MANAGEMENT AND RESECTION OF A COLOBRONCHIAL FISTULA

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A fistula is defined as an aberrant connection between two epithelialized surfaces (1). Review of the literature finds less than 50 total case reports of colobronchial fistulas (2). Here we report a rare case of a colobronchial fistula in a 66-year-old male with foul smelling cough. CASE PRESENTATION: A 66-year-old man presented to the ED with a several month history of worsening chronic cough with foul-smelling sputum. In the time preceding the admission, the patient noted intermittent subjective fevers, chills, and night sweats. The patient had a lengthy surgical which includes a 2018 distal pancreatectomy, splenectomy, colonic resection, and partial diaphragmatic resection secondary to Gastrointestinal Stromal Tumors (GIST). Initial imaging with Chest X-ray and CT scan of the abdomen without contrast identified only a subphrenic abscess. X-ray of the colon with lower GI Gastrografin enema confirmed presence of a colobronchial fistula. During this exam, the patient began coughing up contrast and evidence of contrast in the subphrenic abscess was further confirmed on a CT. At first, the cardiothoracic surgery team recommended an initial non-surgical approach. A 10 French drainage catheter was advanced into the abscess and placed on pleurovac -40 suction. The patient was told to irrigate the cavity with 10 cc of saline 3-4 times per day with the hope the cavity would fill with granulation tissue without resection. The patient was discharged on suction and 10 days later returned with worsening cough and fevers. The fistulous connection was unchanged and the patient was taken to surgery. A muscle sparing left lower thoracotomy provided access to the fistulous communication allowing partial wedge resection of the left lower lobe and debridement of the abscess cavity. The diaphragm was partially resected and pulled away from the former fistula site. 3 Chest tubes were placed including one in the marsupialized abscess cavity and the fistula was successfully divided. DISCUSSION: Colobronchial fistulas are slow to develop and have been reported with numerous pathologic and iatrogenic processes including Crohn’s disease, colonic malignancy, diaphragmatic hernia, and postoperative adhesions (2) Identifying the fistulous tract definitively is challenging and is most commonly found by a lower GI contrast enema with X-ray which is concurrent with our case report (2). Treatment for a colobronchial fistula has always been surgical, with all cases of successful recovery requiring this intervention (2). There are no current cases describing the use of a catheter drainage in attempted marsupialization making this case unique. CONCLUSIONS: Colobronchial fistula is a rare finding that often occurs years after the initial iatrogenic or pathologic insult. It is best identified with a contrast enema imaging study and requires surgical intervention for proper treatment. Reference #1: Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology. 2002;224(1):9-23. Reference #2: Jinbo Zhao, Nan Ma, Zhengwei Zhao, et al. Colobronchial fistula: the pathogenesis, clinical presentations, diagnosis and treatment. Journal of Thoracic Disease. 2017;9(1):187 DISCLOSURES: No relevant relationships by Brenda Affinati, source=Web Response No relevant relationships by Reid Stubbee, source=Web Response