Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases.

BACKGROUND: Various therapeutic approaches to bronchopleural fistula have been reported. Its natural history, which may be key to the best therapeutic management, early detection, and possibly, prevention of fistula formation, has received little attention. METHODS: The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at primary bronchoscopic diagnosis, time of occurrence after operation (days), cause of death, and survival after fistula formation (days) were analyzed. Management consisted of bronchoscopic closure with fibrin sealant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thoracostomy. RESULTS: Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) died during the observation period; in 25, the cause of death was aspiration pneumonia. Only 2 patients who died of aspiration pneumonia had development of a fistula after 90 postoperative days. The aspiration rate dropped with increasing interval between operation and fistula occurrence (p = 0.000). Patient survival after fistula formation was positively correlated to this interval (p = 0.002). Successful fistula closure was achieved by surgical intervention in 21 patients and endoscopically in 11 patients. The overall postoperative mortality rate irrespective of treatment method was 31%. CONCLUSIONS: The incidence of aspiration pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently represents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postoperative months should detect bronchopleural fistula before aspiration occurs.

Arteriovenous flow reversal, experimental investigations. II. Hemodynamic and blood gas analyses in incomplete arteriovenous flow reversal in hind extremities of dogs.

2 types of incomplete arteriovenous flow reversal were tested. When the major arteries were patent, 20% of the blood shunted into a peripheral vein was drained via the arteries whereas 80% was drained via the veins of the leg. If the pressure in the arteries was raised, the flow through the arteries was stopped when the outflow pressure reached 25% of the systemic blood pressure. Under these conditions a moderate oxygen consumption of the peripheral tissues was still observed. When the major arteries and their branches were obstructed by the injection of collagen flocculi the oxygen supply to the tissues was again reduced but not completely abolished. It is concluded that the AVFR procedure may be helpful in avoiding peripheral gangrene in very severe cases of arterial disease. In the first paper of this series (Gottlob and Kunlin, 1985) the hemodynamics of complete arteriovenous flow reversal (AVFR) were studied. In the present communication experiments with incomplete AVFR will be reported on. The animal models described resemble the clinical condition in so far as incomplete AVFR is established and as in both models the flow through the peripheral arteries was hampered.

[New experimental documents on circulatory reversal by arteriovenous fistula in ischemia of the extremities]. / Nouveaux documents expérimentaux sur l'inversion circulatoire par fistule artério-veineuse dans l'ischémie du membre.

The beneficial effects of circulatory reversal by lateral a.-v. fistula was confirmed in 20 hind limbs of dogs made ischaemic by Collagen embolisation. Although not done in the experiments presented here, rupture of the distal venous valves is advisable. The peripheral circulation was studied by measurement of venous pressures and by angiography. Retrograde infusions, with proximal tourniquet, confirmed reversal of flow veins to arteries. Return routes to the heart remain unknown.