Bronchoscopic interventions for bronchopleural fistulas.

Bronchopleural fistula is a potentially fatal disease most often caused after pneumonectomy. Concomitant problems such as pulmonary infection and respiratory failure are typically the main contributors to patient mortality because of the improper contact between the bronchial and pleural cavity. Therefore, bronchopleural fistulas need immediate treatment, which requires the accurate location and timely closure of the fistula. Currently, bronchoscopic interventions, because of their flexibility and versatility, are reliable alternative therapies in patients for whom surgical intervention is unsuitable. Possible interventions include bronchoscopic placement of blocking agents, atrial septal defect (ASD)/ventricular septal defect (VSD) occluders, airway stents, endobronchial valves (EBVs) and endobronchial Watanabe spigots (EWSs). Recent developments in mesenchymal stem cells (MSCs) transplantation technology and three-dimensional (3D) printed stents have also contributed to the treatment of bronchopleural fistula, but more research is needed to investigate the long-term benefits. This review focuses on the effectiveness of various bronchoscopic measures for the treatment of bronchopleural fistula and the directions for future development.

Successful endoscopic management of a persistent bronchobiliary fistula with Histoacryl®/Lipiodol® mixture.

Introduction A bronchobiliary fistula (BBF) following liver directed therapy (resection/ablation) is a rare complication in which an abnormal communication between the biliary tract and bronchial tree is formed. This case report describes the successful management of a persistent BBF following multiple liver wedge resections and microwave ablation in a patient with a metastatic neuroendocrine tumour of the terminal ileum. Case history A 69-year-old man presented with unexplained weight loss and was subsequently diagnosed with a neuroendocrine tumour of the terminal ileum and liver metastasis. Following elective right hemicolectomy and multiple bilobar liver wedge resections combined with liver microwave ablation, he developed an early bile leak. A month later, a right subphrenic collection was identified and four months following surgery, biloptysis was noted. Numerous attempts with endoscopic retrograde biliary drainage (ERBD) failed to achieve sufficient drainage. The patient was treated successfully with endoscopic injection of a mixture of Histoacryl® glue (B Braun, Sheffield, UK) and Lipiodol® (Guerbet, Solihull, UK). There was no evidence of the BBF one year following intervention. Conclusions This novel approach for persistent BBF management using endoscopic Histoacryl® glue embolisation of the fistula tract should be considered either as an adjunct to ERBD or when biliary tract decompression by drainage and/or sphincterotomy fails, prior to proceeding with surgical interventions.

An unusual presentation of pulmonary embolism leading to infarction, cavitation, abscess formation and bronchopleural fistulation.

We report an unusual presentation of pulmonary embolism (PE) where a 58-year-old man first developed symptoms of community-acquired pneumonia. Despite antibiotic therapy, he remained unwell with rising inflammatory markers, general malaise and persistent cough. He developed stony dull percussion and absent breath sounds to his left mid to lower zones. Serial chest x-rays showed progression from lobar consolidation to a large loculated left-sided pleural collection. CT chest showed left-sided lung abscess, empyema and bronchopleural fistulation. Incidentally, the scan revealed acute left-sided PE and its distribution corresponded with the location of the left lung abscess and empyema. The sequence of events likely started with PE leading to infarction, cavitation, abscess formation and bronchopleural fistulation. This patient was managed with a 6-month course of rivaroxaban. After completing 2 weeks of intravenous meropenem, he was converted to 4-week course of oral co-amoxiclav and metronidazole and attained full recovery.

[Application of Intrabronchial Valves in High Risk Patients with Bronchopleural Fistula: an Alternative Therapeutic Option]. / Applikation intrabronchialer Ventile zur Behandlung der persistierenden bronchopleuralen Fistel nach komplikativem Pleuraempyem mit Lungendestruktion.

OBJECTIVES: Persistent air leak or bronchopleural fistula (BPF) is a challenging and frequently observed problem after pulmonary resection and may lead to prolonged chest tube therapy. One efficient nonsurgical approach to manage such a fistula is the application of intrabronchial valves. This may support earlier chest tube removal and hospital discharge. METHODS: Between 04/2015 and 03/2017, n = 8 patients (n = 4 female) with severe pleural empyema and necrotising lung tissue defects developed prolonged air leak and persistent BPF after surgery. Radiological and bronchoscopical investigations revealed the presence of a BPF. For closure, intrabronchial valves were endoscopically inserted into the affected bronchi. In patients with repeat development of empyema, a chest wall window was required (n = 6 patients). RESULTS: The mean age was 61 years (45 - 85 years). After repeated surgical debridement, the space was sterile and the chest wall window was closed. After valve placement, air leaks were no longer detectable. In all patients, the procedures were well tolerated without any negative events. After successful valve placement, chest tubes could be removed in all n = 8 patients within 7 days (3 - 15 days) and patients were discharged thereafter. CONCLUSIONS: Placement of intrabronchial valves presents an alternative option to conventional surgical and non-surgical methods for the treatment of postoperative persistent air leak or BPF. Particularly in high risk patients, this procedure is safe and effective.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA].

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

[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.

Autologous platelet-poor plasma decreases the bronchial stump necrosis in rat.

BACKGROUND: Necrosis of the bronchial stump is a very important trigger for bronchopleural fistula. The administration of local autologous platelet-poor plasma (PPP) could protect the bronchial stump. MATERIALS AND METHODS: Left pneumonectomy was performed in 25 Sprague-Dawley rats. Animals were randomly assigned to a control group (n=13) and PPP group (n=12). PPP was locally administered on the bronchial stump after pneumonectomy. We analyzed histologic changes in the bronchial stump and messenger RNA expression changes of genes involved in wound repair at 10 and 20 d. RESULTS: Local PPP treatment produced a mass of fibrous tissue surrounding the bronchial stump and significantly decreased the presence of necrosis at 20 d. PPP increased the expression of insulin like growth factor 1 at 10 d although it did not reach statistical significance. CONCLUSIONS: Our findings indicate that local PPP treatment of the bronchial stump after pneumonectomy decreased necrosis and could have a protective effect on the bronchial stump.

Repeated lung lavage with extracorporeal membrane oxygenation treating severe acute respiratory distress syndrome due to nasogastric tube malposition for enternal nutrition: a case report.

Enternal nutritional support, a frequently applied technique for providing nutrition and energy, played a pivotal role in the treatment of high risk patients. However, severe complications induced by malposition of nasogastric tube caused great danger and even death to the patients. In this case report, we present a patient with severe acute respiratory distress syndrome (ARDS) induced by bronchopleural fistula (BPF) due to malposition of nasogastric tube. Repeated lung lavage combined with extracorporeal membrane oxygenation (ECMO) was performed after transferring to the ICU of our hospital. Finally, the patient recovered and discharged 7 days after admission.

Manejo nutricional en un paciente con fístula broncopleurocutánea / Nutritional management in a patient with fistula broncopleurocutanea

Paciente femenino de 31 años de edad, con antecedentes quirúrgicos de neumonectomia derecha por quiste hidatídico pulmonar, con cirugía a repetición por hemoptisis y fistula pleurocutánea hace aproximadamente 4 años, más secreciones purulentas por fistula, ingreso por consulta externa de medicina, durante la hospitalización paciente con resultado BK positivo pasa a neumología. La pérdida de peso desde la primera cirugía a la actualidad fue aproximadamente 19 Kg, con transfusiones sanguíneas a repetición aproximadamente 12. Fecha de nacimiento: 28 de diciembre de 1980. Edad: 31 años 2 meses. Sexo: femenino. Fecha de ingreso al hospital: 16/01/2012. Fecha de ingreso a servicio: 24/01/2012. Diagnóstico médico: fístula broncopleurocutánea infectada, tuberculosis pulmonar en tratamiento, empierna tuberculoso, desnutrición crónica y anemia severa.

A comparison of a cyanoacrylate [corrected] glue (Glubran) vs. fibrin sealant (Tisseel) in experimental models of partial pulmonary resection and lung incision [corrected] in rabbits.

INTRODUCTION: Bronchopleural fistulas (BPF) and air leaks (AL) present major complications after pulmonary resection. Various tissue sealants have been proposed for their prevention, e.g., fibrin sealant (FS) and cyanoacrylate glues (CA). Contrary to the safety record of FS, substantial side effects such as foreign body reaction and impaired tissue integration have been reported for CA. This study compares the sealing efficacy and biocompatibility as well as side effects of FS and CA in experimental partial pulmonary resection and lung incision in rabbits. METHODS: 26 New Zealand white rabbits (3 kg) were randomized to one of the three groups: partial pulmonary resection (A, acute model; n = 7 FS/ 7CA), lung incision [2 (B; n = 3 FS/ 3 CA)], and 14-day observation period (C; n = 3 FS/ 3 CA). In all groups (A, B, and C), FS was considered as control and CA as treatment. Surgery was carried out in general anaesthesia and mechanical ventilation. For partial lung resection a median thoracotomy was performed and the apex of the left median lobe was resected and the parenchymal surface covered with 0.09 ml of FS and CA. The thoracic cavity was filled with ringer solution after 5 minutes. The inspiratory minute volume (IMV) was increased by 0.02 l after every 4th inspiration. In groups B and C, a left lateral thoracotomy was performed in the 4th intercostal space and the left median lobe was incised with a scalpel. The incision was covered with 0.5 ml of FS or CA. At autopsy (B and C) the operation site was assessed macroscopically. Histology was performed in all animals. RESULTS: In terms of sealing purposes, FS and CA yielded comparable results in all groups. CA elicited a substantial increase of tissue temperature in the acute phase immediately after application (A). After 14 days CA residues were found, whereas FS was completely degraded. Histology showed a pronounced inflammatory response to CA but not to FS. We conclude that although the effect of airtight sealing was equally satisfying, our results emphasize that FS is preferable to CA for the prevention of BPF and AL due to superior biocompatibility and degradability. Longterm effects of CA residues on pulmonary tissue require further experimental testing.

Colobronchial fistula: an unusual complication after peritonectomy and hyperthermic intra-peritoneal chemotherapy (HIPEC).

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an innovative approach to peritoneal carcinomatosis. Due to the complexity of the combined procedure, high rates of potentially life-threatening complications have been reported. This is the first report of colobronchial fistula following CRS and HIPEC. CASE REPORT: A 70-year-old woman underwent CRS and HIPEC for papillary well-differentiated peritoneal mesothelioma. During the postoperative course, recurrent pneumonia occurred and bacteria of intestinal origin were isolated from expectorated sputum. Water-soluble contrast studies revealed direct communication between the left colon flexure and the bronchial tree. After appropriate medical and supportive therapies, the patient underwent resection of the splenic flexure and immediate anastomosis with complete recovery. CONCLUSION: Colobronchial fistula is a rare and potentially lethal complication of CRS and HIPEC. A suggestive clinical picture and contrast studies allow conclusive diagnosis to be made. Surgery is a safe and effective therapeutic option.

Colobronchial fistula: a late complication of childhood radiotherapy.

We present the case of a colobronchial fistula in a 41-year-old man who underwent radiotherapy for nephroblastoma as an infant. He attended for barium enema, which demonstrated a fistula between colon and bronchial tree. Following right hemicolectomy and pathological examination of the resected bowel, no active disease process was identified to explain the development of this rare fistula. Radiotherapy was deemed the most probable aetiology. We are unaware of this having been previously described.

[Intracavitary laser therapy and its effect on the kallikrein-kinin system of blood in children with pneumothorax].

The article presents the results of low-intensity laser application in complex treatment of 137 children with acute purulent destructive pneumonia complicated by pneumothorax with bronchial fistulas. A method of intracavitary laser therapy, developed in the clinic, allowed obliteration of bronchopleural fistulas without application of bronchial occlusion and other invasive techniques. Evaluation of the kallikrein-kinin system of blood revealed prominent reduction of kininogenesis in most (87%) patients upon admission (3 weeks after the onset of the disease), which is an important link of the pathogenesis of late stages of complicated acute purulent lung destruction in children. The study also demonstrated that low-intensity laser emission modulates pyoinflammatory process due to its effect on cell-mediated immunity, neutrophilic phagocytosis and the kallikrein-kinin system of blood. Intracavitary laser therapy is the treatment of choice in children with acute purulent destructive pneumonia complicated by pneumothorax with bronchial fistulas. Application of intracavitary laser therapy in complex therapy of complicated acute purulent lung destruction in children allowed discharge from the hospital 5 to 7 day earlier, and prevented lung inflammatory process chronization. None of the patients have died within last 10 years.

Successful therapy of severe pneumonia-associated ARDS after pneumonectomy with ECMO and steroids.

Pneumonia and acute respiratory distress syndrome are life-threatening complications after pneumonectomy carrying high mortality. Because pulmonary reserve is inadequately low, an effective therapeutic strategy is needed to treat hypoxia. Extracorporeal membrane oxygenation is a highly effective method to reverse hypoxia in patients with acute respiratory distress syndrome, but has only once been described in a patient with postpneumonectomy pulmonary edema. We report a case of successful extracorporeal membrane oxygenation therapy in a patient with pneumonia-associated acute respiratory distress syndrome after pneumonectomy. Methylprednisolone therapy caused a dramatic improvement of pulmonary and systemic organ function.

Exclusión endoprotésica de fístula aortobronquial con hemoptisis / Endoprosthetic exclusion of aortobronchial fistula with haemoptysis

Introducción. Describimos el uso de una técnica endovascular para la reparación de una fístula aortobronquial (FAB) originada en un pseudoaneurisma aórtico anastomótico secundario a múltiples cirugías aórticas para la reparación de un aneurisma de aorta torácica (AAT) descendente. Caso clínico. Varón de 51 años, ex fumador, bebedor con hepatopatía crónica y con limitación crónica al flujo aéreo, que presenta hemoptisis significativa por FAB secundaria a pseudoaneurisma tras múltiples intervenciones aórticas (reparación de AAT descendente, reparación de FAB secundaria y reparación de un pseudoaneurisma del arco aórtico, incluida la arteria subclavia izquierda, mediante la técnica de elephant trunk). El diagnóstico de FAB se realizó mediante tomografía computarizada (TC), angiorresonancia y angiografía de sustracción digital (ASD). El paciente se sometió a reparación endovascular mediante un abordaje ilíaco, debido al alto riesgo de una reparación convencional. Se colocó una endoprótesis vascular dentro de la prótesis de Dacron existente, y se cubrió el punto de fuga de la fístula. La ASD de comprobación en el quirófano mostró ausencia de fugas. Al paciente se le da de alta a los 5 días de la operación, sin complicaciones, con tratamiento antiagregante. En el control a los 2 años el paciente persiste clínicamente asintomático, y no se visualizan complicaciones en las TC de control. Conclusiones. Las FAB que se presentan a modo de hemoptisis graves son un proceso de evolución tórpida y fatal en muchos casos, de difícil manejo terapéutico, especialmente en aquellos casos con cirugía previa. El abordaje endovascular es una alternativa útil en estos casos, y disminuye la morbimortalidad de la cirugía abierta convencional (AU)

Self-expandable metallic tracheobronchial stent insertion and endobronchial electrocautery with flexible bronchoscopy: preliminary results at a cancer center.

BACKGROUND AND PURPOSE: Technical developments have facilitated the implantation of metallic stents and the use of endobronchial electrocautery through a flexible bronchoscope to reestablish airway patency in patients with airway obstruction. Their application in a 180-bed cancer center is described. PATIENTS AND METHODS: From August 2000 to December 2001, 12 patients (2 women, 10 men, mean age 53.3 yr) were treated by insertion of a self-expandable metallic tracheobronchial stent (SEMS). Malignant airway obstruction was the indication for the procedure in nine patients, two of whom underwent preliminary debulking using SEMS with or without electrocautery. Severe benign subglottic or tracheal stenosis was the indication for the procedure in two patients. The remaining patient with esophageal cancer received a double bronchial and esophageal SEMS due to involvement of a non-obstructing bronchoesophageal fistula. RESULTS: Symptomatic improvement was seen in all 12 patients. Removal was performed in one patient. Five patients died during follow-up with a median survival of 44 days, attributed to the advanced stage of recurrent disease. The median follow-up for the six surviving patients was 23 weeks. No major short-term complications of the procedure were found. CONCLUSIONS: SEMS is a promising technique for the management of airway obstruction. The stent is selected according to the specific clinical situation. Metallic and silicone stents are complementary. SEMS should not be used in patients who require only temporary relief of tracheobronchial obstruction.