an intractable complication for patient with A/H5N1 infection. Occlusion operation by biogel and OB gel through bronchoscopy might be an alternative choice for fixing the bronchopleural fistula.

Comparative study of different treatments for malignant tracheoesophageal/bronchoesophageal fistulae

The aim of this study is to compare the survival time and quality of life (QOL) of patients who have received different treatment for tracheoesophageal/bronchoesophageal fistula. Between January 2003 and December 2007, 35 patients with malignant tracheoesophageal/bronchoesophageal fistula were recorded as the control group, gastrostomy group, and stenting group, respectively, according to the treatments they chose. Two weeks after the treatment, European Organization for Research and Treatment of Cancer Quality of Life Core 30 Questionnaire (QLQ-C30), Quality of Life Questionnaire-esophageal module (QLQ-OES18), and a respiratory symptom-related QOL index are employed to assess QOL of these patients. There is no significant difference in survival time and constituent ratio of death reason among groups. Except for eight patients who died within 2 weeks after the treatment, all other 27 patients returned back the questionnaires. As compared to the control group, patients in the gastrostomy group gained a low score in emotional function and financial situation, while patients in the stenting group had lower scores in financial problems and seven respiratory and eating-related symptoms. In contrast with the gastrostomy group, patients in stenting group had higher scores in emotional and social functions, and lower scores in six respiratory and eating-related symptoms. With patients' QOL considered, the self-expandable coated stenting should be the first choice of therapy for malignant tracheoesophageal/bronchoesophageal fistula, whereas gastrostomy should be kept from use.

[Langerhans cell sarcoma with pulmonary manifestation, mediastinum involvement and bronchoesophageal fistula. A rare location and difficulties in histopathological diagnosis]

Langerhans cell sarcoma, a neoplastic proliferation of Langerhans cells with malignant cytologic features, is a very rare disease. Only a few cases have been documented in the English-language literature. Special methods, like immunohistochemistry and/or ultrastructural examination, are indispensable for appropriate diagnosis. Correct diagnosis is difficult. In fact, the disease is often misdiagnosed. We present the case of a 47 year-old man with a large mass in the middle lobe of the lung, infiltrating anterior mediastinum, with multiple pulmonary round lesions and enlargement of local lymph nodes, and with bronchoesophageal fistula. Clinical examination indicated the possibility of advanced primary lung cancer. However, the first histological diagnosis was Langerhans cell histiocytosis. In spite of treatment, the progression of pulmonary lesions was observed. Therefore, upper- and middle-lobectomy was performed. The diagnosis of Langerhans histiocytosis was confirmed microscopically again. Nevertheless, the patient's condition deteriorated progressively and he was admitted to the National Tuberculosis and Lung Diseases Research Institute in order to establish a final diagnosis. Revision of earlier resected specimens, as well as an immunohistochemical and ultrastructural examination of samples, taken once again from a bronchial tumor, led to the establishment of a diagnosis of a unique form of Langerhans cell sarcoma with rare pulmonary manifestation.

[Prevention and management of postresectional bronchopleural fistula]

Bronchopleural fistula (BPF) is still a life-threatening complication after pulmonary resection. Several factors were identified to contribute BPF. Meticulous surgical technique and the liberal use of prophylactic, pedicled flaps are important for prevention. Although these patients often present compromised and moribund, evaluation and management should proceed in a logical, stepwise fashion. In high-risk surgical patients, bronchoscopic procedures using different glues and sealants may serve as a temporary bridge until the patient's recovery or as a permanent resolution. However persistent conservative therapy may deteriorate patient's condition. Immediate creation of open window thoracotomy has been shown to be a significant predictor of wound closure afterwards. Pedicled muscle or omental flaps are useful to close bronchial stump and to fill the residual space in the thorax after pulmonary resection. Once fistula closed, the pleural space is filled with an antibiotic solution and then the open window thoracotomy closed in layers as Clagett procedure. The transternal transpericardial approach to recalcitrant postpneumonectomy BPF can be considered when patients have failed prior closure attempt. To conclude, survival and excellent result of BPF depends on early diagnosis, and aggressive surgical intervention.

[The risk factors and treatment of bronchopleural fistula after pneumonectomy]

OBJECTIVE

To analyze the risk factors which influencing the development of bronchopleural fistula (BPF) in pulmonary resections for lung cancer. To clarify the preventive techniques and treatment strategies of BPF.

METHODS

Review the clinical data of 32 patients of postpneumonectomy BPF from 965 patients accepted pneumonectomy for lung cancer from May 1987 to May 2007. Univariate and multivariate analyses were performed by the logistic regression procedure to identify the significant risk factors for BPF in 965 pulmonary resections for lung cancer.

RESULTS

The prevalence of BPF was 3.3% (32/965). BPF occurred in the right main bronchial stump in 28 patients, left main bronchial stump in 4 patients. The significant risk factors for BPF formation were right pneumonectomy, preoperative irradiation, prolonged mechanical ventilation, bronchial stump more than 2 cm and hypoalbuminemia. Multivariate analysis identified right pneumonectomy, preoperative radiotherapy and hypoalbuminemia as the risk factors of BPF. Successful closure of BPF was achieved in 13 patients (40.6%). The fistula was successfully closed in 5 of 6 patients who had received biologic glues applied bronchoscopically with a fistula less than 3 mm. Pedicled omentum was successfully used for the treatment in 5 of 6 patients with a fistula more than 3 mm.

CONCLUSIONS

Right pneumonectomy, high-dose preoperative radiation therapy and hypoalbuminemia are risk factors for postpneumonectomy BPF. Biologic glues can be applied bronchoscopically to achieve endobronchial closure of the fistula less than 3 mm. Omentoplasty is useful for the fistula more than 3 mm.

Postoperative residual pleural spaces: characteristics and natural history

This study was conducted in order to re-define the incidence and natural history of postresectional residual pleural spaces (PRS). From 1997 to 2005, 966 patients who were subjected to less than entire lung resections, were followed and any cases of PRS were recorded. The records of these patients were retrospectively analyzed for age, gender, type of resection, side, apical or basal location, size, PRS wall thickness, empyema as well as for bronchopleural fistula occurence, management, and outcome. Postresectional residual pleural spaces outcome was correlated with space characteristics. A total of 92 cases (9.5%) of PRS were documented which developed frequently ( p < 0.001) after upper lobectomies, malignant disease, at an apical location, and on the right side. Unfavorable outcome was strongly correlated with age > 70 years ( p < 0.001), air leak ( p < 0.001), empyema ( p < 0.001), and thickened pleura ( p < 0.001). Good prognosis of PRS was strongly correlated with male gender, apical location, right side, normal pleura thickness, and small size. Postresectional residual pleural spaces of small size without any associated complications should not prolong hospitalization time.

[Treatment and prevention of bronchus-pleural fistula after pneumonectomy for lung cancer]

OBJECTIVE

To explore the methods of the treatment and the principles of the prevention of bronchus-pleural fistula (BPF) after pneumonectomy.

METHODS

The clinical data of 15 cases of BPF after pneumonectomy in 815 lung cancer cases treated from July 1999 to June 2006 were analyzed retrospectively.

RESULTS

The occurrence rate of BPF after right pneumonectomy was 3.9% (12/310), higher than 0.6% (3/505) of left pneumonectomy (P < 0.01). The occurrence rate of BPF in cases with positive cancer residues in stump of bronchus was 22.7% (5/22), higher than 1.3% (10/793) of the cases with negative stump of bronchus (P < 0.01). The occurrence rate of BPF in the cases received preoperative radio- or chemotherapy was 5.0% (6/119), higher than 1.3% (9/696) of the cases received operation only (P < 0.05). There were no BPF occurred in the 76 cases whose bronchial stump were covered with autogenous tissues. All of the cases diagnosed as BPF were undertaken either closed or open chest drainage. Two cases were cured by thoracentesis aspiration and infusion antibiotics repeatedly. Two cases were cured by blocking the fistula with fibrin glue after sufficient anti-inflammatory treatment and hypertonic saline flushing. Six cases were discharged with a stable condition after closed drainage only. One case was discharged with open drainage for long time and 1 case was cured by hypertonic saline flushing after failure to cover the BPF using muscle flaps. Three cases died of multi-organs functional failure.

CONCLUSIONS

BPF are related to the bronchial stump management and positive or negative residue of tumor at the bronchial stump. Autogenous tissues covering of the bronchial stump is a effective method for decrease the rate of BPF and especially for those patients received preoperative radio- or chemotherapy and right pneumonectomy. It should be performed for early mild cases with repeated thoracentesis aspirations or blocking the fistula with fibrin glue together with antibiotics. Chest closed drainage immediately and flushing with hypertonic saline repeatedly are effective methods for BPF.

Bronchobiliary fistula and cholangiocarcinoma: a case report and principles of management

A 64-year-old woman was admitted with fever and cough. At admission, she had jaundice, hepatomegaly, and green-stained sputum. Computed tomography (CT) showed an intrahepatic abscess located near the dome, multiple hepatic metastases, biliary tract dilatation, and a right pleural effusion. Percutaneous transhepatic cholangiography demonstrated a communication between the intrahepatic biliary ducts and the bronchial tree. The patient was treated with antibiotic therapy, pleural and biliary drainages and a percutaneous drainage of the hepatic abscess.

Treatment of Bronchopleural Fistula With Small Intestinal Mucosa and Fibrin Glue Sealant

Bronchopleural fistula can be a devastating complication of pulmonary resections. Treatment options are often limited and carry significant morbidity or mortality, or both. We present a case of bronchopleural fistula occurring after pulmonary lobectomy for aspergilloma in a patient with recurrent acute lymphoblastic leukemia. The bronchopleural fistula was treated using bronchoscopic obliteration with Tisseel VH Fibrin Sealant (Baxter Healthcare Corp, Westlake Village, CA) and small intestinal submucosa with complete resolution and no morbidity. The relevant literature is reviewed.

Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy

Benign gastro-bronchial fistula is a rare and devastating complication of esophagectomy with gastric replacement. The most likely cause is a leak from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. The clinical presentation includes cough upon swallowing, fever, and recurrent pneumonia. Early surgical treatment is the standard of care. A unique case of chronic gastro-bronchial fistula is reported in this article. The patient, a 57-year-old woman, was referred from another hospital after 6 months of symptomatic therapy and total enteral nutrition. A self-expanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation.

Prone position to treat bronchopleural fistula in post-operative acute lung injury

OBJECTIVE

Prone position is used to treat patients with acute lung injury or acute respiratory distress syndrome because it improves gas exchange and respiratory mechanics. When broncho-pleural fistula occurring, the clinical impact of prone position is limited; however, its use could be tried when the fistula is small or other potential treatments are not possible.

METHODS

A 45-year-old man with oesophageal cancer submitted to a total oesophagectomy with intrathoracic transposition of the stomach developed post-operatively respiratory failure and pneumothorax, which were worsened by unilateral pleural rupture and severe subcutaneous emphysema produced after an attempt to introduce through anterior chest wall a second drainage tube.

RESULTS

Prone position associated with lung protective strategy was implemented during 16-18 h daily and after the change of position PaO2/FiO2 increased of 35% and PaCO2-PetCO2 decreased about 40%; at 4th day under treatment, the subcutaneous emphysema and pneumothorax could not be detected either clinically or radiologically. On the 6th day the lung lesion could not be observed under the CT-scan.

CONCLUSIONS

In a patient that underwent a major thoracic surgery the addition of prone positioning to protective lung ventilation rendered possible not only the healing of the acute lung injury, but also the quick repair of a lung rupture owing to a thoracic drainage attempt.

Successful treatment of intractable bronchobiliary fistula using long-term biliary stenting

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

Bronchobiliary fistula successfully treated with n-butyl cyanoacrylate via a bronchial approach

A bronchobiliary fistula is an abnormal communication between the biliary tree and the airway that can result in debilitating amounts of bilioptysis, or bile-stained sputum. The authors present an approach for the conservative management of a bronchobiliary fistula in a patient who failed traditional conservative therapy and refused surgical intervention.

Bronchoscopic gluing for post-lung-transplant bronchopleural fistula

A 44-year-old female patient diagnosed as pulmonary lymphangioleiomyomatosis with respiratory failure underwent bilateral sequential lung transplantation using an entire left lung and a post-lower-lobectomy right lung due to pneumonia. Persistent air leakage during cough was noted and bronchoscopy 12 days after transplantation demonstrated post-lobectomy bronchial stump dehiscence with a large bronchopleural fistula. We applied twice tissue glue instillation on the dehiscent bronchial stump through flexible bronchoscopy. The air leak improved and the patient was discharged 3 months after transplantation uneventfully. Two months after discharge, bronchoscopy showed complete healing of the dehiscent bronchial stump. Now, she lives independently without oxygen support.

[Is endoscopic treatment of bronchopleural fistula useful?]

OBJECTIVE

New endoscopic techniques have been developed as an alternative to surgical treatment of bronchopleural fistula. The objective of this study was to analyze our experience with endoscopic treatment of such fistulas.

MATERIAL AND METHODS

We conducted a retrospective study of patients with bronchopleural fistula diagnosed by fiberoptic bronchoscopy. Patient characteristics, underlying disease, fistula size, and outcome of endoscopic treatment were analyzed. The endoscopic technique consisted of injection of fibrin sealants (Histoacryl and/or Tissucol) through the catheter of the fiberoptic bronchoscope.

RESULTS

Between 1997 and 2004, 18 patients were diagnosed with bronchopleural fistula by fiberoptic bronchoscopy. All were men with a mean (SD) age of 62 (12) years. Bronchopleural fistula was diagnosed after neoplastic surgery in 16 patients, in the bronchial suture after lung transplantation in 1 patient, and concurrently with pleural effusion due to hydatidosis in the remaining patient. The size of the fistula ranged from 1 mm to 10 mm (mean 3.6 [2.7] mm). Fibrin sealants were applied in 14 patients, 2 underwent direct surgery after diagnosis, and the bronchopleural fistula closed spontaneously in the remaining 2. The fibrin sealant used was Histoacryl in 12 patients and Tissucol in 2. Pleural drainage was employed simultaneously and antibiotic therapy was administered at the discretion of the surgeon. The 4 patients whose bronchopleural fistula was associated with empyema also underwent pleural lavage. In 12 patients the fistulas closed as a result of the endoscopic technique (85.7%), and no complications were observed. For 85.7%, fewer than 3 applications of fibrin sealant were necessary.

CONCLUSIONS

The success rate of closure of bronchopleural fistula with fibrin sealants injected under guidance with fiberoptic bronchoscopy is high and there are no complications. This technique can render surgery unnecessary.

[Prophylaxis and treatment of primary insufficiency of bronchial stump after pneumonectomy]

Efficacy of gel DAM+ in bronchial surgery was evaluated in experimental and clinical studies. In clinical practice DAM+ was used for treatment of 22 patients with insufficiency of bronchial stump, and in 12 patients with high risk of stump insufficiency this gel was administered into submucosal layer before stump closure. It is demonstrated that administration of DAM+ gel into submucosal layer is simple and effective method of treatment and prophylaxis of bronchial stump insufficiency.

[Post-pneumonectomic purulent bronchopleural complications in lung cancer: a solution of the problem]

A strategy providing for solution of a number of tactical and technical problems involved in prognosis, prevention and management of postoperative bronchopleural complication after pneumonectomy for lung cancer was suggested. It was followed by a significant decrease in the frequency of bronchopleural fistula, postoperative empyema and lethality from purulent bronchopleural complications.

Transthoracic Closure of a Postpneumonectomy Bronchopleural Fistula With Coils and Cyanoacrylate

Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.

The short-to-midterm results of endovascular stent grafting for acute thoracic aortic diseases in Chinese patients

OBJECTIVE

To review the results of endovascular treatment of acute thoracic aortic diseases in a group of Chinese patients.

DESIGN

Retrospective study.

SETTING

A tertiary referral hospital with a cardiothoracic surgery service.

PATIENTS

All 15 patients presenting with acute thoracic aortic diseases between September 2001 and October 2005 inclusive, of whom eight had traumatic rupture, four had complicated acute dissections, two had mycotic aneurysms, and one an aneurysm with an aortobronchial fistula.

INTERVENTIONS

Thoracic aortic stent grafting.

MAIN OUTCOME MEASURES

Immediate success, 6-month and 1-year survival rates.

RESULTS

The median follow-up period was 20.6 months (range, 0-50.1 months). Stent grafts were deployed with immediate success in all patients. Two patients had ancillary bypass surgery for the supra-aortic branches. There were two in-hospital deaths. Four sustained access artery injury and needed graft repair. Computed tomography at 1 month showed complete thrombosis of the aneurysmal lumen or the thoracic aortic false lumen in 12 of 13 survivors. Computed tomography at 6 months showed complete thrombosis of the aneurysmal lumen or the false lumen in nine of 10 patients due for follow-up. Both 6-month and 1-year survival rates were 87%.

CONCLUSIONS

Thoracic aortic stent grafting for acute thoracic aortic disease is feasible and has a high success rate, with good short-to-midterm results. However, the large size of the stent graft introducer set imposes a high risk of access artery injury, for which further improvements are necessary.

Crohn's disease of the esophagus: treatment of an esophagobronchial fistula with the novel liquid embolic polymer "onyx"

Esophageal involvement in Crohn's disease is very rare. In only a small subgroup of these patients -- up to date fourteen cases have been described in the literature -- the course of the illness may be complicated by esophageal fistula formation. The therapy for fistulizing esophageal Crohn's disease so far has been disappointing, recurrence and progression are likely, and surgery still is the primary treatment modality for refractory patients. We here present a case of severe Crohn's disease with an esophagobronchial fistula and the successful closure of the fistula tract with the novel liquid polymer sealant "Onyx". This approach offers a new option for the treatment of this rare complication of Crohn's disease and should be considered if surgery is not possible.

Bronchopleural Fistula Treatment with Use of a Bronchial Stent-Graft Occluder

The purpose of this report is to describe our experience in the successful treatment of two patients with postpneumonectomy bronchopleural fistula (BPF). With use of computed tomography reformatting, the stent-graft occluders were tailored to precisely fit the fistula site and remnant bronchus stump. These were placed under fluoroscopic guidance via a preexisting chest tube tract in one case and via an open thoracostomy window site in the other. The BPFs were successfully occluded without complications, and the stent-graft occluders remained stable in position for 1 year and 6 months of follow-up, respectively.