Simultaneous bronchopleural and esophagopleural fistulas after pneumonectomy

The simultaneous occurrence of bronchopleural fistula (BPF) and esophagopleural fistula (EPF) after pneumonectomy is very rare. We describe a 60-year-old man who developed empyema associated with bronchopleural fistula as a complication of a right pneumonectomy. Initial chest tube drainage and antibiotic therapy were ineffective. Five months later ingested food particles appeared in the drainage fluid. Esophagoscopy revealed an esophageal fistula of 10 mm in diameter. After nutritional support by feeding jejunostomy both BPF and EPF were repaired by subscapular muscle myoplasty and extensive thoracoplasty through a right thoracotomy. Endoscopic examination performed 1 month after surgery showed complete closure of both fistulas and 9 months after surgery the patient was eating and gaining weight. The patient's death was due to aspiration pneumonia of another origin.     

Staged closure of complicated bronchopleural fistulas

Bronchopleural fistulas remain a major complication after thoracic surgery. Despite continued advances in the treatment of this difficult problem, perioperative mortality remains as high as 15%. Multiple treatment strategies have been described with varying degrees of success. Successful treatment of chronic bronchopleural fistulas requires aggressive control of infection, adequate drainage of the chest cavity, closure of the fistula with vascularized tissue, and obliteration of the chest cavity. The authors present their experience with 3 patients who underwent a two-stage closure of their bronchopleural fistulas with pectoralis major muscle flaps followed by omental flap obliteration of the chest cavity. Each patient had previously undergone an Eloesser procedure for chest cavity drainage. The initial muscle flap operation is a small procedure that can be done rapidly with minimal morbidity in chronically ill patients. The intervening period between procedures allows patients to continue aggressive nutritional and physical rehabilitation until they are able to tolerate a second operation for chest cavity obliteration. All bronchopleural fistulas in our series healed, with one minor complication. A staged closure is a safe and effective alternative treatment for chronic and recurrent bronchopleural fistulas.     

Successful management of a large bronchopleural fistula after lobectomy: Report of a case

The development of bronchopleural fistula after pulmonary resection is a well-known complication associated with a high mortality rate. We herein describe the successful management of a bronchopleural fistula using a rib and intercostal muscle in a patient with a large stump opening of 25 mm in diameter. A flap with rib and intercostal muscle is useful for large bronchopleural fistulas to avoid airway stenosis.     

Transthoracic closure of a postpneumonectomy bronchopleural fistula with coils and cyanoacrylate

Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.     

Bronchial stump insufficiency: treatment and results

A bronchopleural fistula following lung resection is a dangerous complication. Records from 25 patients with a bronchopleural fistula were followed up in order to propose a therapeutic concept. An early onset of fistula should be treated as an emergency. Late fistulas can be reoperated electively because they are most often rather small and the patients are in a better condition. The suture of the stump alone was successful in only 3 out of 13 cases. Patients with fistulas following lobectomy were reoperated by pneumonectomy with good results. In fistulas due to pneumonectomy the results of either an isolated muscle-flap or a thoracoplasty were disappointing. Instead, a closure of the stump was accomplished by the combination of thoracoplasty and muscle-flap in 3 out of 4 patients. However, 2 patients with an early fistula after pneumonectomy died from septic complications after the fistulas had already been managed. Endoscopic maneuvers like gluing and insertion of spongiosa did not show any success unless combined with operative measures but rather delayed the onset of re-intervention.     

Closure method of bronchopleural fistula with omental pedicle flap in three cases following pneumonectomy

This report presents that successful closure of bronchopleural fistula was performed by using omental pedicle flap for three postpneumonectomy patients. In our department, these cases were experienced among 142 pneumonectomies from January 1984 to July 1989. The initial operations were a pleuropneumonectomy for empyema, a pneumonectomy and a sleeve pneumonectomy for lung cancer. Our technique was direct closure of bronchopleural fistula with omental pedicle flap without thoracoplasty. Although none of them had recurrence of bronchopleural fistula nor other complications in postoperative course, two patients died of cancer.     

Treatment of bronchopleural fistula after pneumonectomy

Breakdown of the closure of the main-stem bronchus after pneumonectomy is a dreaded complication, and empyema and bronchopleural fistula frequently develop in patients who survive. Management of these fistulas remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. We report our experience with anterior transpericardial closure, emphasizing the ability to expose either main-stem bronchus by this approach. The case histories of three patients who had bronchopleural fistula after pneumonectomy are presented. The first patient had left pneumonectomy for complicated tuberculosis; the second had right pneumonectomy for neoplasm; and the third had right pneumonectomy for trauma. All fistulas were treated surgically via a median sternotomy and transpericardial approach to the distal trachea. The posterior pericardium was divided between the superior vena cava and aorta. In-continuity staple closure (with two lines of staples) of the proximal main-stem bronchus was employed in all cases. Two patients remain clinically well 21 and 17 months after the operation. The third patients did well initially but developed a recurrent bronchopleural fistula 2 1/2 months after the operation and has required repeat closure with pedicled muscle flaps. In postpneumonectomy bronchopleural fistula, the anterior, transpericardial approach to bronchial closure has several advantages: the relatively well-tolerated median sternotomy, the avoidance of dealing directly with areas of postoperative scarring and the devascularized bronchial stump, the avoidance of areas of chronic sepsis, and the avoidance of thoracoplastic surgical deformity of the chest wall, with possible associated compromise in pulmonary function. Our experience also indicates that either main-stem bronchus is accessible through an approach between the superior vena cava and aorta, without division of either pulmonary artery.     

Closure of a bronchopleural fistula using a fibrin-glue coated collagen patch

Bronchopleural fistulas can occur as a life-threatening sequelae after pulmonary resection. Two bronchopleural fistulas more than 3 mm in diameter were successfully treated by using a fibrin-glue coated collagen patch at the site of bronchopleural fistula under flexible bronchoscopic observation. This is the first report of the bronchoscopic closure of bronchopleural fistulas by using a fibrin-glue coated collagen patch. This treatment would be recommended for patients with a postoperative bronchopleural fistula with an orifice that is more than 3 mm in diameter.     

Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate

We report herein 2 patients with intractable postoperative bronchopleural fistula with empyema after lobectomy or subsegmentectomy. The patients underwent several treatments including thoracotomy, but the fistula closure was not successful. Finally, the bronchopleural fistula was successfully treated by endobronchial closureusing vascular occluding coils and n-butyl-2-cyanoacrylate (Histoacryl).     

Treatment of AIDS-related bronchopleural fistula by pleurectomy.

Spontaneous pneumothorax in patients with acquired immunodeficiency syndrome (AIDS) may require prolonged therapy for treatment of a persistent bronchopleural fistula, and treatment by standard methods often fails. This pilot study was done to test the effectiveness of aggressive surgical therapy for definitive treatment of persistent bronchopleural fistula in patients with AIDS. Between March 1989 and September 1991, 44 patients with AIDS were treated for spontaneous pneumothorax with closed tube thoracostomy; 14 of these patients had development of persistent bronchopleural fistula for more than 10 days, and 2 patients had subsequent bronchopleural fistula on the opposite side. Operative therapy in 14 patients included 15 thoracotomies and one sternotomy. The bronchopleural fistula was closed directly with suture or staples in 15 procedures and resected by lobectomy in 1 patient. All 14 patients received adjuvant parietal pleurectomy. Operative mortality was 7% (1 of 14 patients). The fistula was closed in all survivors and 13 patients were discharged between 7 and 28 days postoperatively. Pathologic examination confirmed Pneumocystis carinii in 13 patients with a high incidence of diffuse involvement and subpleural necrosis, further demonstrating the need for pleurectomy. These data suggest that in selected patients bronchopleural fistulas associated with AIDS can be effectively controlled by surgical closure combined with pleurectomy.     

Bronchopleural fistula after stapled closure of bronchus.

The incidence of bronchopleural fistula after stapling among 2,243 pulmonary resections at the Rush-Presbyterian-St. Luke's Medical Center has been reviewed. There were 35 fistulas in 1,773 stapled and in 470 sutured bronchi (segmentectomy, 2; lobectomy, 1; bilobectomy, 9; and pneumonectomy, 23). We have found that the stapler is expedient and simple to use, and that it produces a hermetic and uniform closure. The stapler is contraindicated when the bronchus is thickened, inflamed, or of insufficient length. The overall incidence of bronchopleural fistula was 1.6%. Approximately two thirds of the patients with bronchopleural fistula had preoperative radiation therapy or chemotherapy or both.     

Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap.

OBJECTIVES: The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively. METHODS: Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded. RESULTS: Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed. CONCLUSION: The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.     

Transsternal transpericardial closure of a postpneumonectomy bronchial fistula in a patient who underwent pneumonectomy because of a war injury

Most common causes of intrathoracic empyema include pulmonary infections and postoperative bronchopleural fistulas complicating a lung surgical resection, mainly pneumonectomy, as a result of the failure of the bronchial stump to heal. A 22-year-old Serbian patient presented with chronic posttraumatic empyema. Two years before during a war, he experienced chest injury due to a firearm wound, with massive intrathoracic bleeding and need for emergency left pneumonectomy. Empyema with a bronchopleural fistula occurred during the postoperative course. The patient underwent left open window thoracostomy with a daily bandage change. Here we report the treatment of the bronchopleural fistula using sequential surgical approach including transsternal transpericardial closure of the fistula followed by reconstruction of the chest wall with a regional muscle flap. Our case report highlights the feasibility and efficacy of the transsternal surgical approach to treat postpneumonectomy bronchopleural fistula, thereby avoiding the direct approach to the bronchial stump through the infected pneumonectomy cavity.     

Myoplasty for closure of tracheobronchial fistula

Myoplasty techniques are described in which pedicle or free muscle grafting is used in the closure of either acute or chronic bronchopleural fistula. The pectoralis major muscle, the intercostal muscle pedicles, or the free graft is used according to specific indications.     

Clinical experience of omental pedicle flap for bronchopleural fistula

We present two patients who underwent the omental pedicle flap method for bronchopleural fistula. The first case was a 61-year-old man who developed empyema with bronchial fistula due to recurrent tuberculosis resisted to chemotherapy. He underwent complete muscle and omental flap closure of empyema space. The second case was a 63-year-old man who underwent pneumonectomy for adenocarcinoma of the lung. About two weeks after the operation, a bronchopleural fistula developed at the bronchial stump. He underwent complete omental flap closure of fistula. They are doing well 18 and 9 months following operation, respectively. The omental pedicle flap method is clinically useful as a closure method for bronchopleural fistula because of excellent blood supply of the omentum.     

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.     

Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases

PURPOSE: Urethrovaginal fistulas are commonly repaired transvaginally with local tissue flaps, such as the Martius labial fat pad graft. Although this flap is ideal, if it fails and the fistula persists, subsequent treatment options are limited. We describe the use of a pedicled rectus abdominis muscle flap for the repair of complex and refractory urethrovaginal fistulas. MATERIALS AND METHODS: Six women with a mean age of 53 years (range 41 to 62) who had complex and refractory urethrovaginal fistulas were referred to our continence center. Mean number of prior attempted repairs was 1.3 and in all cases at least 1 Martius flap had failed. Transvaginal urethrovaginal fistula closure was performed followed by a pedicled rectus abdominis muscle flap interposed between the fistula closure and vaginal suture line. The muscle flap was based on the inferior epigastric vessels, and provided additional support to the urethra, bladder neck and bladder base. RESULTS: Urethrovaginal fistula repair with the rectus abdominis muscle flap was successful in all cases. No fistula recurred. Of the patients 5 (83%) were continent and able to void to completion at a mean followup of 23 months (range 2 to 66). CONCLUSIONS: The rectus abdominis muscle flap is a useful adjunct in the repair of complex and refractory urethrovaginal fistulas. It can be used with confidence to provide support to the bladder neck and proximal urethra in patients after failed prior repair with the Martius flap procedure. The pelvic surgeon may be able to recognize other applications for the rectus abdominis muscle flap in pelvic floor reconstruction.     

The use of a Dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.     

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer.

OBJECTIVE: Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS: Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS: The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS: Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.     

Fibrin glue for all anal fistulas

The aim of this study was to determine if a new sphincter muscle-sparing technique that uses fibrin glue was effective in closing all types of anal fistulas. All patients with anal fistulas who were seen by a single surgeon over a 2-year period were treated with fibrin glue. Six to 8 weeks after a seton was placed in the fistula tract, either autologous fibrin glue or commercially available fibrin sealant was used to close the fistula tract. Twenty patients were treated with a mean follow-up of 10 months. Etiology of the anal fistulas was as follows: cryptoglandular in 13, Crohn’s disease in four, and miscellaneous in three. Fibrin glue closure of the anal fistula was successful initially in 15 patients (75%) and was successful after a second treatment in two additional patients, for an overall fibrin glue fistula closure rate of 85% (17 of 20). Functional results have remained excellent with no patient reporting any change in continence after treatment. Fibrin glue is simple and effective treatment for all anal fistulas with excellent functional results. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.