Bronchopleural fistula: successful selective bronchial occlusion with a Fogarty's catheter in a preterm infant

A preterm infant (26 weeks' gestation) mechanically ventilated for respiratory distress syndrome developed severe interstitial emphysema of the right lung with a bronchopleural fistula, pneumothorax and mediastinal shift. Selective occlusion of the right main bronchus with a Fogarty's catheter produced rapid improvement in the clinical condition and radiological features. Occlusion of the main bronchus in a newborn with a bronchopleural fistula and pulmonary interstitial emphysema is an easily performed manoeuvre that can be life-saving.

Esophago-airway fistula in AIDS

Fistula formation between the esophagus and airway in acquired immunodeficiency syndrome is extremely unusual. We report 2 cases, the first in a patient who did not undergo definitive surgical management and died shortly after diagnosis. The second patient was managed successfully for 5 months by insertion of a Celestin endoesophageal prosthesis. This procedure can be performed with low morbidity and mortality, and may become the treatment of choice for this complex problem.

Treatment of esophagorespiratory fistulas with silicone-coated self-expanding metal stents

Nine self-expanding silicone-coated modified Gianturco metal stents were inserted in 8 patients (mean age, 58.2 years) for palliation of malignant esophagorespiratory fistulas caused by esophageal (n = 5) or bronchial (n = 3) carcinoma. One patient with a fistula above a 12-cm-long malignant stenosis received two overlapping stents. The implantation procedure was well tolerated by all patients under intravenous sedation and analgesia. After release, the stents expanded to their full diameter, leading to complete occlusion of the fistulas and bridging of the concomitant stenoses. Two patients with lung cancer received an additional tracheobronchial stent before esophageal stent insertion. Failure to maintain complete contact between the proximal stent margin and the esophageal wall led to insufficient sealing of the fistula of 1 patient and recurrent aspiration, manifested 6 days after stent implantation (overall success, 87.5%). The other patients could swallow semi-solid food until death. Seven patients died of advanced metastatic disease after 21 to 121 days (mean, 54 days) and 1 patient of massive hemoptysis 10 days after stent placement, which could be regarded as a complication (procedure-related mortality rate, 12.5%). These preliminary results suggest that peroral insertion of the modified silicone-coated Gianturco stent is a rapid, reasonably safe, and effective procedure for palliation of malignant esophagorespiratory fistulas.

Independent right lung high frequency and left lung conventional ventilation in the management of severe air leak during ARDS

Pulmonary air leaks are one of the most common problems in patients with the adult respiratory distress syndrome, ARDS. We report what we believe to be the first case in which unilateral high-frequency ventilation combined with contralateral conventional positive pressure ventilation has been used successfully to manage severe air leak in an infant with ARDS.

Selective bronchial occlusion for treatment of bullous interstitial emphysema and bronchopleural fistula

A preterm infant, ventilated for hyaline membrane disease, had severe right-sided pulmonary interstitial emphysema, left-sided compression atelectasis, and bronchopleural fistula. Several modalities of treatment were tried and were unsuccessful. Selective bronchial occlusion with a balloon catheter resulted in dramatic improvement in the patient's clinical and radiographic condition.

[Use of the omentum in the treatment of chronic thoracic empyema]

Thoracic empyema (development of suppuration in the thoracic cavity, usually after pneumonectomy) remains a serious complication which is difficult to treat. Failure of classical procedures (lavage-drainage) in the treatment of certain forms of pleural empyema (post-pulmonary resections), with or without associated fistula, led the authors to use the pedicled omental flaps filling material for the chronic empyema cavity. They report their experience (6 cases over a period of 4 years) and define the indications. Omentoplasty has a real place, next to myoplasty, in the therapeutic arsenal for chronic empyema due to its detersion capacity, particularly useful in a "septic" context and because of its volume which is usually sufficient in retracted cavities. The existence of an associated bronchial fistula, history of radiotherapy, posterolateral thoracostomy (sectioned latissimus dorsi) are additional reasons to prefer omentoplasty over myoplasty.

Pleurodesis using talc slurry

OBJECTIVE

To determine the efficacy and safety of talc slurry for pleurodesis.

DESIGN

Retrospective.

PARTICIPANTS

All patients who received talc slurry via tube thoracostomy at Memorial Sloan-Kettering Cancer Center from March 1991 to April 1992.

RESULTS

Fifty-eight patients received talc slurry in 75 procedures; five patients had 2 unilateral procedures and 12 had bilateral procedures. Fifty-two patients had malignant pleural effusions with the most common cell types being breast (23 of 52, 44 percent), lung (4 of 52, 8 percent), ovarian (4 of 52, 8 percent), and endometrial (3 of 52, 6 percent). Four patients had benign conditions. The mean duration of follow-up was 171 days (range, 2 to 450 days). Success, defined as the absence of pleural fluid reaccumulation, was evaluable in 47 of 73 (64 percent) procedures. Pleurodesis was successful in 38 of 47 (81 percent). Adverse effects associated with pleurodesis included fever (46 of 73, 63 percent), empyema (4 of 73, 5 percent), atrial arrhythmia (3 of 73, 4 percent), hypotension (3 of 73, 4 percent), and hypoxemic respiratory failure (3 of 73, 4 percent). There were no deaths attributable to the procedure.

CONCLUSIONS

Talc slurry instilled through a chest tube is an effective bedside method of pleurodesis. Fever occurs frequently. Respiratory failure is a rare but potentially serious complication that deserves further investigation.

Treatment of a bronchopleural fistula with a Fogarty catheter and oxidized regenerated cellulose (surgicel)

A patient with bronchopleural fistula was successfully treated by occluding the fistula with an inflated Fogarty catheter balloon packed with oxidized regenerated cellulose (Surgicel) using a fiberoptic bronchoscope. After 48 h, the balloon was deflated, the fistula had sealed, and the patient did well. This simple and relatively noninvasive therapy was effective in this patient who was not a surgical candidate.

Clinical efficacy of doxycycline for pleurodesis

To determine the efficacy of doxycycline as a pleural sclerosing agent, we examined the outcomes in 31 patients (aged 31 to 87 years) receiving doxycycline (500 to 1,000 mg) through a chest tube for malignant pleural effusions or persistent bronchopleural fistulae. Of the 27 patients with malignant pleural effusions, 21 patients had a complete short-term response (no fluid reaccumulation during the initial hospitalization); 5 of the 6 short-term nonresponders had partial control of effusions, with improvement in respiratory symptoms. Of the 23 patients who survived longer than 1 month, 15 patients did not have reaccumulation of fluid during follow-up. All four patients with persistent bronchopleural fistulae had resolution of their air leaks; one patient had recurrence with a partial pneumothorax. Pleural pain controllable with narcotic therapy was the only important complication. Thus, doxycycline is a suitable substitute for tetracycline as a pleural sclerosing agent.

[Chemical pleurodesis with iodized talcum in persistent therapy refractory bronchocutaneous fistula]

The common therapy of a persistent bronchocutaneous fistula is the operative endoscopic repair of the leak, the parietal pleurectomy or the endoscopic pleurodesis with different agents. Therefore the thoracotomy with all the risks for the patient can be avoid. Complications seen in the thoracoscopic treatment are low and often the result of techniqual problems. However there must be an alternative therapy for patients with a high operational risk. In our case we treated a bronchocutaneous persistent fistula by the instillation of iodized talc effectively. Although talc and others agents are used in the therapy of malignant pleural effusions, the talc poudrage in the therapy of bronchocutaneous fistulas is a good alternative treatment for patients in a bad condition.

Endoscopic treatment of bronchopleural fistulas using N-butyl-2-cyanoacrylate

Bronchopleural fistulas represent a serious complication of pulmonary surgery. Surgical treatment of bronchopleural fistulas has a high morbidity and mortality rate. Endoscopic sealing procedures are less invasive and more effective. We describe two patients successfully treated for fistulas stemming from pulmonary surgery. Biological (Tissucol) and synthetic glues (N-butyl-2-cyanoacrylate: Histoacryl) have been used. The technique must be chosen according to the fistulas' characteristics: Tissucol for small and medium-size fistulas, Histoacryl for large ones.

Conservative management of empyema thoracis and broncho-pleural fistula

One hundred and eight cases of empyema with and without broncho pulmonary fistula (BPF) were studied to analyse the efficacy of conservative management (aspiration/s and/or ICD). It was successful in 87.04% cases. Among those treated with intercostal drainage, the tube was removed within 2 months in 61.22%, 5 months in 71.42%, and 24 months in 85.71% cases. Only 14.29% cases showed persistent air leak even after 2 years of closed drainage. It was concluded that all cases of simple empyema and most cases of empyema with BPF can be managed successfully with conservative methods including aspirations and closed intercostal tube drainage.

Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature

Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rösch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n = 24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rösch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas.

Cholecystobronchocolic fistula: a late complication of biliary sepsis. Case report of diagnosis and management

A case of a 48 year old woman presenting with bilioptysis due to a cholecystobronchocolic fistula is reported. Bilioptysis is a rare complication of biliary fistulae, with a high mortality due to chemical pneumonitis. Bronchospasm and rapid respiratory failure may ensue if aggressive management is not adopted. The site of fistulation is established by cholangiography, preferably by the percutaneous transhepatic route. Continued biliary drainage can lead to closure of these fistulae, or allow sufficient improvement in clinical condition to allow definitive surgery to be performed electively.

Postoperative bronchopleural fistula: endoscopic closure in 12 patients

Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (methyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopic gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (< 15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopic treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistulas occurred late after the operation (> 15 days) and all had associated empyema. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.

Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils

Persistent peripheral bronchopleural fistulas can be difficult to manage. Endoscopic plugging of involved bronchi has been accomplished in a number of ways. We have devised a method of permanently blocking small peripheral airways using Gianturco vascular occlusion coils placed endobronchially by modified angiographic techniques. This procedure has been applied in 5 cases of complicated parenchymal air leaks. Complete or substantial partial control was achieved in all cases. There were no complications.