Complex bronchopleural fistulas: a case report

Bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. Concomitant problems, such as pulmonary infection and respiratory failure, are typically the main contributors to mortality from BPF because of improper contact between the bronchial and pleural cavity. We present the case of a 75-year-old male patient with a history of right upper lobe lung cancer resection who developed complex BPFs. Following appropriate antibiotic therapy and chest tube drainage, we treated the fistulas using endobronchial valve EBV placement and local argon gas spray stimulation. Bronchoscopic treatment is the preferred method for patients who cannot tolerate a second surgery because it can help to maximize their quality of life. Our treatment method may be a useful reference for treating complex BPF.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

[Retrospective Study of Bronchoscopic Intervention Therapy for Bronchopleural Fistula Induced by Pulmonary Surgery]

BACKGROUND

As a new technique developed in recent years, bronchoscopic intervention therapy has the advantages of minimal invasion, high safety and repeatability. The aim of this study is to investigate the clinical characteristics of bronchopleural fistula (BPF) induced by surgeries for lung malignancies or benign diseases and the effect of bronchoscopic intervention therapy for BPF, so as to provide support for prevention and treatment of BPF.

METHODS

Data 64 patients with BPF who were treated by bronchoscopic intervention in Respiratory Disease Center of Dongzhimen Hospital, Beijing University of Chinese Medicine from June 2020 to September 2023 were collected. Patients with fistula diameter ≤5 mm were underwent submucous injection of macrogol, combined with blocking therapy with N-butyl cyanoacrylate, medical bioprotein glue or silicone prosthesis. Patients with fistula diameter >5 mm were implanted with different stents and cardiac occluders. Locations and characteristics of fistulas were summarized, meanwhile, data including Karnofsky performance status (KPS), shortbreath scale (SS), body temperature, pleural drainage volume and white blood cell count before and after operation were observed.

RESULTS

For all 64 patients, 96 anatomic lung resections including pneumonectomy, lobectomy and segmentectomy were executed and 74 fistulas occurred in 65 fistula locations. The proportion of fistula in the right lung (63.5%) was significantly higher than that in the left (36.5%). Besides, the right inferior lobar bronchial fistula was the most common (40.5%). After operation, KPS was significantly increased, while SS, body temperature, pleural drainage volume and white blood cell count were significantly decreased compared to the preoperative values (P<0.05). By telephone follow-up or readmission during 1 month to 38 months after treament, median survival time was 21 months. 33 patients (51.6%) showed complete response, 7 patients (10.9%) showed complete clinical response, 18 patients (28.1%) showed partial response, and 6 patients (9.4%) showed no response. As a whole, the total effective rate of bronchoscopic intervention for BPF was 90.6%.

CONCLUSIONS

BPF induced by pulmonary surgery can lead to severe symptoms and it is usually life-threating. Bronchoscopic intervention therapy is one of the fast and effective therapeutic methods for BPF.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

OBJECTIVE

To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy.

METHODS

Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality.

RESULTS

During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts.

CONCLUSIONS

Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis

INTRODUCTION

Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate.

CASE PRESENTATION

Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves.

CONCLUSION

The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.

MSCT study for adult esophageal diverticulum with secondary broncho-esophageal fistula

BACKGROUND

Broncho-esophageal fistula (BEF) secondary to esophageal diverticulum is a rare clinical condition, which is often misdiagnosed for a long time. The aim of our study is to summarize and clarify the advantages of MSCT in diagnosing BEF secondary to esophageal diverticulum.

METHODS

We retrospectively analyzed patients clinically diagnosed with BEF from January 2005 to January 2022 at Jilin University First Hospital. Only those patients with BEF secondary to esophageal diverticulum and complete clinical data met our enrolled standard. All patients' clinicopathologic characteristics and MSCT features were systemically evaluated.

RESULTS

17 patients were eligible for our cohort study, including male 10 and female 7. The patient's mean age was 42.3 ± 12.5. The chronic cough occurred in all seventeen patients and bucking following oral fluid intake was documented in nine patients. MSCT distinctly suggested the fistulous tract between the bronchi and the esophagus in all patients. The mean diameter of the orifices in the wall of the esophagus was 4.40 ± 1.81 mm. The orifice in the midthoracic esophagus side was 15 cases and 2 cases at the lower thoracic esophagus. The involved bronchus included 13 cases at the right lower lobe bronchus, 1 at the right middle lobe bronchus and 3 at the left lower lobe bronchus. The contrast agent was observed in the pulmonary parenchyma in 10 of 13 patients who underwent esophagogram. No definite fistula was observed in 3 of 11 who underwent gastroscopy, while the intra-operative findings supported the existence of fistula.

CONCLUSIONS

BEF secondary to esophageal diverticulum tends to occur between the midthoracic esophagus and the right lower lobe bronchus. Compared with esophagography and gastroscopy, MSCT shows more comprehensive information about the fistulous shape, size, course and lung involvement, which are helpful for establishing diagnosis and guiding subsequent treatment.

Inverted Placement of Endoscopic One-Way Endobronchial Valve Combined with Gelfoam in the Closure of Bronchopleural Fistula with Empyema in a Mechanically Ventilated Patient: A Case Report

Bronchopleural fistula (BPF) with empyema caused by severe necrotizing pulmonary infection is a complicated clinical problem that is often associated with poor general condition so surgical interventions cannot be tolerated in most cases. Here, we present the successful management of multiple BPF with empyema in a mechanically ventilated patient with aspiration lung abscess. Occlusion utilizing Gelfoam followed by endobronchial valves (EBVs) implanted inverted via bronchoscope decreased the air leaking significantly and made intrapleural irrigation for empyema achievable and safe. This is the first report of a novel way of EBV placement and the combination use with other occlusive substances in BPF with empyema in a patient on mechanical ventilation. This method may be an option for refractory BPF cases with pleural infection.

Congenital bronchoesophageal fistula in an adult patient

INTRODUCTION

Congenital bronchoesophageal fistulas are extremely rare. Symptoms may not be detected before treatment or may be seen intermittently until advanced ages. Treatment is surgical closure of the fistula.

CASE PRESENTATION

A 20-year-old female patient with presented complaints of sputum production and cough. A fistula was confirmed between the middle esophagus and the left main bronchus by bronchoscopy. Management is by surgical closure of the fistula via right thoracotomy. The patient had an uneventful recovery.

CONCLUSION

Congenital bronchoesophageal fistula malformation can cause long-term respiratory symptoms associated with the fistula and loss of lung parenchyma if left untreated.

Intrathoracic Transposition of a Pedicled Latissimus Dorsi Muscle Flap for Complicated Chronic Empyema Thoracis: A Plea for its Popularity in our Subregion

INTRODUCTION

Empyema thoracis is a debilitating disease that still constitutes a significant burden among thoracic surgical diseases in our environment. It sometimes occurs secondary to ruptured lung abscess with varying degrees of lung destruction and bronchopleural fistula.

CASE REPORT

A 65-year-old woman presented to our unit with a two-month history of cough which subsequently became productive of purulent sputum and posture-dependent, and fever, with progressive dyspnea on exertion. She was subsequently managed for chronic right empyema thoracis secondary to a ruptured lung abscess. We briefly describe the evaluation, indication, and technique for intrathoracic transposition of a pedicled latissimus dorsi muscle flap for operative management of this index disease, and the very good medium and long-term outcomes observed for this patient.

CONCLUSION

Where indicated and with meticulous preoperative planning, transposition of a pedicled latissimus dorsi muscle flap for complicated chronic empyema thoracis can prevent a surgical albatross with a reduced hospital stay, cost of treatment and excellent patient satisfaction at the meagre expense of about 30 minutes or less extra intra-operative time.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BACKGROUND

Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.

CASE PRESENTATION

This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.

CONCLUSIONS

After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Value of preoperative evaluation of FEV1 in patients with destroyed lung undergoing pneumonectomy - a 20-year real-world study

BACKGROUND

Clinical guidelines recommend a preoperative forced expiratory volume in one second (FEV1) of > 2 L as an indication for left or right pneumonectomy. This study compares the safety and long-term prognosis of pneumonectomy for destroyed lung (DL) patients with FEV1 ≤ 2 L or > 2 L.

METHODS

A total of 123 DL patients who underwent pneumonectomy between November 2002 and February 2023 at the Department of Thoracic Surgery, Beijing Chest Hospital were included. Patients were sorted into two groups: the FEV1 > 2 L group (n = 30) or the FEV1 ≤ 2 L group (n = 96). Clinical characteristics and rates of mortality, complications within 30 days after surgery, long-term mortality, occurrence of residual lung infection/tuberculosis (TB), bronchopleural fistula/empyema, readmission by last follow-up visit, and modified Medical Research Council (mMRC) dyspnea scores were compared between groups.

RESULTS

A total of 96.7% (119/123) of patients were successfully discharged, with 75.6% (93/123) in the FEV1 ≤ 2 L group. As compared to the FEV1 > 2 L group, the FEV1 ≤ 2 L group exhibited significantly lower proportions of males, patients with smoking histories, patients with lung cavities as revealed by chest imaging findings, and patients with lower forced vital capacity as a percentage of predicted values (FVC%pred) (P values of 0.001, 0.027, and 0.023, 0.003, respectively). No significant intergroup differences were observed in rates of mortality within 30 days after surgery, incidence of postoperative complications, long-term mortality, occurrence of residual lung infection/TB, bronchopleural fistula/empyema, mMRC ≥ 1 at the last follow-up visit, and postoperative readmission (P > 0.05).

CONCLUSIONS

As most DL patients planning to undergo left/right pneumonectomy have a preoperative FEV1 ≤ 2 L, the procedure is generally safe with favourable short- and long-term prognoses for these patients. Consequently, the results of this study suggest that DL patient preoperative FEV1 > 2 L should not be utilised as an exclusion criterion for pneumonectomy.

Nil Intervention is at Times the Best Intervention: Benign emptying of pneumonectomy space

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions.

Bronchobiliary fistula after stenting of biliary duct as the management of iatrogenic bile duct injury during elective cholecystectomy

BACKGROUND

Bronchobiliary fistula is a rare and complex entity defined by an abnormal communication between the biliary and bronchial systems. The etiopathogenesis is not completely understood, but the most common factors implicated are hepatobiliary tumors, biliary obstruction, iatrogenic damage or trauma.

METHODS

Here we present a case of a 69-year-old man that developed a bronchobiliary fistula and a pulmonary abscess after migration of a bile duct stent placed as part of the treatment of an iatrogenic bile duct injury that occurred during elective cholecystectomy.

RESULTS

A conservative approach, that included broad-spectrum antibiotic, removal of the stent, and sphincterotomy, was enough for the closure of the fistula and resolution of the symptoms.

CONCLUSION

We emphasize the importance of prompt recognition of this entity and a concerted therapeutic strategy to optimize the probability of success, avoiding the destructive consequences of the bile in the pulmonary parenchyma and septic complications.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BACKGROUND

Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.

CASE PRESENTATION

A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.

CONCLUSION

Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

An update on bronchopleural fistulae following cancer-related surgery

PURPOSE OF REVIEW

Bronchopleural fistulae (BPF) are rare complications in cancer-related surgery but impart significant morbidity and mortality. BPF may be difficult to identify, with a broad differential diagnosis at presentation, so it is critical to be aware of newer diagnostic and therapeutic approaches for this disease entity.

RECENT FINDINGS

Multiple novel diagnostic and therapeutic interventions are featured in this review. Reports of newer bronchoscopic techniques to localize BPF, as well as approaches for bronchoscopic management, like stent deployment, endobronchial valve placement, or alternative interventions when indicated are discussed, paying particular attention to factors that influence procedure selection.

SUMMARY

Management of BPF remains highly variable, but several novel approaches have shown improved identification and outcomes. Although a multidisciplinary approach is imperative, an understanding of these newer techniques is important to provide optimal care for patients.

Over-The-Scope clip closure of an acquired bronchoesophageal fistula secondary to an esophageal diverticulum

Esophagorespiratory fistula is a rare entity that occurs as a result of malignant and non-malignant causes. This condition is associated with high morbidity and mortality. Surgical repair has traditionally been the most common treatment and self-expandable metal stent are the first choice among non-surgical techniques. Here, we report a non-malignant bronchoesophageal fistula secondary to an esophageal diverticulum that was successfully closed using an over-the-scope clip.

Endobronchial Watanabe Spigot Placement for Hepatic Abscess and Bronchobiliary Fistula Following Radiofrequency Ablation for Hepatocellular Carcinoma

A bronchobiliary fistula (BBF) is an uncommon but severe complication after radiofrequency ablation (RFA). However, the definitive salvage methods are controversial. We herein report a patient with hepatocellular carcinoma with hepatic abscess and BBF following RFA. We also review previous reports of BBF after RFA. The patient was a man in his 70s who underwent RFA for recurrent hepatocellular carcinoma in the subphrenic area. Despite percutaneous transhepatic abscess drainage, bilioptysis persisted. Finally, the BBF was occluded with an endobronchial Watanabe spigot under fiber-optic bronchoscopy. Placing an endobronchial Watanabe spigot should be considered as a salvage therapy for refractory BBF following RFA.

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8 months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema

OBJECTIVE

The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF).

MATERIALS AND METHODS

We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect.

RESULTS

In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased.

CONCLUSIONS

Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

[Staged reconstructive surgery for bronchopleural fistula]

Treatment of bronchopleural fistula after pneumonectomy is still an urgent problem for thoracic surgeons. Transsternal bronchial stump occlusion should be preferable if possible. However, this is not enough for curing in some cases. We present a patient with concomitant cancer and tuberculosis of lungs whose postoperative period was complicated by bronchial stump failure. Preoperative diagnostic data are presented. We describe the indications for surgeries and main surgical stages. Some interventions including reconstructive surgery using a muscle flap led to recovery. Latissimus dorsi muscle flap on thoracodorsal artery is the best option for reconstructive surgical treatment in patients with extensive chest wall defects and thoracostomy.

[Early predictor of bronchial suture failure after pneumonectomy]

OBJECTIVE

To identify the relationship between serum CRP/albumin and bronchial suture failure after pneumonectomy.

MATERIAL AND METHODS

A retrospective analysis included 100 patients who underwent pneumonectomy with extended lymph node dissection for lung cancer. Patients were divided into 2 groups depending on postoperative complications: group 1 - bronchial stump failure, group 2 - no similar complications. In all patients, we analyzed markers of inflammation (C-reactive protein and albumin) in preoperative period and after 24 postoperative hours. Bronchial stump failure was found in 20 patients (10 patients (14.7%) after left-sided pneumonectomy and 10 (31%) patients after right-sided pneumonectomy). We found a significant relationship between serum CRP/albumin and bronchial stump failure after pneumonectomy (p<0.05). A prognostic formula was based on the ratio of serum C-reactive protein and albumin: PC = CRP/Alb, where PC - prognostic coefficient, CRP - serum C-reactive protein (mg/l) 24 hours after surgery, Alb - serum albumin (g/l) 24 hours after surgery. PC >2.6 determines high risk of bronchial stump failure after pneumonectomy, PC <2.6 - low risk. Sensitivity of this method is 90%, specificity - 97.5%.

Surgical operation combined with bronchoscopy in the treatment of fungal empyema: 5 cases report

RATIONALE

Fungal empyema is a chronic refractory disease. It is difficult to control thoracic infection, and it is faced with the problem of recurrence. How to control the infection and reduce the probability of recurrence is a difficult problem. Surgical operation combined with endobronchial therapy was used to control infection, seal the fistula and eliminate residual cavity and achieved good results.

PATIENT CONCERNS

A total of 5 patients with fungal empyema were treated from 2019 to 2021, aged 27 to 72 years, with an average age of 54.8 ± 7.6 years. Two cases were on the left side and 3 cases on the right side.

DIAGNOSIS

While meeting the diagnostic criteria of empyema, the diagnosis of fungus in pus culture or the discovery of fungus in deep tissue pathology confirmed the diagnosis of fungal empyema in the 5 cases.

INTERVENTIONS

Through surgical operations combined with bronchoscopy and individualized treatment, the infection was controlled, the fistulas were blocked, and the pus cavity was filled.

OUTCOMES

After 11 to 30 months of follow-up, the muscle flap in the abscess cavity was mildly atrophied, and there was no recurrence of empyema. Three patients who completed the second-stage operation had their chest tubes removed and returned to normal life. The 2 patients who did not complete the second-stage operation had no recurrence of thoracic infection and no recurrence of cough or fever, and their quality of life was greatly improved.

LESSONS

Surgical operation combined with bronchoscopy is a reliable method for the treatment of fungal empyema, which can find and plug the fistula more efficiently and eliminate the residual cavity by surgery to avoid recurrence. Therefore, it is a recommended treatment method.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

Surgical Treatment for Pneumothorax and Tumor-bronchial Fistula Secondary to Pulmonary Metastasis of Osteosarcoma in Pediatric and Adolescent Patients

BACKGROUND

Pneumothorax and tumor-bronchial fistula are rare complications of pulmonary metastasis of osteosarcoma.

OBSERVATIONS

We herein report the cases of 3 pediatric and adolescent patients who developed pneumothorax or tumor-bronchial fistula during treatment of pulmonary metastasis of osteosarcoma with chemotherapeutics or antiangiogenic agents. Two patients developed pneumothorax, and the other patient developed tumor-bronchial fistula. All of the patients finally underwent the surgery to treat their complications.

CONCLUSIONS

Although it is not a curative surgery, surgery for pneumothorax and tumor-bronchial fistula is acceptable. The operative procedure should be considered on the basis of the predicted prognosis of the patient.

Surfactant for a Patient with Refractory Pyopneumothorax and Acute Respiratory Distress Syndrome Due to Pneumococcal Necrotizing Pneumonia Complicated by a Bronchopleural Fistula

Background: Necrotizing pneumonia rarely occurs in children, but when it does it can be complicated by bronchopleural fistula, empyema, pneumothorax, sepsis, and acute respiratory distress syndrome (ARDS). Antimicrobial therapy is the cornerstone of its management; however, surgery is necessary in some cases. Ideally, surgical interventions are kept to a minimum, but this is not always possible if there is a mass effect from air and fluid in the pleural space, pulmonary necrosis leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Case Presentation: Herein we present a patient with refractory pyopneumothorax and ARDS due to pneumococcal necrotizing pneumonia complicated by a bronchopleural fistula. The patient's clinical condition deteriorated despite antibiotics, surgical drainage, and assisted ventilation. Owing to pneumothorax with a high percentage of air leakage, bilateral diffuse collapse of the lungs, and insufficient oxygenation, surgical treatment was considered, but because of the patient's lack of tolerance for surgery due to hemodynamic reasons and the complications associated with surgery, medical treatment was determined to be more appropriate. Surfactant treatment was administered to the patient, resulting in significant clinical improvement. Conclusion: To the best of our knowledge, this is the first report of the use of surfactant to treat ARDS due to necrotizing pneumonia. Based on the presented case, we think surfactant can be considered as a salvage treatment for such patients.

The Association of Vacuum-Assisted Closure Therapy with Dynamic Volume Change of a Muscle Flap Transposed in an Empyema Cavity for Chronic Empyema: A Case Report

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.

Drug use-related right-sided infective endocarditis complicated by empyema and bronchopleural fistula

Right-sided infective endocarditis is frequently accompanied by septic pulmonary emboli, which may result in a spectrum of respiratory complications. We present the case of a 25-year-old woman diagnosed with infective endocarditis secondary to intravenous drug use. During a long and arduous hospital course, the patient developed empyema with bronchopleural fistula, representing severe but uncommon sequelae that may arise from this disease process. She was treated with several weeks of antibiotics as well as surgical thorascopic decortication and parietal pleurectomy.

Sepsis in the Postpneumonectomy Space: Pathogenesis, Recognition, and Management

Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema. Pneumonectomy-surgical removal of the entire lung-is the treatment of choice for centrally located bronchogenic carcinoma, diffuse malignant mesothelioma, and chronic inflammatory lung diseases with destroyed lung from pulmonary tuberculosis, fungal infections, and bronchiectasis. In the uncomplicated case, on the pneumonectomy side, the diaphragm becomes elevated as the air-fluid level decreases with chest wall deformation and gradual disappearance of hydrothorax. The pneumonectomy space is at potential risk for getting infected from bacterial contamination and developing empyema.

Video-assisted Thoracoscopic Resection of a Congenital Tracheobiliary Fistula in a Neonate: Technical Report and Review of the Literature

BACKGROUND

Congenital tracheobiliary or bronchobiliary fistulae are rare developmental malformations associated with high morbidity and mortality primarily because of concomitant anomalies as well as delays in diagnosis.

TECHNICAL REPORT

We report a case of a neonate who presented with bilious emesis and progressive respiratory failure requiring bronchoscopy and fluoroscopic bronchography for diagnosis with successful management through video-assisted thoracoscopic surgery. We also review the published literature on tracheobiliary fistula.

CONCLUSION

Use of video-assisted thoracoscopic surgery for fistula resection has been reported in only one other neonate and provides a clinically less invasive option compared with open surgical ligation and resection. To our knowledge, this is the first English language report of thoracoscopic resection in a neonate with congenital tracheobiliary fistula.

Endoluminal management of benign bronchoesophageal fistula

The ideal management of bronchoesophageal fistulas is a debated topic. While open surgical repair remains the most definitive treatment, not all patients are fit for surgery. In this communication, we present a patient who developed a bronchoesophageal fistula 1 year after an Ivor Lewis esophagectomy that involved the native oesophagus and right mainstem bronchus. Endoluminal vacuum therapy was successful at closing this benign bronchoesophageal fistula.

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma: A case report

RATIONALE

Gastrobronchial fistula (GBF) is a rare but life-threatening complication of esophagectomy with gastric conduit reconstruction, and airway management during fistula repair is challenging. Here, we describe airway management in a patient undergoing left-sided GBF repair using video-assisted thoracoscopic surgery.

PATIENT CONCERNS

A 63-year-old man diagnosed with esophageal carcinoma underwent esophagectomy with reconstruction by gastric pull-up and tabularization of the gastric conduit. Subsequently, about 8 weeks later, the patient presented with repeated pneumonia and a 1-week history of cough with significant sputum, dysphagia, and repeated fever.

DIAGNOSIS

GBF, a rare postoperative complication, was located on the left main bronchus at 2 cm below the carina and was diagnosed based on findings from gastroscopy, flexible bronchoscopy, and thoracic computed tomography scan with contrast.

INTERVENTIONS

We performed left-sided one-lung ventilation (OLV) under total intravenous anesthesia instead of inhalational anesthetics. The left-sided OLV, with positive end-expiratory pressure (PEEP) and nasogastric tube decompression, generated positive pressure across the fistula. It prevented backflow into the left main bronchus. Total intravenous anesthesia preserved hypoxic pulmonary vasoconstriction and prevented adverse effects associated with inhalational anesthetics. A right-sided, double-lumen endotracheal tube was inserted after anesthesia induction, and surgical repair was performed through a right-sided video-assisted thoracoscopic surgery.

OUTCOMES

Intraoperative hemodynamics remained relatively stable, except for brief tachycardia at 113 beats/min. Arterial blood gas analysis revealed pH 7.17 and PaO2 89.1 mmHg upon 100% oxygenation, along with hypercapnia (PaCO2 77.1 mmHg), indicating respiratory acidosis. During OLV, pulse oximetry remained higher than 92%. The defect in the left main bronchus was successfully sutured after dissecting the fistula between the left main bronchus and the gastric conduit, and subsequently, OLV resulted in ideal ventilation.

LESSONS

A left-sided GBF could lead to leakage from the OLV during surgery. Possible aspiration or alveolar hypoventilation due to this leakage is a major concern during airway management before surgical repair of the main bronchus.

[Surgical Approach for Treatment of Postoperative Bronchopleural Fistula and Pyothorax]

A bronchopleural fistula is a serious condition that can develop into pyothorax. The incidence of bronchopleural fistula depends on the surgical procedure. Bronchopleural fistulas are classified into early and late types based on the time of development following surgical intervention. Early-stage fistulas show poor prognosis and require prompt treatment. It is important to confirm the status of infection in the thoracic cavity to devise an optimal treatment plan. Bronchopleural fistula closure is challenging and may be unsuccessful in patients with uncontrolled infection. Immediate open window thoracostomy should be performed in patients with empyema. The window is closed after effective clearance of thoracic cavity infection. Prompt and systematic treatment improves prognosis.

[Re-operation for Intrathoracic Complications after Surgery for Thoracic Esophageal Cancer (Chylothorax, Trachea-bronchial Fistula, Post-operative Bleeding)]

Post-operative complications in thoracic esophageal cancer surgery occurred in more than 40% of patients, of which intrathoracic complications are the most serious complications and may require re-operation. Surgeons require a high degree of judgment, skill, and experience at all stages for surgical indications, surgical procedures, and post-operative managements, because re-operation puts a great degree of stress on the patient's mind and body. This article focuses the relatively common post-operative complications that require re-operation, chylothorax, tracheal/bronchial fistula, and post-operative bleeding. The key point of surgery for chylothorax is to identify the site of chylothorax by lymphangiography. The key points of surgery for tracheal and bronchial fistulas are intraoperative and post-operative respi ratory management and reliable covering of the fistula using latissimus dorsi or pectoralis major muscle flaps. The key point of surgery for post-operative bleeding is to reliably identify the point of bleeding and perform hemostasis without damaging the reconstructed gastro-intestinal tract. Surgeons are needed to acquire the knowledge and skills of how to perform re-operation at an appropriate time and method.

Colonic interposition for oesophageal replacement surgery in a patient with left broncho-oesophageal fistula: anaesthetic management

Management of an uncorrected broncho-oesophageal fistula in the perioperative period is a challenge for the anaesthesiologist. Positive pressure ventilation which is inevitable during surgery will lead to gastric insufflation and there is a high risk of aspiration of gastric contents. In this case report, we discuss how we used a double lumen tube to occlude a pericarinal broncho-oesophageal fistula. This method was quite effective as it obviated the need for isolating the lung as well as ensured smooth delivery of positive pressure ventilation during the surgery.

[Successful Negative Pressure Wound Therapy for Pleural Empyema by Closing Bronchopleural Fistula with Cyanoacrylate Products]

A 69-year-old man had experienced right upper lobectomy for inflammatory granuloma. Three months after surgery, he was diagnosed with pleural empyema due to bronchopleural fistula and open window thoracostomy was performed. Since we could not decrease the dead space and the amount of pleural effusion, we introduced negative pressure wound therapy (NPWT). Before applying, we closed the fistula with suturing and cyanoacrylate products. Four weeks later, we performed an operation to close the open window with muscle transposition. NPWT is reported to be useful to treat pleural empyema, but control the air leakage from fistulas is essential to introduce this treatment. We think cyanoacrylate products may be useful in closing fistulas temporarily to introduce NPWT.

Bronchobiliary fistula: a clinical and surgical challenge. Presentation of a pediatric case

INTRODUCTION

Congenital bronchobiliary fistula is an extremely rare malformation with high morbidity and mortality rates. Up to 2016, 36 cases had been reported worldwide.

CLINICAL CASE

11-year-old male patient with history of chronic lung disease and respiratory insufficiency, bile ptyalism and 66-80% arterial saturation, jaundice, asymmetric thorax, finger clubbing, and disseminated crackling rales. He was diagnosed through fibrobronchoscopy and CT-scan. After fistula closure and right pneumonectomy, recurrence occurred due to bile duct hypoplasia as evidenced by endoscopic retrograde cholangiopancreatography. Left lateral hepatic segmentectomy and fistula closure from the abdomen were carried out. Bronchopleural fistula persisted following intensive nutritional and antibiotic treatment. It was surgically closed using a bovine pericardial patch. Six months later, the patient had no symptoms.

DISCUSSION

Given how extremely rare this malformation is, cross-disciplinary treatment and a high grade of suspicion are needed. The presence of bile duct hypoplasia is to be considered, since it requires a thoracoabdominal approach.