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.

[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.

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.

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.

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.

Recurrent pneumonia from an ileobronchial fistula complicating Crohn's disease.

We report the case of a patient with Crohn's disease and recurrent pneumonia for over 3 years before the discovery of an occult ileopulmonary fistula and review five other cases in the literature. Patients often present with chronic cough productive of feculent sputum, pleuritic chest pain, and signs of pulmonary consolidation that fail to respond completely to antibiotic therapy. Mixed enteric flora is cultured from sputum and bronchial washings in most cases. Bronchoscopy findings range from chronic bronchial inflammation to feculent material in the airways. Barium enema is often diagnostic. Surgery and Crohn's-specific therapy are key components of curative therapy.

[Postoperative complications after radiochemotherapy or chemotherapy for bronchial cancers]. / Complications post opératoires après radiochimiothérapie ou chimiothérapie des cancers bronchiques.

OBJECTIVE: The purpose of this study was to evaluate the risk of lung cancer surgery, following induction chemo and/or radiotherapy. METHODS: This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA; n = 25), temporary functional impairment (2 stages IB and 2 stages IIIA [N2]; n = 4); doubtful resectability (stage IIIB [T4]; n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received 2 to 4 cycles of chemotherapy (average = 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (20 to 60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles). RESULTS: Exploratory thoracotomy was performed in 4 patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were 4 reoperations (6%): 3 for bronchial fistula and 1 for bleeding. Thirty five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%). CONCLUSION: Surgery for lung cancer after induction chemo and/or radiotherapy is associated with an increased risk. While the mortality seems "acceptable", the morbidity rate however is high.

[Effectiveness of hyperbaric oxygenation in the treatment of postresection bronchial fistulas]. / Znachenie giperbaricheskoi oksigenatsii v lechenii postrezek- tzionnykh bronkhial'nykh svishchei.

The article discusses the results of treatment of 84 patients with postresection tuberculous pyothorax and bronchial fistulas with hyperbaric oxygenation session (HBO) included in the complex of therapeutic measures. As a result, the bronchial fistulas closed in 30 (35.7%) patients, the diameter of the fistulas reduced markedly in 20 (24.3%) patients, the bronchial fistulas failed to close in 40% of cases. As the result of HBO therapy the count of red cells and lymphocytes increased, leukocytosis and eosinophilia reduced, the ESR diminished. The content of ALT transaminase, sugar, total protein and bilirubin decreased. The migration index for all immune antigens in the reaction of leukocyte migration inhibition and in the nitro blue tetrazolium test increased. HBO promoted the efficacy of radical operations by 29.4% as compared to that in the control group of the similar patients.

Hidatidosis pulmonar: experiencia en 594 pacientes y 830 quistes (1964-1990) / Pulmonary hydatidosis: experience in 594 patients and 830 cysts (1964-1990)

Se presenta la experiencia acumulada entre los años 1964 y 1990 representada por 594 pacientes portadores de 830 Quistes Hidatídicos Pulmonares (QHP), de los cuales 12,7 era asintomático y 3,8 por ciento presentaron hemoptisis masiva. El arco 5§ de Caprón tiene una sensibilidad sñolo del 53,6 por ciento siendo algo amyor en los quistes complicados, sin embargo la inmunoglobulina E total sérica es patológica en 85,5 por ciento de positividad y en 93 por ciento de los casos con QHP complicado. El 50 por ciento de los quistes se encuentran en lóbulos inferiores y en 24,6 por ciento de los casos existe una localización extrapulmonar asociada. Quistes únicos 80 por ciento de los casos. QHP múltiples 18,8 por ciento de los casos que 60,9 por ciento comprometen ambos pulmones. Al acto quirúrgico 45,6 por ciento de los QHP estaban complicados, además existen 43 casos (14,3 por ciento ) de tránsito hepatotorácico y 40 (13,3 por ciento ) de migraciones pleurales. Tratamiento quirúrgico: quistectomía en 536 QHP (60,4 por ciento ), resección pulmonar en 285 (32,1) (segmentectomía 10,4 por ciento , lobectomía 84,3 por ciento y neumonectomía 5,5 por ciento ) y otros procedimientos en 66 quistes (7,5 por ciento ). Entre las complicaciones (12,8 por ciento ) la fistula broncopleural se presenta en 3,5 por ciento de las resecciones efectuadas y la mortalidad es de 2,3 por ciento

Colobronchial fistula: a rare complication of Crohn's colitis.

A 29-yr-old white woman presented with chronic pneumonia in the left lower lobe and with left pleural effusion. She was known to have inflammatory bowel disease, but she was asymptomatic under maintenance treatment with 5-ASA. She received numerous antibiotic regimens according to susceptibility testing of microorganisms cultured from sputum and bronchial lavage and on an empiric basis was also given antituberculosis treatment, but there was no clinical improvement or change in the chest radiographic findings. Sputum was repeatedly examined and yielded, among other organisms, Clostridium inocuum, Enterobacter, Klebsiella pneumoniae, Proteus mirabilis, and Staphylococcus aureus. On one microscopic examination of sputum, the presence of feculent material was suspected. A subsequent gastrografin enema revealed a cologastric and colobronchial fistula between the splenic flexture of the colon and the greater curve of the stomach and the bronchial system. Segmental resection of the colon and resection of the lower lobe of the left lung were performed. Histologic findings of the resected colon were consistent with Crohn's disease. After a long period of postoperative recovery, the patient returned to good general health and well-being. To our knowledge, a colobronchial fistula caused by Crohn's colitis has not been previously reported.

[Esophago-bronchial fistula in adults]. / Les fistules oeso-bronchiques de l'adulte.

The authors report five cases of benign oesophago-bronchial fistula in adults. These chronic bronchitic patients presented with recurrent episodes of secondary lung infections (or even haemoptysis). Questioning of the patients revealed a history of coughing when swallowing liquids in three cases. Two women concealed this symptom, which was only revealed retrospectively. The fistula was detected by upper GI series in three cases and by oesophageal fibroscopy in one case. In the remaining case, it was discovered at operating for severe haemoptysis. In four of the five cases, the fistula was situated on the right and was of post-tuberculous origin. In one case of post-traumatic fistula, it involved the left main bronchus. All of the patients were operated: a resection-suture of the fistula was performed via the oesophageal approach and, via the bronchial approach, simple suture of the fistula was possible in two cases, while resection of the destroyed pulmonary parenchyma was necessary in three cases (one right lower lobectomy, two bilobectomies). Demonstration of the oesophago-bronchial fistula, definition of its site and assessment of the condition of the pulmonary parenchyma are essential steps to be performed prior to surgery.