Combination of transbronchoscopic oxygen insufflation and a digital chest drainage system in endobronchial occlusion: a hybrid technique for localization of fistula in intractable pneumothorax.

BACKGROUND: The management of intractable secondary pneumothorax poses a considerable challenge as it is often not indicated for surgery owing to the presence of underlying disease and poor general condition. While endobronchial occlusion has been employed as a non-surgical treatment for intractable secondary pneumothorax, its effectiveness is limited by the difficulty of locating the bronchus leading to the fistula using conventional techniques. This report details a case treated with endobronchial occlusion where the combined use of transbronchoscopic oxygen insufflation and a digital chest drainage system enabled location of the bronchus responsible for a prolonged air leak, leading to the successful treatment of intractable secondary pneumothorax. CASE PRESENTATION: An 83-year-old male, previously diagnosed with chronic hypersensitivity pneumonitis and treated with long-term oxygen therapy and oral corticosteroid, was admitted due to a pneumothorax emergency. Owing to a prolonged air leak after thoracic drainage, the patient was deemed at risk of developing an intractable secondary pneumothorax. Due to his poor respiratory condition, endobronchial occlusion with silicone spigots was performed instead of surgery. The location of the bronchus leading to the fistula was unclear on CT imaging. When the bronchoscope was wedged into each subsegmental bronchus and low-flow oxygen was insufflated, a digital chest drainage system detected a significant increase of the air leak only in B5a and B5b, thus identifying the specific location of the bronchus leading to the fistula. With the occlusion of those bronchi using silicone spigots, the air leakage decreased from 200 mL/min to 20 mL/min, and the addition of an autologous blood patch enabled successful removal of the drainage tube. CONCLUSION: The combination of transbronchoscopic oxygen insufflation with a digital chest drainage system can enhance the therapeutic efficacy of endobronchial occlusion by addressing the problems encountered in conventional techniques, where the ability to identify the leaking bronchus is dependent on factors such as the amount of escaping air and the location of the fistula.

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.

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.

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.

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.

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.

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.

Tratamiento definitivo de Fistula Broncopleural de difícil manejo con terapia de presión negativa / Definitive treatment of difficult-to-manage Bronchopleural Fistula with negative pressure therapy

Las fistulas bronquiales ocurren como complicaciones de múltiples enfermedades del tórax y procedimientos. El tratamiento de las mismas después de una lobectomía es complicado y requieren largas hospitalizaciones. La Terapia de presión negativa (TPN) ha demostrado beneficios y evidencias en el manejo de las fistulas broncopleurales. Masculino de 25 años de edad, con antecedente de tuberculosis con tratamiento completo, posterior presentó neumonía necrotizante en lóbulo superior derecho y empiema, realizando lobectomía complicándose con fistula broncopleural e infecciones a repetición, requiriendo ventana pulmonar y múltiples internaciones con diferentes tratamientos hasta ser manejada con el sistema presión negativa (TPN) con mejoría marcada. (AU)

Bronchial fistulas occur as complications of multiple chest diseases and procedures. Their treatment after a lobectomy is complicated and requires long hospital stays. Negative pressure therapy (NPT) has shown benefits and evidence in the management of bronchopleural fistulas. A 25-year-old male, with a history of tuberculosis with complete treatment, subsequently presented necrotizing pneumonia in the right upper lobe and empyema, performing lobectomy, complicating with bronchopleural fistula and recurrent infections, requiring a pulmonary window and multiple hospitalizations with different treatments until managed with the negative pressure system (NPT) with marked improvement. (AU)

Treatment of peripheral bronchopleural fistula with interventional negative pressure drainage.

OBJECTIVES: Bronchopleural fistula is a serious complication of pneumonectomy and lobectomy and results in a reduction in the quality of life of patients. This study aimed to evaluate the efficacy and safety of percutaneous drainage tube placement with continuous negative pressure drainage for the treatment of peripheral bronchopleural fistula. METHODS: Data of 16 patients with peripheral bronchopleural fistula were retrospectively analyzed. A percutaneous thoracic drainage tube was placed under fluoroscopy and connected with a negative pressure suction device. The drainage tube was removed when the residual cavity disappeared on computed tomography. RESULTS: All 16 patients underwent lobectomy, including 11 patients with lung cancer (68.8%), 4 patients with pulmonary infection (25.0%), and 1 patient with hemoptysis (6.3%). All patients underwent successful drainage tube placement on the first attempt with a technical success rate of 100%. No serious complications occurred during or after the procedure. The drainage tubes were adjusted 3.25 ± 2.24 times (range: 1-8 times). A total of 30 drainage tubes were used (average per patient, 1.88 ± 1.36 tubes). The cure time of 16 patients was 114.94 ± 101.08 days (range, 30-354 days). The median drainage tube indwelling duration was 87 days, and the 75th percentile was 117 days. CONCLUSION: Interventional percutaneous thoracic drainage tube placement with continuous negative pressure drainage is an effective, safe, and feasible method for the treatment of peripheral bronchopleural fistula.

Percutaneous Treatments for Persistent Bronchopleural and Alveolar-Pleural Fistulae.

Percutaneous glue embolization was investigated as a treatment for bronchopleural fistulae (BPFs) and alveolar-pleural fistulae (APFs) associated with persistent air leak. Seven consecutive patients with persistent air leak were treated with percutaneous glue embolization of the BPF/APF from both iatrogenic and spontaneous causes. Treatment was performed using direct n-butyl cyanoacrylate (nBCA) glue injection for discrete, visible fistulae (n = 4), fibrin glue spray for suspected tiny multifocal leaks (n = 2), or both (n = 1). The number of treatments required per patient was 1 (n = 3), 2 (n = 3), or 3 (n = 1). Technical success was achieved in all cases. Follow-up showed resolution of all air leaks, with mean chest tube removal at 7.1 days after the embolization. The follow-up duration ranged from 2 to 47 months. No significant procedure-related morbidity, mortality, or recurrence was encountered. Percutaneous treatment for persistent BPFs and APFs showed good efficacy in this small case series and warrants further investigation.

Tubercular Bronchoesophageal Fistula in an Adolescent Girl.

Bronchoesophageal fistula is a rare complication of Mycobacterium tuberculosis in children. An adolescent girl who was diagnosed of tubercular mediastinal lymphadenopathy with associated bronchoesophageal fistula at presentation, is reported here. This 16-y-old girl presented with high-grade fever, cough, decreased appetite, weight loss for 3 mo, and breathlessness for 10 d. Chest radiograph revealed hilar lymphadenopathy with bilateral pleural effusion. GA GeneXpert was positive for mycobacterium and rifampicin sensitivity. Despite antitubercular therapy cough persisted and there was a history of dry cough with food intake, especially more on liquids. Bronchoscopy and CECT chest confirmed bronchoesophageal fistula in the right main bronchus just below the carina. Child continued on tube feeding and antitubercular therapy. After completion of intensive phase, child improved with resolution of clinical symptoms and scarring of tract on repeat bronchoscopy. It is concluded that in children with combination of mediastinal lymphadenopathy and persistent cough following intake of food needs careful evaluation for trachea/bronchoesophageal fistula.

Endoluminal Vacuum Therapy for Definitive Management of an Esophagobronchial Fistula.

PURPOSE: Endoluminal vacuum (EVAC) therapy has gained popularity as a minimally invasive option for contained esophageal leaks. EVAC therapy may be useful for esophagogastric anastomotic leak fistulizing to the airway. DESCRIPTION: This report describes EVAC therapy of an esophagobronchial fistula with video depicting the procedure, including technical tips. Video and photographic evidence of progression and ultimate resolution is included. EVALUATION: Sponge exchanges were completed every 3 to 4 days. EVAC therapy was administered through a transnasal approach. In the presented case, a total of 11 exchanges over 6 weeks were required. EVAC sponge placement was transitioned from intracavitary to endoluminal for the final 4 treatments. All but 4 exchanges were able to be completed at the bedside in a monitored setting with sedation. CONCLUSIONS: An esophageal leak that has fistulized to a main airway is a rare and challenging clinical problem. Definitive EVAC therapy for esophageal anastomotic leak with esophagobronchial fistula is a feasible option in selected cases.

Percutaneous Treatment of Bronchobiliary Fistula: Report of a Successful Transhepatic Embolization and a Decision-Making Strategy Driven by Systematic Literature Review.

Bronchobiliary fistula is a rare condition characterized by bile leaking into the bronchial tree causing biliptysis. It may arise from liver infection or as a consequence of resection and thermal ablation of cancer. Currently, there is no consensus about the treatment strategy. Surgery is considered the main therapy by most authors. However, this systematic literature review shows that the success rate of percutaneous treatments may reach 75%. Adding to such evidence, we also report the case of a woman affected by iatrogenic bronchobiliary fistula secondary to liver thermal ablation, successfully treated with percutaneous drainage plus embolization. Summarizing these results, we encourage the percutaneous management of bronchobiliary fistula by providing a 3-step decision-making algorithm, aimed at reducing the need for major surgery.