Pedicle muscle flap transposition for chronic empyema with persistent bronchopleural fistula: experience of a single clinical center in China

PURPOSE

The management of chronic empyema with persistent bronchopleural fistula (BPF) is a major challenge for surgeons. We report our experience of performing pedicle muscle flap transposition for chronic empyema with BPF in a clinical center in China.

METHODS

The subjects of this study were 13 patients with postoperative chronic empyema and persistent BPF. The surgical procedure performed was chosen according to the degree of infection in the empyema cavity. Patients with mild contamination underwent one-stage cavity decortication with flap transposition, whereas patients with severe infection underwent two-stage surgery including open-window thoracostomy and pedicle muscle flap transposition.

RESULTS

Five patients underwent one-stage surgery, followed by an uneventful postoperative course in all except one. The other eight patients underwent two-stage surgery. The fistulas closed spontaneously during the course of dressings and six of these eight patients underwent second-stage surgery uneventfully. A bronchopleurocutaneous sinus developed in the wounds of the other two patients.

CONCLUSIONS

Pedicle muscle flap transposition is a viable option for chronic empyema with BPF; however, surgical procedures should be selected according to the degree of contamination. For two-stage surgery, obliteration of the cavity should be considered, preferably after closure of the fistula.

[Successful Treatment of Empyema with Bronchial Fistulas by Filling under Thoracoscopic Observation; Report of a Case]

Empyema with fistula usually resists conservative treatment such as thoracic cavity drainage and administration of antibacterial agents, thus it often requires surgeries such as fenestration, omental/muscle filling, and thoracoplasty. However, due to advanced age and poor condition, conducting invasive surgeries is often difficult in elderly patients. We report a case with the improvement of empyema by bronchial filling with endobronchial Watanabe spigot (EWS) under thoracoscopic observation for an 89-year-old patient who had developed chronic empyema with a bronchial fistulas. After filling EWS, air-leakage from bronchial fistula disappeared and the patient could discharged from the hospital successfully.

Imaging of a gastrobronchial fistula after gastric bypass surgery and the contrast dilemma

Obesity and bariatric procedures have become more common in the United States over the past 20 years. Therefore, the incidence of previously rare complications is also on the rise. One of the more ominous complications is a gastric leak with subsequent creation of a fistulous tract. A very rare subset of this complication is when the fistulous tract connects the gastric pouch to the bronchial tree. Several contrast agents can be utilized for imaging of the upper gastrointestinal tract, some of which may cause significant adverse effects if not properly tailored to the specific pathology in question. We present a case of a gastrobronchial fistula developing several years after a laparoscopic Roux-en-Y gastric bypass and discuss the ideal choice of contrast material when imaging this specific pathology.

[Bronchial fistulae after pneumonectomy for lung cancer]

Fistula of bronchial stump developed in 246 (9.4%) cases of 2614 patients who were underwent pneumonectomy for lung cancer in 1964-2013. Mortality rate in case of bronchial fistulae was 17.9%. It was analyzed causes of this complication, an important role of infection for its development was emphasized. So prevention of wound infection is main prophylactic action. Postoperative pneumonia and bleeding are considerable risk factors. Clinico-anatomical type of tumor, stage and technique of bronchial stump treating don't affect incidence of fistulae. Bronchial stump covering is important intraoperative preventive measure. Treatment of this complication includes early drainage and pleural cavity sanitation and isolation of fistula from pleural cavity. Endoscopic procedures (impact with silver nitrate, trichloroacetic acid, laser) are preferred to solve the last problem. It allowed to achieve fistulae healing in 58.1% of cases.

Tailored stent for bronchial stump fistula closure and omentoplasty for infection control: a combined approach with low morbidity

Bronchopleural fistula (BPF) after pneumonectomy remains a dangerous complication with high mortality and morbidity. Primary closure of the fistula with muscle flaps and a thoracic window is generally used to treat BPF. New techniques for secondary stump closure including glues, stents and coils have been introduced recently. We report the use of a J-shaped tracheal stent device placed during bronchoscopy combined with omentoplasty to control the symptoms related to BPF and pleural space infection, respectively.

Endovascular exclusion of complex postsurgical aortic arch pseudoaneurysm using vascular plug devices and a review of vascular plugs

We report the management of a patient presenting with haemoptysis due to aortobronchial fistula. He had previously undergone emergency exclusion bypass of a ruptured pseudoaneurysm developing post-aortic coarctation repair. Computed tomography scan showed persistent filling of pseudoaneurysm sac from proximal and distal aortic ligature sites tied during previous exclusion bypass surgery. Successful exclusion of aneurysm was achieved by using 3 vascular plug devices (1 Amplatzer plug II and 2 Amender patent ductus arteriosus occluder devices). We also review types of Amplatzer vascular plugs and their use in peripheral vascular interventions.

[The effectiveness of the valve bronchial occlusion in case of bronchopleural fistulas]

The experience of endobronchial valve «Medlung" installation in 24 patients with bronchopleural fistula was summarized in the article. In 18 (75%) patients the cause of bronchopleural fistula was purulent - destructive processes in the lungs, including the associated trauma in 4 (22.2%) patients, pneumonia in 14 (77.8%) patients. In 3 (12.5%) cases the cause of the bronchopleural fistula was the lung tumors of different localization and in 3 (12.5%) cases - idiopathic pulmonary fibrosis. Reasonable use of endobronchial valve in patients with bronchopleural fistula provides a persistent separation of the fistula and lets to avoid extensive, traumatic operations.

[Bronchus sutures failure in lung cancer surgery]

Main methods of bronchus suturing after lung resection are presented in the article. The safest methods of bronchus closure are manual and mechanical suturing with use of UB apparatus. Use of UO or TL-TLH apparatus with longitudinal orientation of tantalic brackets significantly increases the frequent of bronchus suture failure. It is determined by deterioration of bronchus blood supply and poor trophic healing of bronchus wound.

[Surgical intervention for residual space empyema and bronchopleural fistula after major pulmonary resection]

Residual space empyema, that is a life threatening complication after major pulmonary resection, is based on postresectional hematoma, wound suppuration, and/or bronchopleurl fistula, demanding different strategies from parapneumonic empyema. Optimal managements should be occasionally completed in relation to the patient's physical conditions, serological findings, pathogens, and bronchopleural fistula. Bronchoscopic intervention can be a useful tool for a bronchopleural fistula when small. Thoracoscopic intervention can overcome the intractable residual space empyema. These interventions can save such invasive procedure as open window thoracotomy or thoracoplasty leading to damage pulmonary function as well as cosmetics, and prolong hospitalization. Vacuum-assisted closure system other than conventional thoracoplasty or thoracomyoplasty can be of help to obliterate the residual space empyema cavity after open window thoracotomy.

Interventional pulmonology procedures: an update

Bronchoscopy is the most important tool in diagnosis of respiratory diseases, but also provides therapeutic options in various disorders. Besides hemoptysis, airway stenoses are a frequent indication for therapeutic bronchoscopy interventions. Thereby, a broad spectrum of endoscopic techniques including electrocautery, argon plasma coagulation, laser treatment, cryosurgery and stent implantation is available. In the last decade, development of new endoscopic modalities provides also treatment of patients with chronic obstructive pulmonary disease and uncontrolled asthma.

[Clinical application of a fully covered self-expandable metallic stent in treatment of airway fistula]

OBJECTIVE

To assess the feasibility, safety and efficacy of the use of a fully covered self-expandable stent for the treatment of airway fistula.

METHODS

From August 2005 to November 2011, 9 patients underwent treatment by the introduction of a tracheo-bronchial or bronchial fully covered self-expandable metallic stent. There were 7 males and 2 females, aged from 28-65 years with a mean of 46 years. In this group, 7 cases were diagnosed as bronchopleural fistula, 1 case as tracheopleural fistula, 1 case as broncho-esophageal fistula, 8 cases with thoracic empyema. The fistula orifices were from 3.5-25.0 mm in diameter with a mean 8.4 mm. All patients received topical anesthesia, and L-shaped stent was placed in 6 patients and I-shaped stent in 3 patients under fluoroscopic guidance. After the stent placement, the patients with empyema were treated with continual irrigation of the empyema cavity.

RESULTS

Stent placement in the tracheo-bronchial tree was technically successful in all patients, without procedure-related complications. The operating time was from 5-16 minutes, mean time (10 ± 4) minutes. Except for 1 patient, immediate closure of the airway fistula was achieved in the other patients after the procedure, as shown by the immediate cessation of bubbling in the chest drain system or the contrast examination. In this study, 1 patient coughed the inserted stent out due to irritable cough on the 5th day and had to receive repositioning of a new stent. Among the patients who were with empyema, 1 patient died of septicemia on the 8th day and 1 patient died of brain metastases from lung cancer 6 months after the stent insertion with empyema not cured, the other 6 patients' empyema healed from 2-5 months, mean time 3.7 months. Seven patients were followed from 3 to 36 months with a median of 13.5 months. During follow-up, 1 stent was removed from a patient 8 months after the stent implantation without empyema recurred. The remaining patient presented good tolerability to the existence of stent. The stents remained stable, no migration occurred, no empyema recurred, and the patient with broncho-esophageal fistula fed and drunk well.

CONCLUSION

The use of fully covered self-expandable stents proved to be a safe, effective and fast minimally invasive method to treat airway fistula, especially for patients with a higher surgical risk or other failed treatments.

Surgical treatment for severely damaged lung and pyothorax with bronchopleural fistula 9 years after induction chemoradiotherapy and bilobectomy

Here, we present a 54-year old man 9 years after induction chemoradiotherapy and subsequent lower bilobectomy for Stage IIIA lung cancer suffering late complications of pyothorax and bronchopleural fistula in a severely damaged lung. Open-window thoracostomy and subsequent completion pneumonectomy via median sternotomy and anterior thoracotomy were performed. Although sternal wound infection required steel wire removal and debridement, with wound dressing at home, the patient could return to work. Late complications from infected treatment-damaged lungs need to be taken into consideration after induction chemoradiotherapy and subsequent surgery.

Alternatives to resectional surgery for infectious disease of the lung: from embolization to thoracoplasty

Surgical treatment of lung diseases is based on removal of the affected lung tissue, achieved by atypical or anatomic lung resection. Infectious lung diseases are generally treated by medical therapy, including medications, chest physiotherapy, bronchoscopic toilet, and respiratory rehabilitation. Surgical management of infectious disease of the lung is integrated in the multispecialty care. This article focuses exclusively on nonresectional surgery and other alternatives to lung resection and addresses bacterial infection and fungal disease of the lung.

New ways of bronchial stump closure after lung resection: experimental study

INTRODUCTION

Lung surgery has long been associated with a high rate of mortality and morbidity. Bronchial stump fistula is one of the leading causes of high morbidity and high mortality rate. The objectives of our study are to asses the effect of new ways of closure the bronchial stump after lung resections.

MATERIALS AND METHODS

For our study, we used eighteen adult rabbits. We performed left trans-thoracic inferior lobectomy to each animal because left lung functional capacities are smaller than right lung functional capacities. The bronchial stump was closed in three different ways: simple running suture of 5.0 monofilament polypropylene (Sweet procedure), running suture of 5.0 monofilament polypropylene (horizontal "U" shape model) and Vycril patch, running suture of 5.0 monofilament polypropylene (horizontal "U" shape model) and bovine pericardium patch. All surviving rabbits were sacrificed in 30 day postoperatively.

RESULTS

In our study, we did not notice any deaths among our experimental animals and we did not observe any bronchial stump fistula. In the group of rabbits in which the bronchial stump was closed using a patch of heterologous bovine pericardium, the histological exams revealed a cvasinormal bronchial wall with a normal bronchial epithelium and basal membrane integrity and no inflammatory lympho-plasmocytary infiltrate cell, absence of macrophages at this level.

CONCLUSIONS

Using the heterologous bovine pericardium patch to reinforce the bronchial stump could be beneficial because of the faster healing and scarring process. To our knowledge, no studies have previously evaluated this procedure of bronchial stump closure. Our findings could therefore, serve as an impetus for further research in this area.

Extraperitoneal mobilization of the omentum--analysis of a personal series of 12 patients

OBJECTIVE

The aim of the paper is to evaluate the results achieved after mobilization of the omentum outside the peritoneal cavity.

MATERIAL AND METHOD

Between 01.01.2006-01.01.2012, the main author has performed an extraperitoneal mobilization of the omentum in 12 patients. The indications for the use of this flap were: prophylactic filling of the remnant space after the Miles procedure - 4 cases, solving of some pelvisubperitoneal and perineal complications after rectal surgery - 3 cases, covering of vascular prosthesis - 3 cases (2 of them with active infection) and closure of a post-pneumonectomy bronchial fistula - 1 case. The mobilization of the flap was performed by laparotomy - 10 cases, by laparoscopy - 1 case and transdiaphragmatic (thoracotomy) - 1 case; all the procedures were performed by the same team, with no assistance on behalf of a plastic surgeon.

RESULTS

We have encountered one immediate postoperative death through myocardial infarction on postoperative day 12 (vascular prosthesis infection in a 75 years old patient). Based on the clinical and imagistic evaluation, we have encountered no necrosis of the omental flap. At late follow-up (1-5 years) we have encountered no significant complications related to the use of this flap.

CONCLUSIONS

The omentum is a solution for a great variety of defects located outside the peritoneal cavity; it's mobilization is relatively simple and does not involve a major morbidity. Knowledge of the omentum's anatomy and techniques of mobilization are mandatory in digestive, thoracic and vascular surgery.

[Endoscopic management of broncho-pleural fistula in a patient with acute respiratory distress syndrome after pneumonectomy]

We report the management of endobronchial a patient admitted to the ICU for respiratory distress in the consequences of an surgical recovery of his left pneumonectomy complicated by bronchopleural fistula as part of a bronchial carcinoma non-small cell type adenocarcinoma. Endobronchial treatment by gluing of the fistula may be an alternative to surgery. We discuss its indication in the treatment of bronchial fistula.

[Emergent thoracic endovascular aortic repair in a patient with hemoptysis due to bronchial fistula: a case for airway management]

Bronchial fistula due to bronchial compression is a rare complication following both open surgical and endovascular repair of thoracic aortic aneurysms. We report on the airway management for a case of emergent thoracic endovascular aortic repair (TEVAR) in a patient with left bronchial obstruction due to hemoptysis. A 68-year-old man had undergone total arch replacement 8 years before, and was preoperatively diagnosed with aortobronchial fistula in the left lung. To prevent obstruction of the right lung by rebleeding in the left bronchus, we planned to exchange the single lumen endotracheal tube placed following hemoptysis to a double lumen tube prior to the operation. With assisted spontaneous breathing, bronchoscopy performed before replacing of the endotracheal tube showed obstruction of the left bronchus with many clots. With bronchoscopic assistance, clots were removed from the left bronchus and oxygenation improved significantly. We found a blue nylon suture penetrating the bronchial wall, most likely from a previous operation. However, bronchoscopy did not disclose aortobronchial fistula. Following TEVAR, the patient was diagnosed with bronchopleural fistula induced by bronchial compression due to blood vessel prosthesis and surrounding felt strips. Cooperation from surgeons and careful airway management were required to prevent life-threatening oxygenation insufficiency.