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)

Tratamiento endoscópico combinado para el cierre de una fístula broncopleural de gran tamaño / Combined Endoscopic Treatment for the Closure of a Large Bronchopleural Fistula

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[Translated article] Combined Endoscopic Treatment for the Closure of a Large Bronchopleural Fistula / Tratamiento endoscópico combinado para el cierre de una fístula broncopleural de gran tamaño

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A Large Central Bronchopleural Fistula Closed by Bronchoscopic Administration of Recombinant Bovine Basic Fibroblast Growth Factor: A Case Report.

A large central bronchopleural fistula (BPF) surrounded by mediastinal tissue was successfully closed by local administration of recombinant bovine basic fibroblast growth factor (rbFGF) using the bronchoscope. No complications were observed during and after this bronchoscopic treatment. This is the first report of the bronchoscopic treatment of a large central BPF by the local spray of rbFGF. The bronchoscopic treatment with rbFGF is a potentially cost-effective method for central BPF surrounded by mediastinal tissue.

A Biliobronchial Fistula / Fístula biliobronquial

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Combined intrapleural and intrabronchial injection of fibrin glue for closing alveolar pleural fistula: a case report.

BACKGROUND: The treatment of persistent air leak is a challenge. Herein, we reported the combined intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy to seal off an alveolar pleura fistula developed following necrotizing pneumonia in high-risk patient. CASE PRESENTATION: A 74-year-old man was intubated in emergency for acute ischemic stroke. Percutaneous dilatational tracheostomy was then performed, and 15 days later patient returned to spontaneous breathing. However, he developed alveolar pleural fistula following necrotizing pneumonia with persistent air leaks. The intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy sealed off the alveolar pleura fistula after that other endoscopic treatments as bronchial valve and intrabronchial fibrin glue application had failed. CONCLUSIONS: Our strategy is safe and easy to reproduce. It represents an additional method in the armamentarium of the physicians for the management of PAL when all standard strategies are unfeasible or fail.

Long-term Esophageal Cancer Survivor Treated by Bypass for Esophagobronchial Fistula After Chemoradiotherapy: A Case Report.

BACKGROUND: An esophagorespiratory fistula (ERF) is a fatal complication for patients with tracheobronchial invasion by esophageal cancer. We report the case of a long-term esophageal cancer survivor treated by esophageal bypass operation for ERF after chemoradiotherapy (CRT). CASE REPORT: A 44-year-old man was treated with definitive CRT (i.e. 66 Gy radiotherapy, chemotherapy with cisplatin, and 5-fluorouracil) for unresectable locally advanced esophageal cancer with massive invasion of the left main bronchus. Although a complete clinical response was obtained, the patient developed pneumonia due to an ERF. Esophageal bypass operation was performed for symptomatic relief. The patient's symptoms improved and oral ingestion became possible. No recurrence has been seen for 12 years. CONCLUSION: Esophageal bypass surgery can help in relieving symptoms and might be associated with long-term survival for esophageal cancer patients with ERF after good response to CRT. Thus, bypass surgery is a useful option in the treatment for esophageal cancer with ERF.

Treatment of a broncho-esophageal fistula complicated by severe ARDS.

INTRODUCTION: Broncho-esophageal fistula formation is a rare complication of tuberculosis, most often seen in immunocompromised patients. METHODS AND RESULTS: In this paper, we report the case of a young non-immunocompromised refugee from Somalia diagnosed with open pulmonary tuberculosis complicated by extensive osseous involvement and a broncho-esophageal fistula with consecutive aspiration of gastric contents. The patient rapidly developed a severe acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (ECMO) therapy for nearly 2 months. The fistula was initially treated by standard antituberculous combination therapy and implantation of an esophageal and a bronchial stent. Long-term antibiotic treatment was instituted for pneumonia and mediastinitis. 7 months later, discontinuity resection of the esophagus was performed and the bronchial fistula covered by an intercostal muscle flap. DISCUSSION: This case illustrates that tuberculosis should always be suspected in patients from high-incidence countries in case of lung involvement and that an interdisciplinary approach including long-term intensive care management can enable successful treatment of tuberculosis with severe, near-fatal complications.

An unusual presentation of pulmonary embolism leading to infarction, cavitation, abscess formation and bronchopleural fistulation.

We report an unusual presentation of pulmonary embolism (PE) where a 58-year-old man first developed symptoms of community-acquired pneumonia. Despite antibiotic therapy, he remained unwell with rising inflammatory markers, general malaise and persistent cough. He developed stony dull percussion and absent breath sounds to his left mid to lower zones. Serial chest x-rays showed progression from lobar consolidation to a large loculated left-sided pleural collection. CT chest showed left-sided lung abscess, empyema and bronchopleural fistulation. Incidentally, the scan revealed acute left-sided PE and its distribution corresponded with the location of the left lung abscess and empyema. The sequence of events likely started with PE leading to infarction, cavitation, abscess formation and bronchopleural fistulation. This patient was managed with a 6-month course of rivaroxaban. After completing 2 weeks of intravenous meropenem, he was converted to 4-week course of oral co-amoxiclav and metronidazole and attained full recovery.

Silicotuberculosis with oesophagobronchial fistulas and broncholithiasis: a case report.

A 76-year-old woman was admitted to the hospital four times from November 2007 to June 2009. In this complex case, the patient had silicosis complicated by broncholithiasis, oesophagobronchial fistulas, and relapsed tuberculosis. She had worked as a stone crusher for 3 years and was exposed to a large amount of quartz dust. Barium oesophagography, gastroesophageal endoscopy, and biopsy suggested oesophageal-related chronic inflammation and ulceration, which may have caused the repeated oesophagobronchial fistulas. Bronchoscopy revealed a free broncholithiasis in the left mainstem bronchus. The patient was admitted a fourth time because of silicotuberculosis relapse. After 9 months of antituberculosis treatment, the patient recovered and was still clinically well at the time of this writing.

Utilización de un nuevo cianoacrilato como sellante bronquial en el tratamiento endoscópico de la fístula broncopleural / A new cyanoacrylate used as bronchial sealant in the endoscopic treatment of bronchopleural fistual

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Silicotuberculosis with Esophagobronchial Fistula and Broncholithiasis.

A 69-year-old woman was admitted to hospital 4 times from November 2007 to June 2009. The patient had silicosis complicated by broncholithiasis, esophagobronchial fistula, and relapsed tuberculosis. She had worked as a stone crusher for 3 years and was exposed to a large amount of quartz dust. Barium esophagography, gastroesophageal endoscopy, and biopsy suggested esophageal-related chronic inflammation and ulcer, which probably caused the repeated esophagobronchial fistulas observed. Bronchoscopy revealed a free broncholithiasis in the left main bronchus. The patient was readmitted a fourth time, for the relapse of silicotuberculosis. After 9 months of antituberculous therapy, she was doing well until the recent last follow-up visit.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA].

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

Treatment of Bronchopleural Fistula with Carbolic Acid instilled through Bronchofiberscope in post-pulmonectomy patients.

OBJECTIVE: To investigate the efficacy of carbolic acid treatment of bronchopleural fistula (BPF) using bronchofiberscope (BFS) in post-pulmonectomy patients. METHOD: Twelve patients with post-pulmonectomy BPF were enrolled in this study at the Liaoning Tumor Hospital between February 2009 and March 2012. Three patients had BPF after the right pneumonectomy, six patients after left pneumonectomy, one patient after the right middle and low lobectomy and two patients after left upper lobectomy. BPF patients were instilled with 100 % carbolic acid (0.5-1 ml one time every week) through BFS on the mucosal surface around the fistula, and the bubble disappearance was monitored. Treatment was repeated if the bubble remained. RESULTS: No haemorrhage, severe dyspnea or SpO2 declines occurred in all the 12 patients during the bronchoscopic therapy. BPF orifices were closed in five patients after receiving 5 treatments with carbolic acid, 1 patient received 2 treatments, 1 patient was given 3 treatments, 2 patients received 4 treatments and 3 patients were given 7 treatments. Follow-up was conducted for six months following bronchoscopy. The average treatment and fistula closure time were calculated from the data collected as 20 min and 30 days, respectively, and the cure rate was 100 %. Hematoxylin-eosin (HE) staining results revealed that the white flat hyperplasia tissue after carbolic acid treatment was inflammatory granulation tissue. CONCLUSION: Our results revealed that instillation of 100 % carbolic acid with BFS to treat BPF was 100 % effective, which can be a support for post-pulmonectomy BPF.

Therapeutic drug monitoring and the conservative management of chronic tuberculous empyema: case report and review of the literature.

BACKGROUND: Chronic tuberculous empyema (CTE) is a rare and unusual, low grade and protracted, infection of the pleural space resulting in marked thickening, even calcification of the visceral and parietal pleura. Historically its management has been extraordinarily challenging. Differential penetration of anti-TB drugs into the pleural space has resulted in acquired drug resistance and surgery to remove the empyema or close a complicating bronchopleural fistula (BPF) has been technically difficult or unacceptably hazardous. On the basis of limited experience, the combination of tube thoracostomy or catheter drainage and high-end dosing of anti-TB drugs has been recommended as an initial approach to these lesions. Herein we report the first well documented case of closure of a BPF and cure of a CTE using this approach. The chances of a favorable outcome are improved, we suggest, by using therapeutic drug monitoring (TDM) to guide high-end drug dosing. CASE PRESENTATION: An 84 year old male immigrant to Canada from Croatia was diagnosed with a CTE after he developed a BPF. The diagnosis was made 62 years after what was, in retrospect, an episode of tuberculous pleurisy. He was treated with computed tomography-guided catheter drainage and TDM-guided high-end dosed anti-TB drugs (serum and pleural fluid drug concentrations) over a 10 month period. Sustained closure of the BPF and mycobacteriologic cure of the CTE was achieved. Drug concentrations in the present case and all other reported cases are summarized and interpreted. CONCLUSION: When serum concentrations of the anti-TB drugs isoniazid, pyrazinamide and ethambutol at the high end of the normal range are achieved, pleural fluid concentrations at the low end of the normal range may be anticipated in CTE. Though highly protein bound drugs such as rifampin and moxifloxacin appear to penetrate CTEs less well, their free concentrations in the pleural space may be proportionately higher on account of lower protein concentrations. Interventional radiology and TDM increase the chances that conservative management of CTE will be successful.

Increased incidence of bronchopulmonary fistulas complicating pediatric pneumonia.

BACKGROUND: The frequency of complicated pneumococcal disease, including necrotizing pneumonia, has increased over the last decade. During 2008-2009, we noted an increase in the number of children whose empyema was complicated by the development of a bronchopleural fistula and air leak. We studied these children to see if there was an associated cause. METHODS: This was a retrospective case note and database review of children admitted to our tertiary unit with a parapneumonic effusion or empyema from 2002 to 2007, compared with 2008 to 2009. For the latter period, we also compared the outcomes of those with a bronchopleural fistula to those without. RESULTS: During the 8-year period, 310 children were admitted. In the first 6 years, the frequency of air leaks was 1% (2/258) rising to 33% (16/49) in the last 2 years (P<0.0001). Three children were excluded as their fistulas were possibly iatrogenic. This was associated with a significant increase in median hospital stay (7 vs. 10 days, P<0.0001) and surgical intervention rate (2% vs. 14%, P=0.001). In the latter 2 years, S. pneumoniae serotype 3 was identified in 10/16 (91%) of those with a bronchopleural fistula compared to 1/33 (3%) of those without. CONCLUSIONS: The frequency of bronchopleural fistulas increased markedly in the 2 years 2008-2009. Although these cases were associated with pneumococcal serotype 3 infection, which was not covered by the heptavalent pneumococcal vaccine Prevenar® in use at that time, we do not know whether the increased incidence of fistulas was due to a change in serotype 3 prevalence.

Massive pleural effusion and bronchopleural fistula in Wegener's granulomatosis.

Wegener's granulomatosis (WG) is characterized by systemic granulomatous necrotizing vasculitis, primarily affecting the respiratory tract and kidneys. We describe a rare case in a 28-year-old woman with WG, presenting with a massive lateral pleural effusion, accompanied by an aseptic bronchopleural fistula formed during immunosuppressive treatment. Although any organ can be involved in WG, only left pleuritis and a purpuric lesion on the neck were detected in this case. The pleural effusion and bronchopleural fistula resolved following immunosuppressive treatment for six months. Thus, WG should be considered in the differential diagnosis of a massive pleural effusion, and fistula formation is a possible complication of treatment. Moreover, immunosuppressive treatment was sufficient to resolve the massive pleural effusion and fistula formation without infection (120 words).

Submucosal injection of the silver-human albumin complex for the treatment of bronchopleural fistula.

OBJECTIVE: Postoperative bronchopleural fistula (BPF) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study is to assess the efficacy of the use of the silver-human albumin (SHA) complex injected in the bronchial submucosa for the treatment of BPF. METHODS: From January 2005 to March 2008, we treated 11 patients with BPF (seven post-pneumonectomy and four post-lobectomy) by endoscopic injection of the SHA complex into the bronchial submucosa. In all patients a chest drain was positioned and employed for antibiotic pleural irrigation. Simultaneously, the endoscopic treatment including repeated injection of the SHA complex was started. In 10 patients the diameter of the fistulas was equal to or smaller than 5mm (range: 3-5mm) and in one it was larger than 5mm (8mm). RESULTS: There was no morbidity or mortality related to the procedure. Permanent closure of the fistula was achieved in all 10 patients with a BPF of 3-5mm. In four of these patients (post-lobectomy fistula), the good general condition allowed early discharge with the Heimlich valve before the completion of treatment. Two other patients with a fistula smaller than 5mm presented persisting empyema and compromised general conditions after closure of the post-pneumonectomy BPF. These patients underwent fast-track treatment of the empyema achieving definitive cure. In the patient with a BPF larger than 5mm, the conservative treatment was not sufficient and an omental flap transposition was necessary. CONCLUSIONS: The SHA complex submucosal injection is easy, safe and inexpensive. It can be considered a valid therapeutic option in selected patients presenting an early fistula with a size equal to or smaller than 5mm. Early diagnosis, simultaneous insertion of a chest drain and achievement of a sterile pleural cavity are fundamental conditions for the final success of the procedure.