Case report of retrograde in situ fenestration of the thoracic stent graft with reentry device in a patient with aortobronchial fistula

RATIONALE

In situ fenestration may be necessary to preserve branch arteries during thoracic endovascular aortic repair (TEVAR) when there is an inadequate landing zone.

PATIENT CONCERNS

We report the case of a 74-year-old man presenting with recurrent hemoptysis.

DIAGNOSES

Based on computed tomography (CT) angiogram and bronchoscopy, diagnosis was aorto-bronchial fistula.

INTERVENTIONS

We performed retrograde in situ fenestration with reentry catheter (Pioneer Plus, Volcano Corporation, San Diego, CA) to preserve the left subclavian artery following TEVAR for aorto-bronchial fistula.

OUTCOMES

Following this procedure, the patient had a patent left subclavian artery and no evidence of endoleak. The patient had no further episodes of hemoptysis.

LESSONS

The retrograde in situ fenestration with reentry catheter strategy is an option for patients when carotid-subclavian bypass is deemed unsafe.

Successful endoscopic management of a persistent bronchobiliary fistula with Histoacryl®/Lipiodol® mixture

Introduction A bronchobiliary fistula (BBF) following liver directed therapy (resection/ablation) is a rare complication in which an abnormal communication between the biliary tract and bronchial tree is formed. This case report describes the successful management of a persistent BBF following multiple liver wedge resections and microwave ablation in a patient with a metastatic neuroendocrine tumour of the terminal ileum. Case history A 69-year-old man presented with unexplained weight loss and was subsequently diagnosed with a neuroendocrine tumour of the terminal ileum and liver metastasis. Following elective right hemicolectomy and multiple bilobar liver wedge resections combined with liver microwave ablation, he developed an early bile leak. A month later, a right subphrenic collection was identified and four months following surgery, biloptysis was noted. Numerous attempts with endoscopic retrograde biliary drainage (ERBD) failed to achieve sufficient drainage. The patient was treated successfully with endoscopic injection of a mixture of Histoacryl® glue (B Braun, Sheffield, UK) and Lipiodol® (Guerbet, Solihull, UK). There was no evidence of the BBF one year following intervention. Conclusions This novel approach for persistent BBF management using endoscopic Histoacryl® glue embolisation of the fistula tract should be considered either as an adjunct to ERBD or when biliary tract decompression by drainage and/or sphincterotomy fails, prior to proceeding with surgical interventions.

[The thoracic surgeon and the management of the bronchial biliary fistula of hydatid origin]

INTRODUCTION

The bronchial biliary fistula surgery is a major one, always going with a higher rate of complication especially in case of bile duct obstruction. The aim of this study is to find out the contribution of endoscopic sphincterotomy while reporting the results of surgical treatment of bronchial biliary fistulae by exclusive thoracotomy.

METHODS

This was a retrospective study, which took place in the Department of Thoracic Surgery, University Hospital Hassan II, from January 2009 to March 2016. The parameters studied in connection with the bronchial biliary fistula of hydatid origin were: age, sex, origin, history of surgery especially for hepatic hydatid cyst, term of bilyptysie, imaging results, preoperative cholangiography indications, surgical treatment modalities and patients trends.

RESULTS

A sample of 12 patients was included (6 men and 6 women) with an average age of 44 years old, with a gap spanning between 17 and 81 years. Seven patients had at least a history of hepatic hydatid surgery. The biliptysie was the main symptom in 8 patients. A biological cholestasis syndrome was found in 6 patients. The thoracoabdominal CT scan performed on all patients comes out with results in 100% of cases. Four patients received endoscopic retrograde cholangiography that allowed them to release the bile duct completely by sphincterotomy with extraction of hydatid membrane in one patient and with development of a biliary stent in another patient. The incision was a low posterolateral thoracotomy in 10 patients that went under surgery. It has allowed to deal in one-time liver and lung injuries combined with diaphragmatic breach repair. Inside the group of patients that went under surgery, the postoperative results were simple in 8 cases. We have noted an overall mortality rate of 18.2%.

CONCLUSION

Bronchial biliary fistula surgery complications remains considerable despite the progress of diagnostic imaging. Preoperative endoscopic sphincterotomy is a milestone in the handling of this surgery. It may even be suggested as exclusive therapy in inoperable patients with significant biliptisy.

Esophageal diverticulum serves as a unique cause of bronchoesophageal fistula in children: A case report

RATIONALE

Most of the esophageal diverticulums are congenital traction instead of in childhood. In most conditions, esophageal diverticulums are free of any symptoms. As one of the rare entity, esophageal diverticulum can also result in bronchoesophageal fistula.

PATIENT CONCERNS

A 10-year-old girl was admitted due to a 2-month history of cough and choking after drinking, and fever for 3 days. No symptoms when taking solid food were found.

DIAGNOSES

By esophagogram, 3-dimensional computed tomography and esophagoscopy, an esophageal diverticulum was demonstrated in the middle esophagus with a bronchoesophageal fistula visualized. Then the diagnoses of esophageal diverticulum and bronchoesophageal fistula were established.

INTERVENTIONS

A regular trans-anterolateral thoracotomy was carried out under general anesthesia with patient lying on the right side. The diverticulum was then removed and the fistulous tract was closed.

OUTCOMES

The girl discharged on the 14th postoperative day and received a regular monthly follow-up, at present, no recurrence was found.

LESSONS

Bronchoesophageal fistula may be a complication of esophageal diverticula, and should be considered in cases of unexplained cough or recurrent pneumonia.

[Two Successful Cases of Surgical Treatment of Reconstructed Gastric Tube-Bronchial Fistula after Esophagectomy for Esophageal Cancer by Pedunculated Latissimus Dorsi Flap]

We herein report 2 cases of successful surgical treatment of reconstructed gastric tube-bronchial fistulas caused by leakage after esophagectomy for esophageal cancer. One patient was a 56-year-old man who developed a reconstructed gastric tube-bronchial fistula, and the fistula was closed by conservative treatment. However, he developed pneumonia on postoperative day 117, and the reconstructed gastric tube-bronchial fistula was found to have recurred. Fibrin glue was endoscopically injected into the fistula, but this treatment was unsuccessful. The other patient was a 60-year-old man who developed a reconstructed gastric tube-bronchial fistula and severe pneumonia, and his condition did not improve by conservative treatment. We performed a reoperation for both patients using a pedunculated latissimus dorsi flap, and both patients recovered well.

Tuberculosis presenting as broncho-oesophageal fistula in a young healthy man

A 21-year-old Saudi man presented with a history of dysphagia and choking. CT scan of the chest showed clear evidence of chronic recurrent aspiration pneumonia in the left lung. It also showed a fistula connecting the left main bronchus to the oesophagus. Endoscopy showed clear opening on the oesophageal side. Bronchoscopy also confirmed the presence of a broncho-oesophageal fistula on the left bronchial side with the presence of secretions on swallowing. Bronchoalveolar lavage (BAL) was done and sent for mycobacterial tuberculosis culture. The fistula was closed with clips under endoscopic guidance, which alleviated his symptoms of dysphagia and choking. The BAL culture grew mycobacterial tubercle bacilli. The patient showed marked improvement after starting antitubercular therapy and was discharged to be followed up in the clinic.

[Bronchopleural Fistula;Intraoperative Prevention and Postoperative Treatment]

Postoperative bronchopleural fistula( BPF) is a life-threatening complication requiring immediate and proper treatments. Now days, the main method for closure of the bronchial stump after lung resection is mechanical stapling because of prevailing of commonly performed video-assisted thoracoscopic surgery. The frequencies of BPF seem to be decreased compared with the age of manual sutures under open thoracotomy, probably due to improvement of the stapling instruments. However, if once BPF occurs, the severity of the disease does not differ between these 2 closing methods. Thoracic surgeons should well understand the etiology, prevention, diagnosis, and treatment of the postoperative BPF.

A bronchobiliary fistula due to giant hydatid cyst

Intrathoracic rupture of hydatid cyst of the liver is a rare but severe complication of echinococcal disease. It represent a serious condition responsible for lesions at 3 levels: hepatic, diaphragmatic, and pulmonary. Early diagnosis and management of septic associated complications are essential. We present the case of a 55 year old female patient with a giant hydatid cyst type CE 2 based on WHO Classification, communicating with the biliary tree and with a massive extension to the right hemithorax.

HIV post-tuberculous broncho-oesophageal fistulas: A surgical solution

We present a patient with HIV/AIDS with multiple tracheo-oesophageal fistulas probably due to previous tuberculosis. An Ivor-Lewis procedure was successfully undertaken following stringent pre-operative preparation. Surgical repair of persistent post-tuberculous tracheo-oesophageal fistulas may be safely undertaken in selected patients with HIV/ AIDS.

Open Surgical Treatment of Secondary Aortoesophageal and Aortobronchial Fistula after Thoracic Endovascular Aortic Repair and Esophagocoloplasty in a Second Procedure

Aortoesophageal (AEF) and aortobronchial fistula (ABF) after thoracic endovascular aortic repair (TEVAR) are rare complications with catastrophic consequences without treatment. In this case report, we presented a patient with AEF and ABF after TEVAR successfully treated with endograft explantation and replaced by Dacron graft followed by esophagectomy and left principal bronchus repairing. We report a patient with AEF and ABF after TEVAR who was evaluated due to dysphagia and chest pain followed by hematemesis and hemoptysis. Endoscopic examination revealed lesion of the esophageal wall with chronic abscess formation and stent-graft protrusion into the cavity. Patient was operated on with extracorporeal circulation. AEF and ABF were confirmed intraoperatively. Endograft was explanted and in situ reconstruction of thoracic aorta was carried out with tubular Dacron 22-mm prosthesis wrapped with omental flap. After aortic reconstruction, esophageal mucosal stripping was performed with cervical esophagostomy, pyloromyotomy, and Stamm-Kader gastrostomy for nutrition. In addition, omentoplasty of the defect in the left principal bronchus was performed. To re-establish peroral food intake esophagocoloplasty was carried out 8 months after previous surgery utilizing transversosplenic segment of the colon and retrosternal route. In very selective cases, stent-graft explantation and in situ reconstruction with Dacron graft covered by omental flap followed by esophagectomy and bronchus repairing permit adequate debridement reducing the risk of mediastinitis and graft infection and allow a safe esophageal reconstruction in a second procedure.

Transverse rectus abdominis myocutaneous flap for postpneumonectomy bronchopleural fistula: A case report

RATIONALE

Numerous types of flap coverage have been reported to prevent or to repair bronchopleural fistulas. Most of the flaps were harvested from chest area. However, these pedicled flaps might not be optimal for the patient who has undergone previous radiotherapy on pulmonary parenchyma because the pedicle artery of the flap might have been injured by irradiation. Therefore, an alternative flap outside of the chest area is necessary.

PATIENT CONCERNS

A 61-year-old male was diagnosed of squamous cell carcinoma in right upper lobe lung (cT3N2M0, stage IIIa). After completing the neoadjuvant chemoradiotherapy, he underwent video-assisted thoracoscopic surgery with right side intrapericardial pneumonectomy.

DIAGNOSIS

Persistent air leak due to postpneumonectomy bronchopleural fistula.

INTERVENTIONS

Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was used to repair the bronchial stump.

OUTCOMES

The bronchial stump was repaired successfully, the bronchopleural fistula was obliterated, and the patient was free from air leak after following for 12 months.

LESSONS

This case demonstrated that pedicled TRAM flap is a feasible alternative to repair bronchopleural fistula.

Endovascular Exclusion of Aortobronchial Fistula and Distal Anastomotic Aneurysm after Extra-Anatomic Bypass for Aortic Coarctation

The treatment of choice for aortic coarctation in adults remains open surgical repair. Aortobronchial fistula is a rare but potentially fatal late sequela of surgical correction of isthmic aortic coarctation via the interposition of a graft. The endovascular treatment of aortobronchial fistula is still under discussion because of its high risk for infection, especially if the patient has a history of cardiovascular prosthetic implantation. Patients need close monitoring, most notably those with secondary aortobronchial fistula. We discuss the case of a 65-year-old man who presented with the combined conditions, and we briefly review the relevant medical literature.

Endoscopic Management of Esophagorespiratory Fistulas: A Multicenter Retrospective Study of Techniques and Outcomes

BACKGROUND AND AIMS

Esophagorespiratory fistulas (ERF) are a devastating complication of benign and malignant etiologies. ERF are associated with high mortality, short survival, and poor quality of life. We performed a multicenter analysis of patients with ERF undergoing endoscopic treatment.

METHODS

Multicentre retrospective study.

RESULTS

We analyzed 25 patients undergoing 35 procedures over an 8-year period. Our data showed high technical success rates (97.1% of procedures) and with good, but not ideal, clinical success rates (60% of procedures, 80% of patients), which were defined as fistula closure confirmed by radiographic or repeat endoscopic evaluation and/or a lack of recurrent episodes of clinical aspiration to focus on durable ERF closure as opposed to only initial success. Proximal ERF were the most difficult to manage with the lowest overall clinical success rates, highest rates of recurrent aspiration despite endoscopic therapy, highest adverse events, and shortest survival times. Adverse events occurred in 40.0% of our patients and were all minor. Treatment allowed for diet advancement in 75% of patients.

CONCLUSION

This represents the largest recent collection of US data and the first multicenter study evaluating the clinical success of multiple treatment modalities while stratifying data by fistula etiology and esophageal location. The endoscopic approaches detailed in this study offer a minimally invasive and safe choice for intervention with the potential to improve quality of life despite overall suboptimal clinical success and survivorship rates for in with ERF.

Endoluminal Stent-Graft Repair of Aortobronchial Fistulas: Bridging or Definitive Long-Term Solution?

Purpose:

To describe our experience with endoluminal stent-graft repair of aortobronchial fistulas (ABF) and to analyze midterm results focusing on late chronic graft infections, secondary conversion, and survival.

Methods:

The records of 8 patients (6 men; mean age 69 years, range 28–88) treated between March 1997 and October 2003 for traumatic and postsurgical ABFs were reviewed. Seven presented with hemoptysis and 1 with hemorrhagic shock. According to the severity of emergency, patients underwent computed tomography, angiography, bronchoscopy, and transesophageal echocardiography. Preoperatively, no clinical signs of infection were evident. Two different stent-graft models (Talent and Excluder) were implanted using standard endovascular techniques.

Results:

Procedural and clinical success was achieved in all patients. Paraplegia, secondary intervention, conversion, or procedure-related death was not observed. Mean follow-up was 30 months (range 0.6–77). One patient with a postsurgical ABF (Dacron tube graft) successfully treated with an Excluder stent-graft died 13 months later from hemorrhage secondary to aortoesophageal fistula repair procedures. A second patient died from pneumonia after 42 months. A third patient, in whom 2 Talent stent-grafts had been implanted to treat an ABF from the false lumen of a type B dissection, died 7 months later from massive hemorrhage.

Conclusions:

Endoluminal stent-grafting of ABF is feasible and the preferred method of treatment. Secondary conversion due to endograft infection is not absolutely mandatory, but close surveillance is necessary.

[Epiphrenic oesophageal diverticulum with an oesophagobronchial fistula resulting in a lung abscess]

Epiphrenic oesophageal diverticula are rare and often asymptomatic. In this case report a 58-year-old woman was diagnosed with an epiphrenic oesophageal diverticulum, which developed an oesophagobronchial fistula leading to a pulmonary abscess in the right lower lobe, septicaemia and acute respiratory failure. The patient underwent right lower lobectomy and the diverticulum was stapled off the oesophagus. The post-operative course was uneventful. This complication is only rarely described previously.

Repair of large airway defects with bioprosthetic materials

OBJECTIVE

Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects.

METHODS

Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix.

RESULTS

Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%).

CONCLUSIONS

Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.

Minimally Invasive Surgical Repair for Congenital Bronchobiliary Fistula in an Adult

Congenital bronchobiliary fistula (CBBF) is a very rare disease and usually requires surgical intervention at a young age. We report a case of CBBF in an adult who was treated successfully with a minimally invasive endoscopic operation.

Omentoplasty in Treatment of Early Bronchopleural Fistulas after Pneumonectomy

This study was undertaken to assess the efficacy of omentoplasty in 12 cases of bronchopleural fistula after pneumonectomy. All fistulas formed within 16 days after the primary operation (median, 7 days). In 10 cases, omentoplasty was performed within 10 hours of diagnosis; the other 2 cases were treated at 28 and 31 hours. The greater omentum was mobilized through a laparotomy and secured tightly around the bronchial stump using original principles of fixation. After omentoplasty, dehiscence of the bronchial stump was observed in 5 (42%) patients, but owing to reinforcement with greater omentum, recurrence of the fistula was observed in only one case. In 3 patients, recurrence of pleural empyema did not lead to the return of the bronchopleural fistula. Hospital mortality was 8.3% (one patient). In patients without bronchopleural fistula recurrence, the median postoperative hospital stay was 31 days. Early omentoplasty for bronchopleural fistula after pneumonectomy is an effective procedure that eliminates purulent bronchopleural complications completely within the shortest possible period of time.

[Suggesting the Significance of Pericardial Fat Pad in Bronchial Stump Fistula]

Bronchial stump fistula is a post-operative complication with poor outcome after pulmonary lobectomy. In order to prevent this complication, the bronchial stump is covered with pericardial fat tissue in our hospital. The case was 58 year old male who received adjuvant chemotherapy after sigmoidectomy for sigmoid colon cancer. As he developed multiple pulmonary metastases, 48 courses of chemotherapy were performed. The lesions had been localized at the right lower lobe, and neither increase in the size of these lesions nor development of other lesions were observed. Hence, an operation was performed. After right lower lobectomy, the bronchial stump was covered with the pericardial fat tissue. Three months after the operation, he developed pneumothorax, and bubbles were detected inside the fat. The pneumothorax was cured conservatively, and the bubbles disappeared spontaneously after 10 months. It is rare that the patient with bubbles in the covering tissue observed for a long time is cured conservatively, suggesting the significance of the stump pad.

[Successful Case of Coil Embolization for Repeated Pulmonary Arterial Bleeding in Postoperative Empyema with Bronchopleural Fistula]

A 78-year-old woman underwent right S6 segmentectomy and upper lobe partial resection for adenocarcinoma. About 11 months after the operation, she was diagnosed as having empyema with bronchopleural fistula and open thoracotomy was performed. From the following day, active hemorrhage from the pulmonary artery into the thoracic cavity(500~800 ml) repeated. Tamponade, surgical treatment such as putting hemostasis sheet, or covering with a pedicled latissimus dorsi muscle flap could not prevent rebleeding. Therefore selective pulmonary artery coil embolization was performed, after that the rebleeding did not occur.