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.

Bronchobiliary fistula detected with hepatobiliary scintigraphy

Bile leakage into the thoracic cavity is a rare complication of invasive cancer. A 12-year-old boy was diagnosed with undifferentiated sarcoma of the right lobe of the liver invading the diaphragm. An extended right hepatectomy and total resection of the mass was performed, leaving a patchy tumoral invasion at the anterior diaphragmatic surface. Surgery was followed with a combined chemotherapy regimen. In the sixth postoperative month, he was readmitted with bilious expectoration. Tc-99m mebrofenin hepatobiliary scintigraphy revealed radiotracer accumulation in the right hemithorax. Bile leakage into the right thoracic cavity was diagnosed based on the hepatobiliary scintigraphic findings. For this patient; hepatobiliary scintigraphy, which is routinely used to visualize the liver and biliary tree, provided a noninvasive mean for the precise diagnosis of a bronchobiliary fistula. The fistula was then confirmed and corrected with surgery. The patient recovered uneventfully.

Independent lung ventilation in the management of traumatic bronchopleural fistula

Independent lung ventilation (ILV) is a technique for managing patients with unilateral lung disease or injury who have failed conventional mechanical ventilation. A 20-year-old man sustained severe ballistic injuries to the chest and abdomen. Damage control laparotomy controlled the patient's initial hemorrhage, however, an evolving cavitary pulmonary lesion subsequently developed into a high-volume bronchopleural fistula. Progressive atelectasis of the damaged lung resulted in profound hypoxemia and hypercarbia refractory to conventional mechanical ventilation. Synchronous ILV was initiated using a double-lumen endotracheal tube and two ventilators titrated to optimize the patient's oxygenation and ventilation and minimize ventilator-induced lung injury. Intensive ILV over the next 17 days resulted in recruitment of the atelectatic right lung, resolution of the bronchopleural fistula, and significant improvement in oxygenation and pulmonary compliance. This appears to be the longest reported use of ILV for traumatic lung injury.

[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care]

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.

A Novel Approach: Treatment of Bronchial Stump Fistula With a Plugged, Bullet-Shaped, Angled Stent

PURPOSE

The purpose of this study was to evaluate the initial clinical efficacy of a plugged, bullet-shaped, angled stent for managing bronchial stump fistula.

DESCRIPTION

The stent consisted of two parts. The body part had a diameter of 18 approximately 25 mm and was 30 mm long in a tubular configuration covered with polyethylene at the lower part. The bronchial limb was a bullet-shaped configuration with a dead end, 11 approximately 14 mm in diameter, 10 approximately 30 mm long covered with polyethylene. The body part and the bronchial limb were connected at the angled portion without overlap with use of nitinol wire and polyethylene. The stents were placed in 6 patients under fluoroscopic guidance.

EVALUATION

Stent placement was technically successful in all patients without complications. Immediate closure of the bronchial stump fistula was achieved in all patients after stent placement. Follow-up of 4 approximately 16 months, permanent closure of the bronchial pleural fistula was achieved in 4 patients (66.67%), and permanent closure of the bronchial stump fistula was achieved in 5 patients (83.33%). No complications occurred.

CONCLUSIONS

Closure of the bronchial stump fistula with the stent was a simple, safe, and effective procedure.

Role of computed tomography and magnetic resonance imaging in aortobronchial fistula diagnosis following aortic coarctation reparative surgery. Report of two cases

Aortobronchial fistula (ABF) is an uncommon complication of aortic coarctation repair which may occur years after successful coarctation correction. It is invariably fatal if not diagnosed and treated. ABF diagnosis poses a challenge for clinicians and radiologists because of the difficulty in detecting the fistula and the risks associated with some of the diagnostic procedures. Two cases of ABF occurring 1 and 20 years after reparative surgery of aortic coarctation are reported. The advantages and disadvantages of different imaging procedures for the evaluation of patients with suspected ABF are reviewed and the role of computed tomography angiography and magnetic resonance imaging is underlined.

Ultraflex expandable stents for the management of air leaks

Postoperative empyema and aspergillosis were diagnosed in a 66-year-old man. Since non-operative therapy was not effective, we performed surgery. On the 8th postoperative day, a covered Ultraflex expandable stent (Boston Scientific, Galway, Ireland) was implanted to make a one-way airway for blocking a major air leak from a bronchopleural fistula causing respiratory distress. His general condition improved gradually, and he was discharged 30 days after stenting. In conclusion, we used a covered Ultraflex expandable stent to make an airway to block an air leak. This may be a new application for this stent.

Closure of a Bronchopleural Fistula Using Bronchoscopic Placement of an Endobronchial Valve Designed for the Treatment of Emphysema

Pneumothoraces are sometimes complicated by a persistent air leak or bronchopleural fistula requiring prolonged chest tube drainage. Non-surgical treatment of persistent bronchopleural fistulas is often performed in patients who are poor surgical candidates, but the ideal method of closure is not known. Here we report closure of a persistent distal bronchopleural fistula using a one-way endobronchial valve designed for the treatment of emphysema.

Esophagobronchial fistula in a patient with Behçet's disease: report of a case

Esophageal involvement in Behçet's disease is generally considered to be very uncommon. So far, six cases of esophageal ulcers associated with perforation, penetration, or fistula in Behçet's disease have been described in the English literature. This report describes esophagobronchial fistula in a patient with intestinal Behçet's disease. A 62-year-old man was transferred to our hospital for peritonitis due to a small intestinal perforation after an appendectomy. At the age of 14 years he had had recurrent oral ulcers. Ulcerations of the ileum and epididymitis were found, and a pathological examination revealed nonspecific inflammation. Furthermore, an esophageal ulcer with esophagobronchial fistula was diagnosed. The fistula required not only endoscopic treatment but also surgical intervention. The patient's clinical features were consistent with the active phase of intestinal Behçet's disease. The symptoms gradually resolved without any treatment. Four years after remission, however, the symptoms recurred with gastrointestinal hemorrhage and polyarthritis. In the ileocolic region, punch-out ulcerations were noted. The clinical history and features led to a diagnosis of Behçet's disease associated with recurrent gastrointestinal ulcerations. Steroid therapy (prednisolone, 20 mg daily) was started, and led to a rapid resolution of the symptoms. The patient is now being followed up as an outpatient while receiving prednisolone (10 mg per day), without complaint of any gastrointestinal symptoms.

Aortobronchial fistula from invasive Aspergillus infection of the lung: an endovascular approach to repair

We report the case of an 11-year-old girl with an aortobronchial fistula as a complication from an invasive aspergillosis in the lung. This very rare problem has not been reported in children, to our knowledge. Management of Aspergillus infections of the lung in children and aortobronchial fistulas is reviewed.

Bronchopleural Fistulas

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

Occlusion of a Broncho-Cutaneous Fistula With Endobronchial One-Way Valves

Bronchopleural and broncho-cutaneous fistulas can be problematic after lobectomy for tumors or aspergillomas. Closure of the air leak and treatment of infection are essential to allow the fistula to heal. The initial treatment can usually proceed along standard lines, but if the fistula persists, then treatment can be problematic. This report is the first description of the use of multiple Emphasys Medical endobronchial valve prostheses (Emphasys Medical, Inc, CA) to control a previously intractable broncho-cutaneous fistula. The valves have been specifically designed for airway placement as part of a therapeutic approach to severe emphysema. The advantages of using valves in this situation are discussed.

[Diagnosis and treatment of cervical anastomotic fistula contaminating mediastinum or pleural cavity after esophagogastrostomy: a report of five cases with literature review]

BACKGROUND & OBJECTIVE

A special kind of fistula will be formed when cervical gastroesophageal anastomotic fistula occurs and its contents contaminate mediastinum or pleural cavity after esophagogastrostomy. The diagnosis and treatment are difficult to made. It is very dangerous if the treatment is incorrect. This study was to analyze the causes, preventive measures, diagnosis methods and standard, and appropriate treatments of this kind of fistula.

METHODS

Clinical data of 5 patients who suffered cervical anastomotic fistula contaminating mediastinum or pleural cavity after esophagogastrostomy, treated in our hospital, were retrospectively analyzed; the related literature was reviewed.

RESULTS

The morbidity of this kind fistula was 1.83%(4/219) in our hospital. All the 5 patients suffered fistula 1-13 days after esophagogastrostomy; bronchopleural fistula occurred in 2 patients. The main causes of this kind of anastomotic fistula were hypertensive anastomosis, low anastomotic location, incomplete suture of thorax-esophagus outlet, defection of surgical technique, and so on. The fistula could be diagnosed correctly when the patient suffered high fever, dyspnea and thoracalgia after operation, with cervical anastomotic external fistula which could not been healed when the wound was opened, X-ray-showed widened mediastinum and hydropneumothorax, and drainage, esophagoraphy and CT-confirmed anastomotic fistula. All patients were cured in a short term with sufficient drainage and irrigation, enough nutrition, appropriate use of antibiotics, and pyothorax dissection and muscle flaps transplantation for bronchopleural fistula.

CONCLUSION

Most cervical anastomotic fistulas happen 1-13 days after esophagogastrostomy with critical conditions; timely diagnosis and proper treatment including operation could shorten the disease course and greatly decrease the mortality.

Successful management of ARDS with bronchopleural fistula secondary to miliary tuberculosis using a conventional ventilator

Most institutions in India and other developing countries do not have facilities for high frequency ventilation in adults. We report the successful management of a case of ARDS with bronchopleural fistula secondary to miliary tuberculosis using a conventional ventilator and early empiric anti-tubercular therapy.

[Bronchoesophageal fistula in a patient with untreated malignant lymphoma]

Bronchoesophageal fistulae associated with lymphomas are generally associated with chemo-radiotherapy. We report here an unusual case of lymphoma with a therapy-unrelated bronchoesophageal fistula. Previously, only 10 similar cases have been reported. A 70-year-old male was diagnosed as having gastric diffuse large B-cell lymphoma in May 1998. In January 1999, he noted a cough after eating and drinking. Because of the presence of a febrile temperature, productive cough and dyspnea, he was referred to our hospital and diagnosed as having aspiration pneumonia. Antibiotics did not improve his symptoms. When tracheal intubation was performed with bronchoscopy, a bronchoesophageal fistula was revealed. Malignant lymphoma cells were found around the fistula in the biopsy specimen. The patient died of pneumonia after treatment with airway stenting and chemotherapy. Induction of necrosis by chemotherapy or low blood flow with stenting and dopamine probably caused enlargement of the fistula.

Bronchobiliary fistula evaluated with magnetic resonance imaging

Bronchobiliary fistula (BBF) is a rare disorder consisting of a passageway between the biliary ducts and the bronchial tree. Many conditions may give rise to this development. Management of these fistulas is often difficult and can be associated with high morbidity and mortality rates. We present a case of BBF developing after hemihepatectomy in a 74-year-old man treated with endoscopic biliary drainage and illustrate MRCP findings.

Caval Perforation with Bronchial Communication: A Rare Complication of Long-term Venous Access

Superior vena cava (SVC) perforation with bronchial communication is a very rare complication of long-term venous access. A patient recently presented with erosion of a venous port catheter into a bronchus, with infusion of medications into the bronchus and associated SVC syndrome. A high position of the catheter tip against the wall of the SVC and the beveled style of cut on the catheter tip contributed to this complication. A unique combination of percutaneous techniques was helpful in managing this complication, and surgery was avoided.

Use of a modified endobronchial tube for mechanical ventilation of patients with bronchopleural fistula

Mechanical ventilation in patients with bronchopleural fistula after lung resection is a major problem, as it causes increase of the air-leak, complicates the healing process and makes residual lung tissue ventilation difficult. We present two cases in which the use of a modified double lumen endobronchial tube improved ventilation and eliminated the fistula air-leak. We used a right-sided double lumen sher-i-bronch tube (Sheridan Catheter Corp., USA). This method, by blocking the airflow through the fistula, may facilitate the expansion of the residual lung parenchyma. In both the patients treated with this technique, we obtained a good expansion of the residual parenchyma. Despite the procedure, the first patient died of septic shock; in the second patient, we achieved improvement of the respiratory function, the weaning from the mechanical ventilation, and thereafter, the healing of the fistula. The use of a modified double lumen sher-i-bronch tube in mechanically ventilated patients with post-resection bronchopleural fistula allows the anaesthesiologist to suction separately the two lungs and to ventilate adequately the remaining lung tissue, thus obtaining the lung reexpansion and the consequent reduction of the residual pleural space, and facilitating the healing of the fistula.

[A postoperative bronchopleural fistule--a success of the conservative treatment (a case review)]

Disintegration of the bronchial stub following the lung resection procedures together with development of the bronchopleural fistule and the postoperative empyema of the thorax, remain a feared complication following all lung resections, but especially pneumonectomies. In this case review, the authors report on a successful conservative management case, which followed an unsuccessful surgical revision and an attempt for the endobronchial stent introduction. 20 months following the closure of the fistule, the patient shows no signs of a relapse of the disorder.

Post-pneumonectomy empyema: Current management strategies

Post-pneumonectomy empyema is an uncommon but potentially life-threatening complication. It has a strong association with bronchopleural fistula, which acts as a continued source of infection into the thoracic cavity. Numerous risk factors have been identified and strategies formulated to minimize its occurrence. When bronchopleural fistula occurs, its treatment depends on several factors including extent of dehiscence, degree of pleural contamination and general condition of the patient. Early diagnosis and assessment with appropriate investigations, and aggressive therapeutic strategies are paramount in controlling sepsis, facilitating closure of fistula, and sterilization of the closed pleural space. Recent success with repeat debridement has made routine space obliteration not mandatory in management. The development of minimal-access interventions including video-assisted thoracic surgery, endoscopic application of tissue glue and stenting may be additional tools to complement conventional surgery in post-pneumonectomy empyema management.

Successful therapy of severe pneumonia-associated ARDS after pneumonectomy with ECMO and steroids

Pneumonia and acute respiratory distress syndrome are life-threatening complications after pneumonectomy carrying high mortality. Because pulmonary reserve is inadequately low, an effective therapeutic strategy is needed to treat hypoxia. Extracorporeal membrane oxygenation is a highly effective method to reverse hypoxia in patients with acute respiratory distress syndrome, but has only once been described in a patient with postpneumonectomy pulmonary edema. We report a case of successful extracorporeal membrane oxygenation therapy in a patient with pneumonia-associated acute respiratory distress syndrome after pneumonectomy. Methylprednisolone therapy caused a dramatic improvement of pulmonary and systemic organ function.

Transphrenic fistulization of a subphrenic abscess to lung parenchyma

A 53-year-old woman was admitted with respiratory distress. For several years, she had chronic alcoholic pancreatitis with ductal stones that were treated with a stent and with shockwave lithotripsy. Both treatments were unsuccessful, and the pancreatitis was complicated with an infected pseudocyst. The pancreatic head had to be resected, which was complicated with recurrent subphrenic abscesses. She then was admitted with respiratory distress and initially diagnosed with pneumonia of the right lower lobe. Further investigations showed supradiaphragmatic and subdiaphragmatic air-fluid levels. In both collections Streptococcus milleri was cultured, and subsequently the patient was diagnosed with a fistula connecting the subdiaphragmatic abscess with pulmonary tissue. This was treated with intravenous amoxicillin/clavulanate and drainage of the subdiaphragmatic collection. She did not develop a pulmonary empyema, because multiple adhesions, which were due to recurrent abscesses after pancreatic surgery, prevented breakthrough into the pleural cavity.