Management of Tumor- and Nontumor-related Aorto-esophageal and Aorto-bronchial Fistulas.

BACKGROUND: This study aims to review and compare the clinical presentation, management, and outcome in patients with tumor-related (TR) and nontumor-related (NTR) aorto-esophageal fistula (AEF) and aorto-bronchial fistula (ABF) with particular focus on the thoracic endovascular aortic repair. METHODS: We retrospectively reviewed a series of 16 consecutive patients with TR (n = 8) and NTR (n = 8), ABF (n = 6), and AEF (n = 10) admitted to our hospital from 2011 to 2019. RESULTS: The median age was 62 years (range 46-81), with 11 men. The most common predisposing factor was esophageal or gastric cardia cancer (n = 6), followed by open repair of the thoracic aorta (n = 5). Endoluminal vacuum therapy (Endo-SPONGE®) accounted for 3 cases of AEFs. Thoracic endovascular aortic repair (TEVAR) was applied in 13 patients (4 with ABFs and 9 with AEFs). The primary technical success of the TEVARs was 100%. One patient (8%) was complicated with postoperative middle cerebral artery syndrome and left-sided hemiparesis. The respective in-hospital, 6-month, and 1-year mortality rates were 0% (n = 0), 25% (n = 2), and 25% (n = 2) for the NTR group and 63% (n = 5), 88% (n = 7), and 100% (n = 8) for the TR group. After a mean period of 13 months, 5 (31%) patients were still alive, and one patient lost to follow-up after 11 months. The survivors (n = 5) had all nontumor-related ABF. Progression of underlying cancer and hemodynamic shock were the most common causes of death. CONCLUSIONS: TEVAR represents a reliable option in the treatment of NTR ABFs. In the cases of TR fistulas and NTR AEFs, TEVAR should be applied more selectively. The associated mortality remains very high.

Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula.

INTRODUCTION: This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula. MATERIALS AND METHODS: The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated. RESULTS: The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence. CONCLUSIONS: The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Clinical outcomes of metallic Y-shaped covered stents for bronchopleural fistula around upper carina after lobectomy.

BACKGROUND: Few studies have reported the placement of metallic Y-shaped covered stents (Y stents) for bronchopleural fistula around the upper carina. METHODS: Eighteen patients were treated with Y stents insertion under the guidance of fluoroscopy. All covered stents were custom-designed and inserted to fit the upper carina anatomy. Clinical data and medical imaging data were analyzed retrospectively. RESULTS: The stents were implanted successfully for the first time in 17 patients, and one patient needed a second attempt due to stent migration during withdrawal of the guide wires. In total, 19 small Y single-plugged stents were inserted in the upper carina and 5 large Y stents additionally in the main carina. Nineteen complications were observed in 14 patients, including 4 major complications. Stents were successfully removed in 12 patients due to complications or cure efficacy, for a median duration in place of 89.5 days. One patient lost follow-up. Nine patients were cured, and three had clinical improvement. One patient died of ventricular fibrillation the second day after the procedure and 4 patients died of tumors 7.8 to 91.7 months after stent placement. The 1-, 3-, and 5-year survival rates were 87.5, 80.8 and 80.8%, respectively. CONCLUSIONS: Metallic Y stent placement is technically feasible, effective and safe for bronchopleural fistula disease around the upper carina.

Primary and secondary arterial fistulas during chronic Q fever.

OBJECTIVE: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.

Role of Endovascular Aortic Repair in the Treatment of Infected Aortic Aneurysms Complicated by Aortoenteric or Aortobronchial Fistulae.

BACKGROUND: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). METHODS: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. RESULTS: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). CONCLUSION: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis.

PURPOSE: Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings. METHODS: A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis. RESULTS: The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47). CONCLUSIONS: The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Incidence and Management of Post-Lobectomy and Pneumonectomy Bronchopleural Fistula.

INTRODUCTION: Bronchopleural fistula is a rare but potentially fatal complication of pulmonary resections and proper management is essential for its resolution. In this study, we analyzed the incidence of fistula after pulmonary resection and reported data about endoscopic and conservative treatments of this complication. METHODS: From January 2003 to December 2013, 835 patients underwent anatomic lung resections: 786 (94.1 %) had a lobectomy and 49 (5.9 %) a pneumonectomy. Bronchopleural fistula was suspected by clinical signs and confirmed by endoscopic visualization. RESULTS: Eighteen patients (2.2 %) developed a bronchopleural fistula, 11 in lobectomy group (1.4 %) and 7 in pneumonectomy group (14.3 %). The fistula size ranged between <1 mm and 6 mm and mean time of fistula onset was 33.9 ± 54.9 days after surgery. Of 18 patients who developed fistula, one died due to acute respiratory failure and another one was reoperated and then died to causes unrelated to the treatment. All the remaining 16 patients were treated with a conservative therapy that consisted in keeping or replacing a drainage chest tube. Nine of them underwent also endoscopic closure of the fistula using biological or synthetic glues. The mean period of time elapsed for the resolution of this complication was shorter with combined (conservative + endoscopic) than with conservative treatment alone (15.4 ± 13.2 vs. 25.8 ± 13.2 days, respectively), but without significant difference between the two methods (p: 0.299). CONCLUSION: Endoscopic therapy, associated with a conservative treatment, is a safe and useful option in the management of the postoperative bronchopleural fistula.

Factors affecting major morbidity after video-assisted thoracic surgery for lung cancer.

BACKGROUND: Video-assisted thoracic surgery (VATS) has been widely applied in the treatment of lung cancer. However, few studies have focused on the clinical factors predicting the major postoperative complications. METHODS: Clinical data from 525 patients who underwent resection of primary lung cancer with VATS from January 2007-August 2011 were retrospectively analyzed. Risk factors related to major postoperative complications were assessed by univariate and multivariate analyses with logistic regression. RESULTS: Major complications occurred in 36 (6.86%) patients, of which seven died (1.33%) within 30 d, postoperatively. Major complications included respiratory failure, hemothorax, myocardial infarction, heart failure, bronchial fistula, cerebral infarction, and pulmonary embolism. Univariate and multivariate logistic regression analyses demonstrated that age >70 y (odds ratio [OR], 2.105; 95% confidence interval [CI] 1.205-3.865), forced expiratory volume during the first second expressed as a percentage of predicted ≤70% (OR, 2.106; 95% CI 1.147-3.982) combined with coronary heart disease (OR, 2.257; 95% CI 1.209-4.123) were independent prognostic factors for major complications. CONCLUSIONS: Age >70 and forced expiratory volume during the first second expressed as a percentage of predicted ≤70% combined with coronary heart disease are independent prognostic factors for postoperative major complications. Patients in these groups should undergo careful preoperative evaluation and perioperative management.

Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study.

Malignant airway-oesophageal fistulas (AEF) are a serious complication of advance oesophageal or lung cancer. The aim of this study was to assess the quality of life before and after stent insertion, and to examine the role of treatment and location of AEF as factors influencing survival in AEF patients managed with airway and/or oesophageal stent insertion. 112 patients with AEF were included prospectively. 83 (74%) patients had advanced lung cancer and 29 (26%) patients had oesophageal cancers. Airway stents were inserted in 65 (58%) patients, oesophageal stents in 37 (33%) patients, and both airway and oesophageal stents in 10 (9%) patients. Seven (6%) patients developed respiratory failure and required transient ventilator support in the intensive care unit (four patients with airway stenting, two patients with double stents and one patient in the oesophageal stenting group). None of the patients developed stent migration or needed stent repositioning. Overall, mean survival was 236.6 days (airway stent 219.1 days, oesophageal stent 262.8 days and combined airway-oesophageal stent 252.9 days). Backward, stepwise regression revealed the site of stent placement (airway and/or oesophagus; p < 0.028), exact location of the fistula in airway (p = 0.011) and additional treatment with chemotherapy and/or radiation (p < 0.001) as independent risk factors predicting increased survival. The mean quality of life score (QoL) was 81 prior to stent insertion and 72 post-stent insertion (p < 0.001). Airway and/or oesophageal stent insertion provides an effective approach to improve the QoL in patients with malignant AEF.

Endovascular treatment of aortoesophageal and aortobronchial fistulae.

BACKGROUND: Even when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys. METHODS: A voluntary national survey was conducted among Italian universities and hospital centers with an endovascular program. Questionnaires were distributed by e-mail to participating centers and aimed to evaluate the results of endovascular repair of established AEF or ABF. RESULTS: Seventeen centers agreed to participate and provided data on their patients. Between 1998 and 2008, a total of 1138 patients were treated with TEVAR. In 25 patients (2.2%), the indication to treatment was an AEF and/or an ABF. In 10 of these cases (40%), an associated open surgical procedure was also performed. Thirty-day mortality rate of AEF/ABF endovascular repair was 28% (7 cases). No cases of paraplegia or stroke were observed. Mean follow-up was 22.6 months (range, 1-62). Actuarial survival at 2 years was 55%. Among the 18 initial survivors, five patients (28%) underwent reintervention due to late TEVAR failure. CONCLUSIONS: Stent grafting for AEF and ABF represents a viable option in emergent and urgent settings. However, further esophageal or bronchial repair is necessary in most cases. Despite less invasive attempts, mortality associated with these conditions remains very high.

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.

Acute management of aortobronchial and aortoesophageal fistulas using thoracic endovascular aortic repair.

BACKGROUND: Aortobronchial fistula (ABF) and aortoesophageal fistula (AEF) are rare but lethal if untreated; open thoracic surgery is associated with high operative mortality and morbidity. In this case series, we sought to investigate outcomes of thoracic endovascular aortic repair (TEVAR) for emergency cases of ABF and AEF. METHODS: We retrospectively reviewed all patients with AEF and ABF undergoing TEVAR in three European teaching hospitals between 2000 and January 2009. Eleven patients were identified including 6 patients with ABF, 4 patients with AEF, and 1 patient with a combined ABF and AEF. In-hospital outcomes and follow-up after TEVAR were evaluated. RESULTS: Median age was 63 years (interquartile range, 31); 8 were male. Ten patients presented with hemoptysis or hematemesis; 4 developed hemorrhagic shock. All patients underwent immediate TEVAR, and 3 AEF patients required additional esophageal surgery. Five patients died (45%), including 3 patients with AEF, 1 patient with ABF, and 1 patient with a combined ABF and AEF, after a median duration of 22 days (interquartile range, 51 days). The patient with AEF that survived had received early esophageal reconstruction. Causes of death were: sepsis (n = 2), acute respiratory distress syndrome (ARDS) (n = 1), thoracic infections (n = 1), and aortic rupture (n = 1). Median follow-up of surviving patients was 45 months (interquartile range, 45 months). Six additional vascular interventions were performed in 3 survivors. CONCLUSION: TEVAR does prevent immediate exsanguination in patients admitted with AEF and ABF, but after initial deployment of the endograft and control of the hemodynamic status, most patients, in particular those with AEF, are at risk for infectious complications. Early esophageal repair after TEVAR appears to improve the survival in case of AEF. Therefore, TEVAR may serve as a bridge to surgery in emergency cases of AEF with subsequent definitive open operative repair of the esophageal defect as soon as possible. In patients with ABF, additional open surgery may not be necessary after the endovascular procedure.

Thoracic endovascular aortic repair of aortobronchial fistulas.

BACKGROUND: Thoracic endovascular aortic repair of aortobronchial fistulas is an emerging treatment modality for this highly lethal condition. The feasibility and long-term durability of this form of intervention are largely unknown. METHODS: The records of five patients who received endografts to treat aortobronchial fistulas at our institution were reviewed. A literature review was also conducted using MEDLINE to identify reports detailing outcomes of patients undergoing thoracic endovascular aortic repair for this condition. Primary outcome end points included intraoperative mortality, 30-day mortality, and aortobronchial fistula recurrence. RESULTS: For the five patients treated at our institution, technical success was 100%. In follow-up, aortobronchial fistulas recurred in two patients, resulting in one patient death and one endograft explantation. We identified 32 reports that met inclusion for our final review. Inclusive of the five patients treated at out institution, 67 patients with reported outcomes comprised the overall analysis. Most patients (55%) had previously undergone thoracic aortic surgery. Commercially manufactured thoracic endografts were used in 75% of patients. No intraoperative mortality was reported, and the 30-day mortality was 1.5%. Aortobronchial fistula recurred after endovascular repair in six patients (9%) through a mean follow-up of 21.5 months. Three cases of recurrent aortobronchial fistula resulted in patient death. CONCLUSIONS: Thoracic endovascular aortic repair of aortobronchial fistulas appears to a viable alternative to conventional open repair with excellent short-term results. Recurrence of the aortobronchial fistula after endovascular repair is a potential complication necessitating long-term surveillance. Individual risk assessment is needed to determine if endovascular repair should be used as bridge therapy or as a definitive repair.

Stent-graft repair of aortobronchial fistula: a review.

PURPOSE: To evaluate the role of aortic stent-graft implantation in managing aortobronchial fistula (ABF). METHODS: A search of the Medline, EMBASE, and Cochrane databases for studies reporting on ABF treated with stent-grafts from 1996 to 2008 retrieved 44 articles with data on 82 ABFs. Most (57 ABFs) were published in 30 case reports; the others were retrieved from 14 acute aortic series. RESULTS: In the perioperative period, 4 (4.9%) deaths (3 from hemorrhage) were reported, but no paraplegia/stroke. Local graft-related complications were more common, including arm ischemia (n = 4) and iliac ruptures (n = 3). Long-term data were available for only a few studies. Recurrent hemorrhage (14%) occurred from 2 weeks to 9 years after repair. Reinterventions to manage recurrences were generally based on redo endografting. CONCLUSION: A contaminated field and the emergency setting make stent-graft repair of ABFs challenging. After successful stent-graft deployment, the risks of recurrence and mortality are concerning. One can infer from the data that endografting might be a reasonable temporary bridge solution, but potentially unstable in the long term. Open repair likely will remain indicated once the patient has been stabilized physiologically with emergent stent-graft repair.

Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas.

PURPOSE: To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF). METHODS: The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF. RESULTS: Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018). CONCLUSION: TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.

Comparative study of different treatments for malignant tracheoesophageal/bronchoesophageal fistulae.

The aim of this study is to compare the survival time and quality of life (QOL) of patients who have received different treatment for tracheoesophageal/bronchoesophageal fistula. Between January 2003 and December 2007, 35 patients with malignant tracheoesophageal/bronchoesophageal fistula were recorded as the control group, gastrostomy group, and stenting group, respectively, according to the treatments they chose. Two weeks after the treatment, European Organization for Research and Treatment of Cancer Quality of Life Core 30 Questionnaire (QLQ-C30), Quality of Life Questionnaire-esophageal module (QLQ-OES18), and a respiratory symptom-related QOL index are employed to assess QOL of these patients. There is no significant difference in survival time and constituent ratio of death reason among groups. Except for eight patients who died within 2 weeks after the treatment, all other 27 patients returned back the questionnaires. As compared to the control group, patients in the gastrostomy group gained a low score in emotional function and financial situation, while patients in the stenting group had lower scores in financial problems and seven respiratory and eating-related symptoms. In contrast with the gastrostomy group, patients in stenting group had higher scores in emotional and social functions, and lower scores in six respiratory and eating-related symptoms. With patients' QOL considered, the self-expandable coated stenting should be the first choice of therapy for malignant tracheoesophageal/bronchoesophageal fistula, whereas gastrostomy should be kept from use.

Risk assessments for broncho-pleural fistula and respiratory failure after lung cancer surgery by National Clinical Database Japan.

BACKGROUND: Broncho-pleural fistula (BPF) and respiratory failure (RF) are life-threatening complications after lung cancer surgery and can result in long-term hospitalization and decreased quality of life. Risk assessments for BPF and RF in addition to mortality and major morbidities are indispensable in surgical decision-making and perioperative care. METHODS: The characteristics and operative data of 80,095 patients who had undergone lung cancer surgery were derived from the 2014 and 2015 National Clinical Database (NCD) of Japan datasets. After excluding 1501 patients, risk models were developed from these data and validated by another dataset for 42,352 patients derived from the 2016 NCD dataset. Receiver operating characteristic curves were generated for postoperative BPF and RF development. The concordance-index was used to assess the discriminatory ability and validity of the model. RESULTS: BPF and RF occurred in 259 (0.3%) and 420 patients (0.5%), respectively, in the model development dataset and in 129 (0.3%) and 198 patients (0.5%), respectively, in the model validation dataset. Characteristic variables including types of surgery and comorbidities were identified as risk factors for BPF and RF, respectively. The concordance indexes of assessments for BPF and RF were 0.847 (p < 0.001) and 0.848 (p < 0.001), respectively, for the development dataset and 0.850 (p < 0.001) and 0.844 (p < 0.001), respectively, for the validation dataset. CONCLUSIONS: These models are satisfactory for predicting BPF and RF after lung cancer surgery in Japan and could guide preoperative assessment and optimal measures for preventing BPF and RF.

Complex Tracheocarinal Reconstructions Using Extrathoracic Muscle Flaps as Airway Substitutes.

BACKGROUND: Extrathoracic muscle flaps can be used as airway substitutes for the closure of complex bronchopleural or tracheoesophageal fistulas or in the context of tracheocarinal reconstructions after resection for centrally localized tumors in order to alleviate excess anastomotic tension. METHODS: Evaluation of all patients undergoing tracheocarinal reconstructions with extrathoracic muscle flap patches as airway substitutes in our institution from 1996 to 2016. RESULTS: A total of 73 patients underwent tracheocarinal reconstructions using extrathoracic muscle flap patches as airway substitutes for the closure of bronchopleural fistulas (n = 17) and complex tracheoesophageal fistulas (n = 7), or in the context of airway reconstructions after carinal resections in combination with pneumonectomy/sleeve lobectomy for centrally localized lung tumors (n = 36) and noncircumferential tracheal resections for tracheal disease processes (n = 14). The size of airway defects replaced by muscle patches ranged from 2 × 2 to 8 × 4 cm and was at most 40% of the airway circumference. The postoperative 90-day mortality was 8.2% and was only observed after right-sided pneumonectomy. Complications at the airway reconstruction site occurred in 8 patients (10%): 4 airway dehiscence (5%) with uneventful healing after reoperation (n = 2) or temporary stenting (n = 2) and 4 airway stenosis (5%) that required repeated bronchoscopy and stenting. Overall, 63 of 67 surviving patients (94%) revealed intact airways without further bronchoscopic interventions or tracheal appliance during follow-up. CONCLUSIONS: Extrathoracic muscle flaps used as airway substitutes are an interesting and sometimes life-saving option to close difficult tracheocarinal airway defects or to reduce anastomotic tension in the context of complex tracheocarinal surgeries.

Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks.

BACKGROUND: To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. METHODS: We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. RESULTS: In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. CONCLUSION: Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy.

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.