Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center.

Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.

Lemierre syndrome complicated by bronchopleural fistula.

We present a 19-year-old woman, a case of Lemierre syndrome, who presented with fever, sore throat, and left shoulder pain. Imaging revealed a thrombus in the right internal jugular vein, multiple nodular shadows below both pleura with some cavitations, right lung necrotizing pneumonia, pyothorax, abscess in the infraspinatus muscle, and multiloculated fluid collections in the left hip joint. After inserting a chest tube and administering urokinase for the pyothorax, a bronchopleural fistula was suspected. The fistula was identified based on clinical symptoms and computed tomography scan findings. If a bronchopleural fistula is present, thoracic lavage should not be performed as it may cause complications such as contralateral pneumonia due to reflux.

Right basal bronchial fistula due to amebic infection: a case report.

BACKGROUND: Pleuropulmonary amebiasis is the second most common form of extraintestinal invasive amebiasis, but cases that include bronchopleural fistula are rare. CASE PRESENTATION: A 43-year-old male was referred to our hospital for liver abscess, right pleural effusion, and body weight loss. He was diagnosed with a bronchopleural fistula caused by invasive pleuropulmonary amebiasis and human immunodeficiency virus (HIV) infection. After initial medical treatment for HIV infection and invasive amebiasis, he underwent pulmonary resection of the invaded lobe. Intraoperative inspection revealed a fistula of the right basal bronchus in the perforated lung abscess cavity, but the diaphragm was intact. The patient was discharged on postoperative day 3 and was in good condition at the 1-year follow-up. CONCLUSIONS: Clinicians should be aware that pleuropulmonary amebiasis can cause a bronchopleural fistula although it is very rare.

HFOV in inhalational injury associated ARDS with broncho-pleural fistula - An old friend to the rescue: Case report.

Introduction: Patients with acute respiratory distress syndrome (ARDS) on mechanical ventilation often require high inspiratory pressure and positive end-expiratory pressure (PEEP). However, effective ventilation becomes difficult in cases where a large air leak develops in patients. The management of such a case requires improvisation and the adoption of special ventilation strategies. Case and outcomes: We present a case study of a burn patient with airway involvement, developing ARDS and who developed a bronchopleural fistula (BPF) leading to failure of conventional ventilation. He was managed successfully with high-frequency oscillatory ventilation (HFOV) and finally discharged. Conclusion: HFOV is a feasible option for ventilating patients with BPF when conventional ventilation fails. At a time when HFOV has largely been relegated to obsolescence, we hope to re-emphasize its relevance under particular circumstances.

[Staged reconstructive surgery for bronchopleural fistula]. / Etapnaya rekonstruktivno-vosstanovitel'naya khirurgiya pri bronkhoplevral'nom svishche.

Treatment of bronchopleural fistula after pneumonectomy is still an urgent problem for thoracic surgeons. Transsternal bronchial stump occlusion should be preferable if possible. However, this is not enough for curing in some cases. We present a patient with concomitant cancer and tuberculosis of lungs whose postoperative period was complicated by bronchial stump failure. Preoperative diagnostic data are presented. We describe the indications for surgeries and main surgical stages. Some interventions including reconstructive surgery using a muscle flap led to recovery. Latissimus dorsi muscle flap on thoracodorsal artery is the best option for reconstructive surgical treatment in patients with extensive chest wall defects and thoracostomy.

Stemming the Leak: A Novel Treatment for Gastro-Bronchial Fistula.

Laparoscopic sleeve gastrectomy (LSG) is a commonly used procedure in bariatric patients that often has excellent results. Despite its advantages, LSG is burdened by specific intraoperative and postoperative early and late complications. One of the life-threatening complications is gastric fistula, usually treated with a multidisciplinary surgical-endoscopic approach. In case of failure of the latter, alternative nonoperative techniques such as the use of autologous stem cells truly represents an innovative possibility, with only few cases described in literature. Here, we report the case of a 25-year-old man with post-LSG broncho-gastric fistula treated with application of autologous stem cells after the failure of the conventional surgical/endoscopic approach.

Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review.

BACKGROUND: The development of esophago-bronchial fistula after esophagectomy and reconstruction using a posterior mediastinal gastric tube remains a rare complication associated with a high rate of mortality. CASE PRESENTATION: A 63-year-old man with esophageal cancer underwent a thoracoscopic esophagectomy with two-field lymph node dissection and reconstruction via a gastric tube through the posterior mediastinal route. Postoperatively, the patient developed extensive pyothorax in the right lung due to port site bleeding and hematoma infection. Four months after surgery, he developed an esophago-left bronchial fistula due to ischemia of the cervical esophagus and severe reflux esophagitis at the site of the anastomosis. Because of respiratory failure due to the esophago-bronchial fistula and the history of extensive right pyothorax, right thoracotomy and left one-lung ventilation were thought to be impossible, so we decided to perform the surgery in three-step systematically. First, we inserted a decompression catheter and feeding tube into the gastric tube as a gastrostomy and expected neovascularization to develop from the wall of the gastric tube through the anastomosis after this procedure. Second, 14 months after esophagectomy, we constructed an esophagostomy after confirming blood flow in the distal side of the cervical esophagus via gastric tube using intraoperative indocyanine green-guided blood flow evaluation. In the final step, we closed the esophagostomy and performed a cervical esophago-jejunal anastomosis to restore esophageal continuity using a pedicle jejunum in a Roux-en-Y anastomosis via a subcutaneous route. CONCLUSION: This three-step operation can be an effective procedure for patients with esophago-left bronchial fistula after esophagectomy, especially those with respiratory failure and difficulty in undergoing right thoracotomy with left one-lung ventilation.

[Surgical treatment of bronchopleural complications after lung resection and pleurectomy in patients with tuberculosis]. / Khirurgicheskoe lechenie bronkhoplevral'nykh oslozhnenii posle rezektsii legkogo i plevrektomii u bol'nykh tuberkulezom.

OBJECTIVE: To increase an efficiency of surgical treatment of bronchopleural complications after lung resections and pleurectomies through the development of modern indications, treatment strategies, techniques and postoperative management. MATERIAL AND METHODS: We analyzed data in 252 patients with bronchopleural complications after lung resections and pleurectomies. The study included patients who underwent treatment at the Central Research Institute of Tuberculosis for the period 2004-2010, Clinical Hospital of Phthisiopulmonology of the Sechenov First Moscow State Medical University for the period 2011-2017 and Thoracic Center of the Republic of Ingushetia for the period 2015-2019. The study included patients with postoperative pleural empyema divided into two groups: group I - 138 patients with empyema and bronchial fistula; group II - 114 patients with empyema and no bronchial fistula. In the 1st group, 1 patient had bronchial and esophageal fistulas. RESULTS: At discharge, empyema and bronchial fistula were eliminated in 245 (97.2%) patients of both groups. Overall in-hospital mortality was 1.6% (4 cases). Two (1.4%) patients died within 30 days in group I and 1 (0.9%) patient died in group II. Within 90 days after surgery, another patient died from acute cerebrovascular accident in group I. In long-term period, overall effectiveness of treatment of bronchopleural complications was 97.2% (208 out of 214 cases). CONCLUSION: The original surgical approach for bronchopleural complications considers timing of postoperative empyema, its spread and duration. This method together with minimally invasive interventions reduces mortality and ensures stable recovery after bronchopleural complications in 97.2% of patients.

[Aorto-esophago-bronchial and aorto-pulmonary fistulas in a patient with aortic aneurysm]. / Aortopishchevodno-bronkhial'nyi i aortolegochnyi svishchi u bol'nogo s anevrizmoi aorty.

Aorto-esophageal and aorto-bronchial fistulas are rare and life-threatening diseases if emergency treatment is absent. The most of publications devoted to this problem are case reports describing successful treatment of patients with aorto-esophageal and aorto-bronchial fistulas by using of endovascular or open transthoracic surgery. However, we did not find reports of several aortic fistulas in a patient after previous aortic stenting. It is presented case report of patient with aorto-esophago-bronchial and aorto-pulmonary fistulas in postoperative period after thoracic endovascular aortic repair (TEVAR).

Metallic small y stent placement at primary right carina for bronchial disease.

BACKGROUND: Metallic large Y stent placement has been used mainly for airway disease around the main carina. However, few studies have reported this treatment for bronchial disease around the primary right carina. METHODS: Twenty-eight patients were treated by small y stent. All stents were custom-designed and placed under fluoroscopic guidance. Clinical and imaging data were analyzed retrospectively. RESULTS: Thirty-one stents were successfully inserted in 28 patients. Twenty-five patients succeed at the first attempt (89.3%), and 3 patients needed a second attempt. Twelve complications occurred in 10 patients (35.7%). Stent restenosis and sputum retention were the most common complications. Five patients underwent successful stent removal due to complications or cure efficacy. During follow up, 17 patients died of tumors and one died of myocardial infarction. The 1-, 3-, and 5-year survival rates were 49.3, 19.6 and 19.6%, respectively. CONCLUSIONS: Metallic small y stent placement is technically feasible, effective and safe for bronchial disease around the primary right carina.

[Bronchial fistula management. Is the exit found?] / Lechenie bronkhial'nykh svishchei. Vykhod naiden?

AIM: To present treatment of bronchial fistulas by using of occluders. MATERIAL AND METHODS: For the period from March 2015 to October 2016 Atrial Septal Defect (ASD) occluders have been used for bronchial fistulas occlusion (Lepu Medical Technology Co., Ltd.; Lifetech Scientific Co., Ltd.). These are devices designed to close ventricular and atrial septal defects. The procedure was performed in 8 patients with main bronchus fistula occurred after pulmonectomy for tuberculosis in 5 patients and lung cancer in 3 patients. Fistulas' dimensions were 6-26 mm. The procedure was performed with double visualization from pleural cavity (through the thoracostomy and port-assisted approach) and from bronchial lumen. RESULTS: Seven out of 8 patients are currently alive (1 patient died from advanced tuberculosis of single lung). Occlusion is adequate in 6 patients, air drainage around around the occluder is noted in 1 patient. In 1 patient esophageal-pleural fistula occurred besides bronchial fistula. There was significant 2-3-fold decrease of residual pleural cavities volume and output volume. Patients feel satisfactory.

[Pleural cavity concerns]. / Los quebraderos de cabeza del espacio pleural.

INTRODUCTION: Persistent air leak (PAL) is a common problem. We asses our experience in the management of these patients. MATERIAL AND METHODS: Retrospective review of patients with chest tubes after bronchopulmonary pneumothorax (due to lung resections, spontaneous pneumothorax, necrotizing pneumonia) from 2010 to 2015. We studied clinical data, PAL incidence, risk factors and treatment, considering PAL ≥ 5 days. RESULTS: Thirty-seven cases (28 patients) between 0-16years: 26 lung resections, 11 pneumothorax. We found no differences in the distribution of age, weight, indication or comorbidity, but we noticed a trend to shorter hospital stay in infants. Patients with staple-line reinforcement presented lower PAL incidence than patients with no mechanical suture (43% vs 37%), the difference is even apparent when applying tissue sealants (29% vs 50%) (p > 0.05). We encountered no relationship between the size of the tube (10-24 Fr) or the type of resection, with bigger air leaks the higher suction pressure. We performed 13 pleurodesis in 7 patients (2 lobectomies, 3 segmentectomies and 2 bronchopleural fistulas), with 70% effectiveness. We conducted 7 procedures with autologous blood (1.6 ml/kg), 2 with povidone-iodine (0.5 ml/kg), 2 mechanical thoracoscopic and 2 open ones. We repeated pleurodesis four times, 3 of them after autologous blood infusion: 2 infusions with the same dose (both effective) and the other 2 as thoracotomy in patients with bronchopleural fistulas. After instillation of blood 3 patients presented with fever. After povidone-iodine instillation, the patient suffered from fever and rash. CONCLUSIONS: Intraoperative technical aspects are essential to reduce the risk of PAL. Autologous blood pleurodesis, single or repeated, is a minimal invasive option, very safe and effective to treat the parenchymatous PAL.

INTRODUCCION: La fuga aérea persistente (FAP) es un problema común. Evaluamos nuestra experiencia en el manejo de estos pacientes. MATERIAL Y METODOS: Revisión retrospectiva 2010-2015 de pacientes con drenaje endotorácico por neumotórax broncopulmonar (resecciones pulmonares, neumotórax, neumonía necrotizante). Revisamos datos clínicos, incidencia de FAP, factores determinantes y tratamiento, considerando FAP ≥ 5 días. RESULTADOS: Treinta y siete casos (28 pacientes) con edades entre 0-16 años: 26 resecciones pulmonares, 11 neumotórax. No encontramos diferencias en distribución de edad, peso, indicación quirúrgica ni comorbilidad, aunque sí tendencia a menor estancia hospitalaria en lactantes. Los pacientes con sutura no mecánica presentaron más fugas que los pacientes con sutura mecánica (43 vs 37%), así como los pacientes a los que no se aplicaron sellantes tisulares (29 vs 50%) (ambos p > 0,05). No encontramos relación con el tamaño del tubo (10-24 Fr) ni con el tipo de resección, manteniendo más fuga aérea los de mayor presión de aspiración. Realizamos 13 pleurodesis en 7 pacientes (2 lobectomías, 3 segmentectomías y 2 fístulas broncopleurales), con efectividad del 70%. Realizamos 7 con sangre autóloga (1,6 ml/kg), 2 con povidona iodada (0,5 ml/kg), 2 mecánicas toracoscópicas y 2 abiertas. Se repitió la pleurodesis en 4 ocasiones, 3 de ellas tras sangre autóloga: dos con repetición de la misma dosis (ambas efectivas) y otras dos por toracotomía en los pacientes con fístula broncopleural. Tras la instilación de sangre 3 casos presentaron fiebre. Tras la de povidona iodada, fiebre y exantema. CONCLUSIONES: Los aspectos técnicos intraoperatorios son esenciales para disminuir el riesgo de FAP. La pleurodesis con sangre autóloga, única o repetida, es una opción poco invasiva, muy segura y efectiva para las FAP parenquimatosas en nuestra muestra.

Pseudoaneurysm and aorto-bronchial fistula following balloon dilation of recoarctation.

This case report documents the successful surgical repair of an aorto-bronchial fistula and a giant aortic pseudoaneurysm at the proximal anastomosis of a dacron interposition tube graft that was balloon dilated for recurrent coarctation. Balloon dilation for recoarctation of a dacron interposition tube graft may lead to serious complications.

Repair of postpneumonectomy bronchopleural fistula using pedicled pericardial flap supported by fibrin glue.

Effective closure of the postpneumonectomy bronchopleural fistula (PBF) with the use of different techniques still remains a challenge for thoracic surgeons. The aim of this study was to evaluate the efficacy of modified method of PBF closure using pedicled pericardial flap (PPF) supported by fibrin glue (FG). The efficacy of the late PBF closure with the use of two surgical methods was compared. In 10 patients, the edges of the PBF were covered with FG and PPF. In the second group of nine patients, myoplasty was used to close the bronchial fistula. Postsurgical follow-up was for 1 year. In the first group, the healing of the fistula was achieved in 100% of the cases, whereas in the second, myoplasty group, healing was achieved in only 66·67% of the cases. The number of complications was similar in both groups. Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of PBF in selected patients.

Flow dynamics using high-frequency jet ventilation in a model of bronchopleural fistula.

BACKGROUND: Positive pressure ventilation in patients with a bronchopleural fistula (BPF) is associated with variable, unpredictable gas leaks that can impair gas exchange. The optimum settings for high-frequency jet ventilation in this scenario are unclear. We investigated flow dynamics with BPFs of 2 and 10 mm, at various positions and with different jet ventilator settings in a bench-top model. METHODS: A 2 or 10 mm length fistula was created at proximal, middle, or distal sites in standard artificial ventilator 'test' lungs and cadaveric porcine lungs. The effects of alterations in frequency, applied pressure, and on entrained, expired, and leak volumes were determined using gauge and differential pressure sensors. RESULTS: Entrained, delivered, and leak volumes were affected markedly by ventilator settings, particularly frequency: leaks were much greater at frequencies <100 min(-1). The leak/expired volume ratio varied between 0% and 92%. Leak and entrained volumes increased progressively with more proximally situated fistulae, whereas the measured expired volume decreased. Leak volumes with a 2 mm fistula were approximately half that of a 10 mm fistula across all ventilator frequencies. All volumes increased with increased driving pressure. The optimum injection time varied depending on BPF position and the accepted compromise between leak and expired volumes. Entrained volume contributed up to 50% of the total tidal volume. CONCLUSIONS: These data suggest that gas leak will be minimized and ventilator volumes maintained during jet ventilation using frequencies >200 min(-1) and lower driving pressures, but confirmatory clinical studies are required. Values displayed by the jet ventilator are unreliable.

Hard to diagnose and potentially fatal: slow aortic erosion post spinal fusion.

BACKGROUND: Delayed aortic injuries are a rare, but well-recognized complication of spinal surgery. They are a result of slow erosion of osteosynthesis material into the aorta. Although this is a life-threatening complication, patients might present years later with nonspecific symptoms. OBJECTIVE: A complex case of slow aortic injury after thoracic spinal surgery is presented, which highlights the challenges involved in diagnosis and treatment. CASE REPORT: A 62-year-old man had a T6 vertebrectomy and T5-7 anterior spinal fusion for multiple myeloma 5 years earlier. Two years postoperatively, the patient developed intermittent hemoptysis that triggered several presentations to the emergency department and consecutive hospital admissions during a 3-year period. All investigations, including endoscopy, bronchoscopy, and repeated chest computed tomography (CT) scans, were unremarkable. Eventually, the patient presented with frank hemoptysis associated with severe left-sided chest pain. Urgent CT angiography revealed a pseudoaneurysm measuring 34 × 20 mm at the level of the vertebrectomy. The patient underwent emergency surgery and an endoluminal stent graft was successfully placed. The patient remains well after 6 months. CONCLUSIONS: The close proximity of the aorta and spine entertains the risk of aortic injury associated with vertebral osteosynthesis. Long-term complications of slow aortic erosion are extremely difficult to diagnose. The presented patient suffered from an undetected bronchio-aortic fistula with consecutive pseudoaneurysm formation and rupture. Awareness of slow aortic erosion is important for correct diagnostic pathways and subsequent early diagnosis to ensure a positive outcome for the patient.

Persistent air leak secondary to pneumothorax in COVID-19: A case report and review of literature.

An air leak is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow. The communication can originate from a distal portion of the airway, causing an alveolar-pleural fistula, or from a more proximal airway, causing a bronchopleural fistula. When the air leak persists beyond 5-7 days, it is classified as persistent air leak (PAL). PAL has serious implications on patient management and outcomes, such as prolonged chest tube maintenance, high rate of infections, ventilation-perfusion mismatch, and prolonged hospital stay with higher morbidity and mortality. There are currently no guidelines for the management of PAL in COVID-19 patients. We presented a case of PAL in a patient with COVID-19-associated pneumothorax successfully treated with a one-way endobronchial valve. We also reviewed current published cases of PAL secondary to COVID-19-associated pneumothorax and the various methods they were treated. The first line treatment was insertion of one or more chest tubes, but the persistence of an air leak then led to other treatment modalities. Initial early surgical evaluation followed by pleurodesis is recommended for the management of PAL. The most common surgical approaches include VATS or open thoracotomy with mechanical or chemical pleurodesis or pleurectomy. However, surgery is not always a feasible option for critically ill patients. In such cases, there are multiple less invasive options for the management of PAL, including implantable devices, such as Watanabe spigots and stents, and chemical agents, such as thermal treatments, hemostatic substances, and tissue adhesives.

Bullous Lung Disease due to Pulmonary Tuberculosis: A Rare Case Complicated With Tension Pneumothorax and Bronchopleural Fistula.

Bullous lung disease caused by tuberculosis is rare, and complications have a poor prognosis with uncertain pathophysiologic mechanisms. We describe a 29-year-old male patient who was admitted to the emergency department due to bilateral tension pneumothorax, which was complicated by bronchopleural fistula. This was managed with the placement of chest tubes, continuity of anti-TB drug treatment, and Heimlich valve placement.

Congenital bilio-bronchial fistula in an adult: a review of literature and video demonstration of laparoscopic fistula tract excision.

This article presents a review of the literature on congenital bilio-bronchial fistula (BBF), a rare anomaly characterized by abnormal communication between the bile duct and respiratory tract. Congenital BBF often presents with bilioptysis in early neonates and infants; however, patients with no overt symptoms may occasionally present in adulthood. Our literature search in Medline from 1850 to 2023 revealed 42 reported cases of congenital BBF, primarily managed with thoracotomy and excision of the fistula tract. About one-third of these cases required multiple surgeries due to associated biliary anomalies. The review underscores the importance of diagnostic imaging, including bronchoscopy, in identifying and delineating the extent of the fistula. It also highlights the evolving surgical management, with recent cases showing the efficacy of minimally invasive approaches such as laparoscopy and thoracoscopy. In addition to the literature review, we report a young female patient with a history of recurrent respiratory infections presenting with bilioptysis and extensive left lung damage. Initial management included bronchoscopy-guided glue instillation, left thoracotomy, and pneumonectomy. Following the recurrence of symptoms, the patient was successfully treated with laparoscopic excision of the fistula tract. In recent times, minimally invasive approaches such as laparoscopy and thoracoscopy, with excision of the fistula tract are gaining popularity and have shown good results. We suggest biliary communication being the high-pressure end, tackling it transabdominal may prevent recurrent problems.