Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey

OBJECTIVE

We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.

METHODS

We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.

RESULTS

Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19).

CONCLUSIONS

The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

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.

Pneumonectomy After High-Dose Radiation and Concurrent Chemotherapy for Nonsmall Cell Lung Cancer

BACKGROUND

Pneumonectomy after high-dose radiotherapy and concurrent chemotherapy has been associated with high operative mortality. Therefore, most induction protocols limit radiation to 5,000 cGy or less. Additionally, the safety of right pneumonectomy after induction therapy has been questioned. The feasibility of pneumonectomy after high-dose radiotherapy and concurrent chemotherapy is reviewed.

METHODS

From 1990 to 2005, 30 patients with locally advanced nonsmall-cell lung cancer underwent pneumonectomy after 5,940 cGy of radiation and two cycles of etoposide and cisplatin. To minimize postpneumonectomy pulmonary edema, patients were treated with a protocol that included fluid restriction and 48 hours of mechanical ventilation. Morbidity, mortality, and survival were examined.

RESULTS

There were 18 right and 12 left pneumonectomies. Death occurred in 4 patients (13.3%) but in only 1 (5.6%) after right pneumonectomy. Causes of death included aspiration, bronchopleural fistula, pneumonia, and massive pulmonary embolus. Major morbidity occurred in 5 (pneumonia in 2 and aspiration in 3). Median hospital stay was 9 days (range, 2 to 45), and intensive care unit stay was 2 days (range, 2 to 35). Median overall survival was 22 months with a 5-year survival of 33%. Patients surviving operation had a median survival of 33 months and a 5-year survival of 38%.

CONCLUSIONS

The mortality rate after pneumonectomy after high-dose radiation and concurrent chemotherapy is relatively high but results in significant survival. The mortality rate is not increased after right-sided operations. Pneumonectomy should continue to be offered to patients with advanced locoregional disease after induction high-dose radiotherapy and concurrent chemotherapy when a complete resection cannot be carried out with a lesser procedure.

Risk of a Right Pneumonectomy: Role of Bronchopleural Fistula

BACKGROUND

The purpose of this study is to compare the morbidity and mortality of right versus left pneumonectomy.

METHODS

We used a retrospective review of pneumonectomies performed during the period 1990 to 2000 and included a meta-analysis of relevant literature.

RESULTS

There were 187 pneumonectomies: 68 right, 119 left. The primary study end point was in-hospital death. There were 11 deaths: 7 (10.3%) right, 4 (3.3%) left (p = 0.10). Six deaths were attributable to bronchopleural fistula and its subsequent complications. The risk of bronchopleural fistula was higher on the right (9 [13.2%]) versus left (6 [5.0%]; p = 0.0472), as was the mortality associated with bronchopleural fistula (4 of 9 [44%] right versus 2 of 6 [33%] left). Right pneumonectomies were more likely to require an intrapericardial or extended dissection (p = 0.003), hand-sewn bronchial closure (p < 0.0001), or the closure buttressed (p < 0.0001). By univariate analysis, factors associated with an increased mortality were bronchopleural fistula (p < 0.0001), hand-sewn closure (p = 0.001), and a history of smoking (p = 0.01). By multivariate analysis, the most important factor was bronchopleural fistula (odds ratio, 43.3; 95% confidence limits, 4.2 to 441.9; p = 0.002). A meta-analysis combining our results with those from the literature found increased mortality of right pneumonectomy with a relative risk of 3.39 (95% confidence limits, 2.10 to 5.48; p < 0.00001).

CONCLUSIONS

Right pneumonectomy is associated with a higher mortality even in the absence of induction therapy. This is primarily related to the increased risk of bronchopleural fistula on the right. The increased number of bronchopleural fistulas on the right may be attributable to more extensive resection. Addressing technical factors that contribute to early bronchopleural fistula may reduce the mortality of right pneumonectomy.

Predictors of Cardiac Morbidity And Mortality in Patients Undergoing Endovascular Repair of the Thoracic Aorta

The aim of this study was to determine predictors of cardiac morbidity and mortality in patients undergoing endovascular repair of the thoracic aorta. This was a retrospective cohort study that took place in a University-affiliated county hospital. Preoperative and intraoperative variables were collected from a consecutive series of patients who underwent repair of the thoracic aorta at our institution between 1998 and 2003. Perioperative complications and mortality were identified for each patient. Fifty-nine patients underwent endovascular repair of the thoracic aorta. The endografts were successfully deployed in 58 (98%) patients. Nine (15%) died perioperatively, 4 (7%) from cardiac causes. There were 12 (20%) perioperative cardiac events. A history of myocardial infarction (MI) was the only preoperative risk factor that was predictive of a cardiac event (p = 0.001). The cardiac event rate was 29% for patients who did not receive perioperative beta-blockade vs. 8% in patients who did (p = 0.04). Intraoperative predictors of MI were estimated blood loss (2480 cc vs. 680 cc, p = 0.01), intravenous (i.v.) fluids (2955 cc vs. 2010 cc, p =0.02), and length of operation (269 min vs. 178 min, p = 0.02). From these results we concluded that mortality associated with endovascular repair of thoracic aorta remains significant. Patients with a history of MI had a higher perioperative cardiac event rate. Intraoperative predictors of perioperative cardiac events included blood loss, i.v. fluid requirement, and length of operation. Perioperative beta-blockade is important in endovascular thoracic surgery as a protection against postoperative cardiac events.

Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management

Postoperative aortobronchial and aortopulmonary fistulas are rare and late complications of cardiac surgery. They mostly complicate descending thoracic aortic procedures. Hemoptysis is the main symptom, and may be massive or intermittent. The reported interval between the time of operation and the onset of hemoptysis ranges from 3 weeks to 25 years. Diagnostic examinations are often unable to directly visualize a fistula. Indication for surgical or endovascular repair mostly relies on clinical suspicion and nonspecific diagnostic features. Urgent treatment is based on the association of the following elements: (1) hemoptysis, (2) history of previous cardiac or aortic operation, (3) presence of lung infiltrates on the chest roentgenogram, (4) lung hemorrage on the computed tomographic scan, and (5) and visualization of a pseudoaneurysm. Aortobronchopulmonary fistulas are uniformly fatal if untreated. The overall surgical mortality rate is 15.3%. There is no procedure-related mortality after endovascular stent grafting. A review of the English-language literature from 1947 to October 2002 is presented.

Management of empyema after lung resections (pneumonectomy/lobectomy)

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.

Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management

BACKGROUND

The incidence of a bronchopleural fistula (BPF) as a major complication after non-small cell lung carcinoma (NSCLC) surgery has decreased in recent years, due to new surgical refinements and a better understanding of the bronchial healing process. We reviewed our most recent experience with BPFs and tried to determine methods which may effectively reduce its occurrence.

METHODS

Data on 490 patients with lung resections for NSCLC over a period from 1990 to 1999 were retrospectively reviewed. Details regarding surgery and the subsequent treatment were carefully reviewed. Particular attention was paid to factors possibly affecting the occurrence of BPFs: the technique of the initial bronchial closure, previous radiation and/or chemotherapy, need for postoperative ventilation and presence of residual carcinomatous tissue at the bronchial suture line. Information about age, sex, clinical diagnosis, associated conditions, TNM stage, period between primary operation and rethoracotomy and postoperative outcome was also recorded.

RESULTS

The overall BPF incidence was 4.4% (22/490). There were 21 (95.5%) males and 1 (4.5%) female, mean age was 57.8 years. BPFs occurred after pneumonectomy in 12 (54.6%), after lobectomy in 9 (40.9%) patients and after sleeve resections in 1 (4.5%) patient. Mortality rate was 27.2% (6/22). Right-sided pneumonectomy and postoperative mechanical ventilation were identified as risk factors for BPFs (p<0.05). Initial chest re-exploration was performed in 20 (90.9%) patients. After debridement, the bronchial stump was reclosed by hand suture in 10 (45.4%) patients. All 10 (45.4%) patients with a post-lobectomy- and sleeve resection BPF necessitated completion surgery. The BPF was additionally covered with a vascularized flap in 20 (90.9%) patients. In 2 (9%) patients with small BPFs and poor overall condition the initial treatment was endoscopic. In both the fistula persisted and the stump had to be surgically resutured.

CONCLUSIONS

A BPF remains a major complication in the surgery of NSCLC because of its high mortality and morbidity rate. A BPF is more common after right-sided pneumonectomy and is frequently associated with postoperative mechanical ventilation. The management varies according to the initial type of surgery, the size of the BPF, the overall patient condition and that of the remaining lung. Endoscopic treatment is reserved only for small fistulas associated with poor general condition.

Thoracic rupture of hepatic hydatidosis (123 cases)

BACKGROUND

Hydatid disease is frequently endemic in countries with poor environmental sanitation and in geographic areas where interaction between humans and animals is common. Pulmonary complications result from the proximity of hydatid cysts in the liver and the diaphragm.

METHODS

The medical records of 123 patients, with established hydatid disease manifesting abnormal chest roentgenograms, were retrospectively analyzed for the period January 1990 to December 1999.

RESULTS

Chest roentgenogram and abdominal ultrasound provided a correct preoperative diagnosis in 108 patients (87.8%). Expectoration of bile, demonstration of fistula by ultrasound, expectoration of cyst contents, and additional ultrasound or imaging findings were the criteria used to establish the preoperative diagnosis. The remaining 15 cases were confirmed at operation. Men outnumbered women nearly 3:1. Mean age was 36.2 years. Pulmonary resection was performed in 67 cases. Sixty-eight patients presented with a bronchobiliary fistula (55.3%). Morbidity rate was 14.6% and mortality rate was 8.9%.

CONCLUSIONS

Thoracotomy offers adequate simultaneous access to both the chest and hepatic lesions with acceptable morbidity and mortality. Endoscopic sphincterotomy undertaken preoperatively is useful in reducing biliary complications.

Transsternal closure of bronchopleural fistula after pneumonectomy

BACKGROUND

Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula.

METHODS

From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done.

RESULTS

Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy.

CONCLUSIONS

Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Management of malignant esophagorespiratory fistula

For patients with malignant esophagorespiratory fistula, four important points need to be stressed: (1) once the diagnosis is made, treatment should be instituted immediately; (2) all treatment is palliative and directed at stopping soilage of the respiratory tract; (3) the type of therapy is dictated by the performance status of the patient at presentation; and (4) esophageal bypass offers the best palliation for those able to tolerate the procedure.

Malignant esophagorespiratory fistula: management options and survival

The development of a malignant esophagorespiratory fistula is a devastating complication. Data comparing various treatment options in a large group of patients are sparse. To assess the results of therapy, we reviewed our experience in 207 patients with malignant esophagorespiratory fistula. Records of 207 patients admitted to our institution with malignant esophagorespiratory fistula from 1926 to 1988 were reviewed and results of management analyzed. Age ranged from 21 to 90 years (median, 59 years); the male/female ratio was 3:1. Primary tumor site was esophagus in 161 (77%), lung in 33 (16%), trachea in 5 (2%), metastatic nodes in 4 (2%), larynx in 3 (1%), and thyroid in 1. Symptoms and signs of malignant esophagorespiratory fistula included cough in 116 (56%), aspiration in 77 (37%), fever in 52 (25%), dysphagia in 39 (19%), pneumonia in 11 (5%), hemoptysis in 10 (5%), and chest pain in 10 (5%). Respiratory location of fistula included trachea in 110 (53%), left main bronchus in 46 (22%), right bronchus in 33 (16%), lung parenchyma in 13 (6%), and multiple sites in 5 (2%). The percentage of patients alive at 3, 6, and 12 months by treatment modality was 13%, 4%, and 1% for supportive care (n = 104); 17%, 3%, and 0% for esophageal exclusion (n = 29); 21%, 14%, and 0% for esophageal intubation (n = 14); 30%, 15%, and 5% for radiation therapy (n = 20); and 46%, 20%, and 7% for esophageal bypass, respectively. Patients treated with radiation therapy and esophageal bypass had a significantly prolonged survival compared with patients treated with the other modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Empyema after pneumonectomy--empyema window or thoracoplasty?

369 pneumonectomies carried out within the years 1981 to 1988 and their empyema complications form the basis for a retrospective analysis to assess the outcome of treating pneumonectomy cavity empyema by window healing. During the same period 31 empyema after 322 pneumonectomies to treat bronchial carcinoma are investigated in more detail as far as their therapeutic modalities are concerned. 20 patients received a thoracic window. 18 of 31 patients (58%) could be cured, and 9 of these were in the thoracic window group. The hospital mortality of empyema patients after pneumonectomy amounted to 42%. In an historical comparison no progress could be recognized in the treatment of this septic complication.

Persistent bronchopleural air leak during mechanical ventilation. A review of 39 cases

Bronchopleural fistula (BPF), or bronchopleural air leak, is regarded as an ominous complication of ventilator management in acute respiratory failure, but data on its natural course and prognosis are lacking. We reviewed all instances of mechanical ventilation at a major trauma center during a four-year period, and found that 39 of the 1,700 mechanically-ventilated patients developed BPF lasting at least 24 hrs. Overall mortality in these 39 patients was 67 percent, and this was higher when BPF developed late in the illness (16 of 17, or 94 percent, when mean onset was hospital day 13), than when it occurred within 24 hours of admission (ten of 22, or 45 percent, p = 0.002). Survival in patients with chest trauma (12 of 27, 44 percent), most of whom had air leaks on or just after admission, was better than in those with other primary diagnoses (one of 12, 8 percent, p less than 0.005). All eight patients whose maximum air leak exceeded 500 ml per breath died, whereas 13 of 30 with smaller maximum leaks survived (p less than 0.05). Despite leaks as large as 900 ml per breath, however, conventional ventilator adjustments permitted avoidance of severe respiratory acidosis (pH less than 7.30) in all but two patients. We conclude that the occurrence of BPF during mechanical ventilation identifies patients with high mortality, but that unmanageable respiratory acidosis from this complication is rare.

Pessimism concerning palliative bypass procedures for established malignant esophagorespiratory fistulas: a report of 18 patients

Eighteen patients with established malignant esophagorespiratory fistulas due to primary esophageal cancer were managed by substernal gastric bypass and isolation of the cancerous esophageal segment. Seven fistulas were esophagotracheal and 11 were esophagobronchial. Ten patients died in the hospital between two days and six weeks after operation. Eight patients left the hospital, surviving an average of 3 1/2 months, but 2 patients lived 5 and 7 months, respectively. Unrelenting respiratory infection and clinical inanition caused 7 hospital deaths in patients reestablished on oral alimentation with their fistulas disconnected. Anastomotic leaks occurred in 5 patients; three of these leaks closed. In the other 2 patients, cervicomediastinal sepsis and bilateral pneumonia with respiratory failure caused death. One patient died of anoxic cardiac arrest 48 hours postoperatively. Fifteen of the 18 patients resumed oral alimentation, but the overall results of palliative surgical therapy achieved in this series were not observably worthwhile for the majority.

Management of bronchopleural fistula following pneumonectomy

Bronchopleural fistula developed in 28 (12.5%) of 225 pneumonectomies performed for pulmonary carcinoma of non-small cell types during a 10-year period. The incidence of fistula apparently decreased significantly when chromic catgut was replaced by Dexon for closure of the bronchial stump. The fistula presented as an emergency in nine cases and was subacute in 19. The overall mortality from bronchopleural fistula was 28.6%. Conservative treatment, i.e. bronchoscopic application of silver nitrate to destroy the epithelium in the bronchial stump and induce granulation, achieved closure of fistula in all the surviving patients. In the seven patients with sterile pleural cavity the pleura was not drained. The results justified our principle of conservative management when a bronchopleural fistula does not present as an emergency. In emergency situations, however, or if the pleural fluid is purulent, pleural drainage should be instituted.

Postpneumonectomy empyema does not improve survival in bronchogenic carcinoma

There is much disagreement in the literature about the beneficial effect of postpneumonectomy empyema on survival following operation for bronchogenic carcinoma. We had the opportunity to gather data on 407 patients with this serious complication. The survival data for a group of patients with postpneumonectomy empyema and fistula were compared with those for another group without such complications. Our statistical analysis confirms that postpneumonectomy empyema does not improve life expectancy.

Survival with residual tumor on the bronchial margin after resection for bronchogenic carcinoma

Sixty-four (14.7 percent) of 434 consecutive patients having pulmonary resection for bronchogenic carcinoma were found to have microscopic residual tumor on the cut margins of the resected specimens. These subjects were further subdivided histologically into those with direct extension of the tumor (34 patients), lymphatic permeation (14 patients), clumps of cancer cells in parabronchial tissues (six patients), and the presence of carcinoma in situ change (10 patients). Bronchopleural fistulas developed in eight (12.5 percent) of 64 patients. The operative mortality rate was 15.6 percent, with four of the deaths occurring as the result of bronchopleural fistulas. Thirty-two patients (50 percent) survived 1 year, 21 (32.8 percent) survived 3 years, and 15 (23.4 percent) lived for 5 years or more. The patients with tumor in the submucosal and peribronchial lymphatics had the worst prognosis. 78.6 percent having died within 1 year and the remainder within 3 years. All 5-year survivors were men with squamous cell carcinoma and had relatively small tumors (mean diameter 2.9 cm). No direct relationship between the length of the resected bronchial stump and survival could be established; a short stump did not preclude long survival. The possible factors involved in the relatively high 5 year survival rate in this group of patients and the therapeutic implications of these factors are discussed.

Bronchopleural fistula. Thirteen-year experience with 77 cases

Bronchopleural fistula, although reduced in incidence in recent years, remains a grave complication of pulmonary disease and of pulmonary resection. In a series of 77 patients treated for bronchopleural fistula over a 13 year period, 49 of whom had postresection fistulas, only 44 (57.1 percent) were cured of the fistula and 15 (19.5 percent) died. Prevention assumes great importance. Key factors in prevention are avoidance of pulmonary resection in tuberculous patients with positive sputum; overzealous dissection of the bronchus; a long bronchial stump; tumor in the bronchial stump; contamination of the pleural cavity; and too little tissue left behind to fill the pleural space. Treatment should be surgical. In none of the six patients treated conservatively was the fistula obliterated. Seventy-one patients were treated surgically, and 133 operations were needed to effect fistula obliteration in the 44 patients (62 percent) in whom this was achieved. Adequate surgical drainage has always been the sine qua non of effective treatment, and yet this alone brought about closure of the fistula in only nine patients. Early resuture of the bronchial stump succeeded in only two of five patients. Thoracoplasty combined with drainage effected closure in seven of 11 patients. The highest rate of fistula closure with the lowest mortality occurred among the 20 patients who underwent myoplasty, usually combined with a limited thoracoplasty. In this group, the fistula was obliterated in 16 patients, with one death.