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.

Successful Sealing of Post-COVID-19 Bronchopleural Fistula with Computed Tomography Scan-Guided Percutaneous Cyanoacrylate Glue Injection: A Case Series

Bronchopleural fistula (BPF), a sinus tract between the bronchial system and the pleural space, is associated with COVID-19 and can lead to pneumothorax, which increases the mortality rate. Due to the analytical status of COVID-19 patients, sealing the BPF necessitates the least minimal invasive treatment. Herein, we demonstrated a technique of sealing post-COVID-19 BPF with direct injection of cyanoacrylate glue under the guidance of a computed tomography scan. Following glue injection, the BPF was completely sealed in all four patients. In conclusion, in COVID-19 patients with small and distal BPF, percutaneous glue injection is recommended for BPF closure.

Complications of Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Case Report of Bronchobiliary Fistula Development in a 68-Year-Old Man

BACKGROUND Bronchobiliary fistulas (BBFs) are abnormal communications between the biliary tract and bronchial tree. Transcatheter arterial chemoembolization (TACE) is a widely employed treatment for advanced hepatocellular carcinoma (HCC). While TACE is generally considered safe, there have been reports of severe complications. This case report is about a 68-year-old man who developed a BBF 6 months after undergoing TACE for HCC. CASE REPORT A 68-year-old man was diagnosed with HCC and underwent TACE at a local medical department. Two months after TACE, he presented with a liver abscess, which was drained and catheterized. Subsequently, the patient was transferred to our hospital. Initial MRI revealed abscesses in the right hepatic lobe extending into the lung cavity. Intrahepatic catheter replacement was performed. Six months after TACE, the patient developed cough and yellow sputum. Subsequent MRI confirmed smaller lung and liver abscesses, along with a BBF. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous catheter replacement were conducted, closing the BBF with a covered stent. Despite drainage, antibiotics, and nutritional support, the patient's condition deteriorated. Transition to hospice care was initiated, and the patient died due to sepsis and multiple organ failure. CONCLUSIONS This case highlights the importance of obtaining a comprehensive patient history when a patient has bile in the sputum, and discusses the rare but previously reported BBF as a complication of TACE for HCC. The presence of bile collections in the lungs and liver can result in tissue necrosis, potentially leading to chronic infection, emphasizing the need for early diagnosis and management.

Tuberculous Bronchopleural Fistula: A Rare and Life-Threatening Disease

Tuberculous bronchopleural fistula (BPF) is a rare and potentially life-threatening complication of pulmonary tuberculosis, in which abnormal connections form between the bronchial tree and the pleural space. These abnormal connections allow air and secretions to pass from the lungs into the pleural space, causing a range of symptoms from benign cough to acute tension pneumothorax. The management of tuberculous BPF requires an individualized approach based on the patient's condition and response to treatment. Anti-tuberculosis therapy is essential for controlling the active tuberculosis infections. Intercostal drainage and suction are also commonly used to drain air and fluid from the pleural space, providing relief from the symptoms. For some patients, more invasive surgeries, such as decortication, thoracoplasty or pleuropneumonectomy are required to definitively close the fistula when medical management alone is insufficient. Herein, we describe a rare case of tuberculous BPF in a young adult female, who was treated with anti-tuberculosis medications and open thoracotomy.

Special presentation of bronchobiliary fistula after transcatheter arterial chemoembolization: A case report

RATIONALE

Transcatheter arterial chemoembolization (TACE) is a widely adopted treatment for advanced stage hepatocellular carcinoma (HCC). Nevertheless, several complications may occur, such as hepatic artery injury, nontarget embolization, pulmonary embolism, hepatic abscess, biloma, biliary strictures, and hepatic failure. However, bronchobiliary fistula is rarely mentioned before.

PATIENT CONCERNS

A 65-year-old man with HCC underwent the TACE procedure, and then he encountered fever, dyspnea, abdominal pain, and abundant yellowish purulent bronchorrhea.

DIAGNOSIS

Bronchobiliary fistula was diagnosed based on the computed tomography (CT) scan of his chest, which revealed the right lower lobe of his lung was connected to a hepatic cystic lesion.

INTERVENTIONS

Percutaneous transhepatic cystic drainage was performed, and we obtained yellowish bile, showing the same characteristics as the patient's bronchorrhea.

OUTCOMES

We kept drainage of his biloma and provided supportive care as the patient wished. Unfortunately, the patient passed away due to progressive right lower lobe pneumonia 2 weeks later.

LESSONS

This case exhibits a typical CT scan image that was helpful for the diagnosis of post-TACE bronchobiliary fistula. Post-TACE bronchobiliary fistula formation hypothesis includes biliary tree injuries with subsequent biloma formation and diaphragmatic injuries. Moreover, the treatment of bronchobiliary fistula should be prompt to cease pneumonia progression. Therefore, we introduce this rare complication of post-TACE bronchobiliary fistula in hopes that future clinicians will keep earlier intervention in mind.

Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula

Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.

Successful Right Atrium-Pulmonary Artery ECMO in an Infant With Severe Necrotizing Pneumonia and Bilateral Bronchopleural Fistula

We report an infant with necrotizing pnuemonia and bilateral broncho pleural fistula, who failed on conventional and high frequency ventilation and was managed successfully on Veno-venous Extra Corporeal Membrane Oxygenator (V-V ECMO) with a unique configuration for 12 days, and weaned off successfully.

Empyema with Multiple Bronchopleural Fistulae Improved by Bronchial Occlusion Using an Endobronchial Watanabe Spigot with the Push and Slide Method

The push and slide method is a method of endoscopic bronchial occlusion using an endobronchial Watanabe spigot that facilitates occlusion of the target bronchus rapidly and accurately using a guidewire. We herein report the case of a man who was diagnosed with empyema forming bronchopulmonary fistulae that was successfully treated by endoscopic bronchial occlusion. Because of the multiple fistulae, balloon occlusion was not a favorable therapeutic approach. Instead, the push and slide method was used in order to detect the fistulae. Endoscopic occlusion, particularly that using the push and slide method, may be a valid treatment option for empyema with multiple bronchopulmonary fistulae.

Bronchobiliary fistula following radiofrequency ablation for liver metastases from breast cancer: A case report and literature review

RATIONALE

Bronchobiliary fistula (BBF) is a rare clinical condition which is characterized by a channel between biliary tract and bronchial tree. BBF can present with fever, dyspnea, and cough. However, it can be easily misdiagnosed as biliary vomiting, dyspnea, or even severe pneumonia.

PATIENT CONCERNS

A 53-year-old woman was diagnosed with breast cancer in April 2011 and underwent radical mastectomy and lymph node dissection, chemotherapy, and radiotherapy. Unfortunately, the patient suffered from bone metastasis during the 1st year and liver metastasis during the 2nd year after radical mastectomy. In 2013, the patient underwent transcatheter arterial chemoembolization therapy twice for liver metastasis. The patient was then treated with radiofrequency ablation (RFA) in 2016. Unfortunately, the patient developed a cough with bitter-tasting yellow sputum and chest tightness 2 weeks after the RFA treatment. Approximately 6 months later, the patient still complained of a cough with yellow sputum and persistent chest tightness. The patient was then admitted to our department.

DIAGNOSES

The presence of bile in the sputum supported a diagnosis of BBF. Bronchoscopy was performed, and the presence of bile in the lavage fluid confirmed the diagnosis of BBF.

INTERVENTIONS

The patient was treated with antibiotics including sulbactam, cefoperazone, levofloxacin and meropenem, was well as hepatoprotectants, nutritional support and other supportive treatments in our department.

OUTCOMES

The patient died because of liver failure.

LESSONS

This case demonstrates that we should consider the possibility of BBF when patients experience a recurrent cough with discolored sputum after RFA. In particular, a diagnosis of BBF should be considered in patients who do not respond to antibiotic treatment.

Bronchobiliary fistula: a rare complication after pancreaticoduodenectomy

Biliary anatomic pathologies are rare disease occurrences that can result from a number of causes, most commonly iatrogenic, infectious and malignant aetiologies. Communications between the biliary and bronchial systems are even rarer and few cases have been documented in the literature. The present study describes a case of a 70-year-old man who underwent a pancreaticoduodenectomy (Whipple Procedure) as a curative procedure for an early stage neuroendocrine tumour. He presented nearly a decade after surgery with a communication between the biliary and bronchial tree initially manifesting as bilioptysis. His underlying medical conditions and poor clinical picture made treatment options limited. Therefore, he was treated conservatively with percutaneous biliary balloon dilation of the anastomotic stricture followed by temporary percutaneous internal/external drain and made a full recovery.

Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success

BACKGROUND

Nonmalignant esophago-respiratory fistulas (ERF) are frightening clinical situations, involving surgery with high morbi-mortality rate. We described the endoscopic management of benign ERF. The aim of the study was to describe outcomes of endoscopic treatment of nonmalignant ERF and to analyze factors associated with its success.

METHODS

This is a retrospective study involving patients managed for benign ERF in our center between 2012 and 2016. The ERFs were classified into three groups of sizes: (I) punctiform, (II) medium, and (III) large. The primary aim was to document the endoscopic success (= fistula's healing after 6 months). The secondary objectives were characteristics of endoscopic treatment, the functional success and death, and identifying factors associated with success and death.

RESULTS

22 patients were included. The etiologies of ERF were surgery in 12 patients, esophageal dilatation in 3, invasive ventilation in 3, radiation therapy in 2, and tracheostomy in 2. Ninety-three procedures were performed (mean of number: 4.2 ± 4.5/patient). Twenty-one patients had stent placement, eight over-the-scope clips (OTSC), and seven a combined therapy. The endoscopic success rate was 45.5% (n = 10; 67% in punctiform, 50% in medium, and 14% in large ERF), and the functional success was 55% (n = 12). Serious adverse events occurred in 9 patients (40.9%). Six patients died (27%). The persistence of the orifice after 6 months of endoscopic treatment was associated with failure (OR 44; IC95: 3.38-573.4; p = 0.004 multivariate analysis). The orifice's size was associated with mortality [71% of death if large fistulas (p = 0.001) univariate analysis].

CONCLUSION

Endoscopic treatment of ERF leads to 45.5% of successful endoscopic closure and 55.5% of functional success, depending on fistula's orifice size. After 6 months without healing, the chances for success dramatically decrease.

Endoscopic bronchial occlusion for postoperative persistent bronchopleural fistula with computed tomography fluoroscopy guidance and virtual bronchoscopic navigation: A case report

RATIONALE

The development of postoperative bronchopleural fistula (BPF) remains a challenge in thoracic surgery. We herein report a case of BPF successfully treated with endoscopic bronchial occlusion under computed tomography (CT) fluoroscopy and virtual bronchoscopic navigation (VBN).

PATIENT CONCERNS

A 63-year-old man underwent right upper lobectomy with concomitant S6a subsegmentectomy for lung adenocarcinoma. On postoperative day 24, he complained of shaking chills with high fever.

DIAGNOSES

BPF with subsequent pneumonia and empyema.

INTERVENTIONS

Despite aggressive surgical interventions for the BPF, air leakage persisted postoperatively. On days 26 and 34 after the final operation, endobronchial occlusions were performed under CT fluoroscopy and VBN.

OUTCOMES

The air leaks greatly decreased and the patient was discharged.

LESSONS

CT fluoroscopy and VBN can be useful techniques for endobronchial occlusion in the treatment of BPF.

A bronchobiliary fistula treated with cyanoacrylate glue in a patient with liver cirrhosis

A 60-year-old male was operated upon in 2002 for liver hydatidosis, which included partial right hepatectomy with cholecystectomy and bilioduodenal anastomosis. He then developed liver cirrhosis secondary to left hepatic duct stricture. He presents at the emergency room with dry cough, which he had for a month and then became associated with yellowish, bitter-tasting "fluid" expectoration. A chest-abdominal CT scan revealed a 6 x 5-cm collection roughly located somewhere between the middle pulmonary lobe and subphrenic area . A fistula was suspected, which prompted a sputum biochemistry test that was positive for bilirubin. Given the patient's impaired liver function because of his liver disease conservative treatment was initiated with an inner-outer drain under transparietal hepatic cholangiography (TPHC) to promote bile outflow via the duodenum. Subsequently, TPHC was used to locate the point where contrast leaked from the biliary tree into a pleural cavity, and the fistula was sealed using cyanoacrylate glue, which resulted in improved symptomatology.

Independent lung ventilation in the management of ARDS and bronchopleural fistula

Independent lung ventilation is a decades-old, but infrequently used technique for physiological separation in critically-ill patients with asymmetric lung disease. Here we present a case report of bilateral necrotizing pneumonia complicated by acute respiratory distress syndrome and bronchopleural fistula, which was successfully managed with independent lung ventilation. The use of independent lung ventilation allowed for adequate oxygenation with use of high positive end expiratory pressure in the "good lung" while simultaneously allowing for closure of the bronchopulmonary fistula in the contralateral lung by maintaining relatively low airway pressures.

Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema

A prolonged air leak caused by pulmonary tuberculosis is difficult to treat, and little is known about optimal treatment strategies. We herein report the case of a 60-year-old man who demonstrated tuberculous empyema with a fistula. An air leak from a tuberculous cavity in his left upper lobe persisted for approximately 4 months; surgical repair could not be performed due to a poor physical status and undernourishment. However, the air leak was successfully treated with endobronchial occlusion using two silicone spigots in left B3b and B4, without any adverse effects or aggravation of the infection.

Large tracheobronchial fistula due to esophageal stent migration: Let it be!

We report tracheal-bronchial migration of a covered esophageal self-expanding metal stent used to relieve dysphagia in a patient with advanced esophageal cancer. The stent eroded the trachea and completely occluded the main left bronchus. Surgery was contraindicated due to her poor clinical condition, and insertion of another stent in the trachea, esophagus, or both was contraindicated due to extension of the fistula. Esophageal exclusion with a combination of cervical esophagostomy and an enteral feeding tube was the only feasible treatment to minimize spoilage by aspirated saliva and provide enteral nutrition.

Bedside placement of an endobronchial valve to aid invasive ventilation and weaning from extracorporeal membrane oxygenation

A bronchopleural fistula (BPF) is a life-threatening complication of cardiothoracic surgery and acute illness. There is no consensus on how best to treat a BPF. Recently, endobronchial one-way valves, designed for bronchoscopic lung volume reduction in emphysema, have been used to treat BPFs. We describe the use of an endobronchial oneway valve, placed at the bedside via flexible bronchoscopy, to treat a BPF in a patient with hypoxic respiratory failure, supported by extracorporeal membrane oxygenation (ECMO), secondary to pneumonia. We believe that this is the first published description of this technique being used in a patient needing ECMO support.

[Thoracic Drainage Using Nasal Airway for Postoperative Broncho-pleural Fistula]

A 61-year-old man with right lung cancer underwent right lower lobectomy. He suffered from postoperative broncho-pleural fistula, which was treated with thoracic drainage. After disappearance of air leakage, a drainage tube was removed. Forty days later, severe back pain, cough and fever were observed. Chest computed tomography showed enlarged thoracic cavity around the bronchial stump. Bronchoscopical examination revealed complete dehiscence of the bronchial stump. Because thoracic cavity was localized and located dorsal to the bronchial stump, a fenestration surgery was difficult. We placed a nasal airway from the dorsal to directly thoracic cavity, followed by disappearance of the symptoms. Thoracic cavity around the bronchial stump was gradually decreased and a nasal airway was successfully removed. Because a nasal airway was soft enough to keep supine position, we chose it as a drainage tube. Thoracic drainage using nasal airway may be a suitable therapeutic approach for localized small thoracic cavity.

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.

[Nutritional treatment for bronchopleural fistula-promising effect of arginine as a pharmaconutrient]

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

[Bronchoesophageal fistula secondary to mediastinal lymph node tuberculosis: a case report and review of the literature]

OBJECTIVE

To analyze the clinical features of 1 case of bronchoesophageal fistula (BEF) secondary to mediastinal lymph node tuberculosis.

METHODS

The clinical, auxiliary examinational and pathological data of 1 case with BEF were presented, and the literatures were reviewed.

RESULTS

The patient was a 19 year old female, who was admitted to hospital because of fever and cough associated with liquid intake. It was diagnosed by chest CT scan, endobronchial ultrasound biopsy of mediastinal lymph nodes, and clinical testing (methylene blue). The BEF was closed after anti-tuberculosis therapy and preventing contamination of the fistula by indwelling stomach tube.

CONCLUSIONS

Bronchoesophageal fistula secondary to mediastinal lymph node tuberculosis is rare. Chest CT scan, fiberoptic bronchoscopy, and clinical testing (methylene blue) are useful diagnostic tools for BEF.

Plastic tube-assisted gastroscopic removal of embedded esophageal metal stents: A case report

A patient with stent embedding after placement of an esophageal stent for an esophagobronchial fistula was treated with an ST-E plastic tube inserted into the esophagus to the upper end of the stent using gastroscopy. The gastroscope was guided into the esophagus through the ST-E tube, and an alligator forceps was inserted into the esophagus through the ST-E tube alongside the gastroscope. Under gastroscopy, the stent wire was grasped with the forceps and pulled into the ST-E tube. When resistance was met during withdrawal, the gastroscope was guided further to the esophageal section where the stent was embedded. Biopsy forceps were guided through a biopsy hole in the gastroscope to the embedded stent to remove silicone membranes and connection threads linking the Z-shaped wire mesh. While the lower section of the Z-shaped stent was fixed by the biopsy forceps, the alligator forceps were used to pull the upper section of the metal wire until the Z-shaped metal loops elongated. The wire mesh of the stent was then removed in stages through the ST-E tube. Care was taken to avoid bleeding and perforation. Under the assistance of an ST-E plastic tube, an embedded esophageal metal stent was successfully removed with no bleeding or perforation. The patient experienced an uneventful recovery after surgery. Plastic tube-assisted gastroscopic removal of embedded metal stents can be minimally invasive, safe, and effective.

Open window thoracostomy for the treatment of bronchopleural cutaneous fistula -- case report

Pleural empyema and bronchopleural fistula (the communication between the pleural space and the airways) are early or late complications of various diseases. We present the case of a 29-year-old patient operated for cavitary pulmonary tuberculosis and giant caseoma at the age of seven, who also had fibrocavitary pulmonary tuberculosis positive for mycobacterium tuberculosis at the age of 19. The patient presented with low grade fever, chills, sweating, cough with mucopurulentsputum, dyspnea on mild exertion, perioral cyanosis, cyanosis of the limbs at exertion, anorexia, weight loss and skin suppuration on the left side of thorax. The diagnosis of chronic pulmonary suppuration, the failure of conservative therapy (multiple antibiotic treatments in the last three years), the presence and size of the bronchopleural cutaneous fistula, thepatient's surgical history (presence of "lifesaving"sutures), as well as his immunocompromised state required that conservative medical treatment (antibiotics, antimycotics and supportive medication for six months) be associated with surgery. An open window thoracostomy was selected over segmentectomy or lobectomy due to their associated risks caused by anatomic changes in the large vessels. The open window thoracostomy should not be forgotten or abandoned as it may be the only approach that ensures patient survival and the effective management of the residual cavity and chronicsuppuration in selected cases.

First case of bronchiolar-pleural fistula repair with platelet-leukocyte rich gel

Bronchiolar-pleural fistulas are a frequent complication of thoracic surgery. Current treatment strategies and their invasiveness are quiet different, but often surgeons decide for a new surgical intervention and definitive closure of the breach. We report the case of a bronchiolar-pleural fistula in a 75 years old man with important co-morbidities that we treated with instillation of platelet-leukocyte rich gel (PLR-G). We discuss actual indications for PLR-G as well as its possible role in thoracic surgery.

[Two cases of airway stent placement to treat tracheal and bronchial fistula using general anesthesia under spontaneous respiration]

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.

Successful exclusion of a large bronchopleural fistula using an Amplatzer II vascular plug and glue embolization

We report a case of a 63-year-old man with a complicated postsurgical bronchopleural fistula (BPF), which was treated with a minimally-invasive hybrid procedure using fluoroscopy, bronchoscopy, and thoracoscopy. A previous surgical attempt had failed to seal the pathologic tract. An Amplazter II vascular plug was successfully deployed into the BPF, followed by autologous blood and glue injection. An adjunctive endoscopically-guided glue embolization was deemed necessary. The 14-month clinical and imaging follow-up confirmed the successful exclusion of the BPF. No migration of the device was noted and the patient remained asymptomatic. The combined endoscopic and fluoroscopic guided management of a BPF using the Amplatzer II vascular plug and glue was proven safe and effective after mid-term follow-up.

Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

[Optimization of treatment methods of surgical complications in lung cancer]

The present report analyses the immediate and long-term results of treatment of surgical complications in 998 patients with lung cancer. There were complications in 37,5% of the cases, with a fatality rate of 14,7%. The most frequent complications were as follows: postoperative empyema with bronchopleural fistula (41,3%), bleeding (12,0%), pneumonia (9,8%), pulmonary arteries embolism (8,1%) and heart rhythm disorders (8,1%). Adjuvant and neoadjuvant treatment does not increase the rate of surgical complications as compared to just surgery alone (p = 0,1). Postoperative empyema with bronchopleural fistula requires intensive therapy, affects the quality of life of patients but does not decrease survival rates as compared to patients at the same stages of disease with uncomplicated course (p = 0,001). Timely drainage of pleural cavity accompanied by its adequate sanation does not differ (p = 0,1) from usage thoracoplasty (MS 29,9 months to 33,2 months).

[A case of chronic tuberculous empyema with a fistula treated with an endobronchial Watanabe spigot before surgery]

A 78-year-old man was referred to our hospital because of pyrexia in October 2008. Chest X-ray films and chest computed tomography (CT) indicated chronic tuberculous empyema in the right hemithorax. His general condition was not improved by antibiotic treatment, and CT showed pyothorax with a niveau and bronchial fistulas in May 2009. We subsequently performed open window thoracostomy and decortication of the residual dead spaces, but the bronchial fistulas remained. As this approach makes it difficult to ensure the sterility of the cavity, we therefore performed fiberoptic bronchoscopy and occluded the bronchus with an endobronchial Watanabe spigot (EWS). However, the bronchial fistula recurred, and therefore we performed this treatment again. We continued to carefully wash the cavity and the leakage stopped, whereupon the cavity became sterile. We then performed omental pedicle and muscle flap closure and thoracoplasty in April 2010. The empyema was cured without any complications. These findings suggest that using an EWS before surgery can be highly effective in controlling chronic tuberculous empyema with fistulas.

[Bronchobiliary fistulae as a complication of hepatic cystic echinococcosis]

Cystic hydatid disease or cystic echinococcosis (CE) rarely occurs in the Czech Republic. In 2005 - 2009, eleven cases were recorded, mostly among immigrants from the Balkans. Presented here is a case report of a 38-year-old patient with hepatic CE complicated by bronchobiliary fistulae. Ten days before surgical removal of the hydatid cysts, treatment with mebendazole was started. During surgery the affected part of the lungs was resected and the liver cysts were drained using transthoratic access. The follow-up was complicated by leakage of bile into the pleural cavity. The leakage was associated with continued communication between the liver cyst and the pleural cavity which did not close spontaneously after removal of the drain. Endoscopic nasobiliary drainage decreased pressure in the bile duct and within 14 days, it led to the spontaneous closure of the communication between the liver cyst and the pleural cavity. Seven months after the operation, the patient was in a very good clinical condition.

[Usefulness of esophageal stenting by using a covered self-expandable metallic stent for esophagorespiratory fistula associated with esophageal carcinoma]

We report three cases of esophagorespiratory fistula associated with esophageal carcinoma successfully treated with esophageal stenting by using a covered self-expandable metallic stent (SEMS). All three cases had advanced esophageal carcinoma at middle thoracic esophagus with esophagorespiratory fistula at the level of esophageal carcinoma. Case 1 is a 58-year-old man who had lung abscess due to esophagopulmonary fistula caused after induction chemoradiotherapy. He underwent a surgical resection of the affected lung and intraoperative esophageal stenting with dietary intake starting on day 26 after stenting. Case 2 is a 60-year-old man with esophagopulmonary fistula caused after primary chemotherapy. He started to take an oral intake on day 3 after esophageal stenting. Case 3 is a 68-year-old man with esophagobronchial fistula detected at the first medical examination. He started to take an oral diet on day 7 after esophageal stenting. All three cases had a rapid improvement of respiratory symptoms, pneumonia and malnutrition by esophageal stenting leading to marked improvement of impaired general condition. Esophageal stenting is a useful method for palliation of esophageal carcinoma with respiratory fistula.

Bronchoscopic management of bronchopleural fistula

In recent years successful bronchoscopic management of bronchopleural fistulas (BPFs) by locating its site and then blocking the leaking segment with any of the several agents available has gained recognition. It is now considered as an alternate mode of management of BPF. Here we present a case of non-resolving pneumothorax that was managed successfully using bronchoscopic glue (cyanoacrylate glue) instillation.

Endovascular treatment of aortobronchial fistula secondary to coronary artery bypass graft (CABG)

Aortobronchial fistula (ABF) is a rare and late complication of cardiac surgery. If untreated, mortality rate is approximately 100% secondary to exsanguinations haemoptysis. Early diagnosis and treatment are essential for successful management. Open surgical repair is associated with high morbidity and mortality rate, ranging from 25% to 41%. Endovascular treatments of ABF is a less invasive treatment modality and have become an important alternative to open surgical intervention in aortic pathologies. We present a case of ABF that successfully is managed by endovascular approach.

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.

Thoracobiliary fistula. A rare complication of thoracoabdominal trauma

Thoracobiliary fistulas (bronchobiliary and pleurobiliary) are rare complications of thoracoabdominal trauma. Owing to their rarity, there is little consensus on the optimal management . The diagnostic suspicion however must be considered and it's important the correct selection of diagnostic imaging techniques. Biliptysis is the pathognomonic physical finding of bronchobiliary fistulas. Demonstration of high bilirubin levels in the pleural effusion is diagnostic for a pleuro-biliary fistula. The optimal treatment of bronchobiliary fistulas is operative, in order to prevent their dramatic consequences. For pleurobiliary fistulas, a light aggressive conservative approach is an appealing option in the beginning. Newer endoscopic techniques increase the non-operative approach.

Closure of pneumonectomy stump fistula using custom Y and cuff-link-shaped silicone prostheses

Large postpneumonectomy stump fistulas pose a significant problem for thoracic surgeons and interventional bronchoscopists. We present a case of successful rigid bronchoscopic repair of a complete right pneumonectomy stump dehiscence using a custom-built stent made of a sculpted silicone Y stent sutured to a new cuff-link-shaped DJ-Fistula stent. This resulted in rapid symptom resolution, weaning from mechanical ventilation and discharge home in a patient with bronchogenic carcinoma, respiratory failure, and significant other comorbidities that precluded repeat thoracotomy.

Iatrogenic bronchopleural fistula occuring during redo cardiac surgery

Cardiac re-operations are associated with increased morbidity and mortality rates due to adhesion of tissues in the anterior mediastinum. Especially, previous usage of left internal thoracic artery constitutes a major challenge for cardiovascular surgeons. In such cases, the left lung frequently adheres to the thoracic wall and may be injured during dissection. This leads to air leak and the complication may in turn increase the risk of mediastinal infections and the hospital stay. A bronchopleural fistula case treated by a novel technique is reported. In patient iatrogenic bronchopleural fistula occured during dissection of the adhesions which resulted due to the first coronary artery bypass grafting and left internal thoracic artery usage. The air leakage was successfully controlled and treated by a novel method: self adhesive BioGlue immersed and coated Surgicel patch. Although it is a single case experience it may be a promising method as it is less traumatic when compared to the classical treatment methods of bronchopleural fistula.

Chronic expanding hematoma with bronchopleural fistula and empyema space

Chronic expanding hematoma of the thorax is not typically accompanied by a bronchopleural fistula or purulent lesion. We report an extremely rare case of chronic expanding hematoma with a bronchopleural fistula and empyema space in a 66-year-old man with a history of tuberculous pleurisy admitted because of fever and bloody sputa. Computed tomography and a magnetic resonance imaging revealed a huge mass and an air space in the right thorax. A fiber-optic bronchoscope examination showed hemorrhagic effusion from the apical bronchus of the right lower lobe. First, open-window thoracostomy was undertaken to control the septic state and to prevent aspiration of infected pleural fluid. At operation, air leakage was found at the most superior portion in the rear of the thoracic empyema space; this was thought to be from the bronchopleural fistula. Enterococcus casseliflavus was detected in cultures for bacteria of the effusion from the empyema space. After an improvement of his general condition, a radical operation, including the complete extirpation of the hematoma and intrathoracic muscle transposition using the latissimus dorsi muscle, was successfully performed.

[Clinical characteristics and therapeutic experience of case of severe highly pathogenic A/H5N1 avian influenza with bronchopleural fistula]

OBJECTIVE

To summarize the clinical characteristics and therapeutic experience of A/H5N1 infected patient with intractable bronchopleural fistula.

METHOD

The data of a patient with A/H5N1 infection complicated with bronchopleural fistula was collected and analyzed.

RESULTS

A 44-year-old woman with pneuminian was diagnosed as A/H5N1 infection by reverse-transcription polymerase chain reaction (RT-PCR) in laboratory from the sample of secretion of respiratory tracts. She had exposed to sick or dead poultry 3 days before development of illness. She developed acute respiratory distress syndrome 7 days after onset of sickness. After comprehensive management with antiviral agents, antibiotics, convalescent serum and invasive ventilation, her clinical condition improved and turned to stable. However, 16 days after onset of illness, her clinical situation deteriorated due to ventilator-associated pneumonia, bilateral pneumothorax and persistent right bronchopleural fistula. After partly failure of beside assist thoracoscopy to fix the pleural fistula, transbronchoscopic bronchial occlusion by autoblood was explored and the air leakage stopped soon after occlusion. Three days after the autoblood clot was expectorated out and air leak recurred. Then, bronchopleural fistula on the surface of visceral pleura was successfully blocked by biogel and OB gel through pleural cavity by fibrobronchoscopy. The patient was discharged from the hospital 99 days after onset of illness (at the 94th hospital day).

CONCLUSION

Bronchopleural fistula was an intractable complication for patient with A/H5N1 infection. Occlusion operation by biogel and OB gel through bronchoscopy might be an alternative choice for fixing the bronchopleural fistula.