Bronchopleural Fistula Research Articles

Bronchopleural Fistula after Lobectomy for Lung Cancer: How to Manage This Life-Threatening Complication Using Both Old and Innovative Solutions.

Our goal is to evaluate the correct management of broncho-pleural fistula (BPF) after lobectomy for lung cancer. We retrospectively reviewed our 25-years' experience and reported our strategies and our diagnostic algorithm for the management of post-lobectomy broncho-pleural fistula. Five thousand one hundred and fifty (5150) patients underwent lobectomy for lung cancer in the period between 1998 and 2023. A total of 44 (0.85%) out of 5150 developed post-operative BPF. In 11 cases, BPF was solved by non-invasive treatment. In nine cases, direct surgical repair of the bronchial stump allowed BPF resolution. In 14 cases, a completion intervention was performed. In six cases, we performed open window thoracostomy (OWT) after lobectomy; in two cases, the BPF was closed by percutaneous injection of an n-butyl cyanoacrylate glue mixture. In two cases, no surgical procedure was performed because of the clinical status of the patient at the time of fistula developing. Thirty-day and ninety-day mortality from fistula onset was, respectively, 18.2% (eight patients) and 22.7% (ten patients). Thirty-day and ninety-day mortality after completion pneumonectomy (12 patients) was, respectively, 8.3% (one patient) and 16.6% (two patients). The correct management of BPF depends on various factors: timing of onset, size of the fistula, anatomic localization, and the general condition of the patient. In the case of failure of various initial therapeutic approaches, completion intervention or OWT could be considered.

Analysis of treatment-related adverse events and wound complications of surgical resection after neoadjuvant chemoimmunotherapy for non-small cell lung cancer.

Neoadjuvant chemoimmunotherapy is becoming an increasingly important part of the management of lung cancer to facilitate surgical resection. This study aimed to summarize the treatment-related adverse events (TRAEs) and wound complications of neoadjuvant chemoimmunotherapy in non-small cell lung cancer (NSCLC). Eligible studies of neoadjuvant chemoimmunotherapy for NSCLC were identified from PubMed, Embase and Web of Science. The endpoints mainly included TRAEs and wound complications. Stata18 software was used for statistical analysis with p < 0.05 considered statistically significant. Twenty studies including a total of 1072 patients were eligible for this study. Among the patients who received neoadjuvant chemoimmunotherapy, the pooled prevalence of any grade TRAEs was 77% (95% confidence interval [CI] [0.64-0.86]), grade 1-2 TRAEs was 77% (95% CI [0.58-0.89]) and grade ≥3 TRAEs was 26% (95% CI [0.16-0.38]). Surgery-related complications rate was 22% (95% CI [0.14-0.33]). Among the wound complications, the pooled rate of air leakage was 10% (95% CI [0.04-0.23]), pulmonary/wound infection was 8% (95% CI [0.05-0.13]), bronchopleural fistula was 8% (95% CI [0.02-0.27]), bronchopulmonary haemorrhage was 3% (95% CI [0.01-0.05]), pneumonia was 5% (95% CI [0.02-0.10]), pulmonary embolism was 1% (95% CI [0.01-0.03]), pleural effusion was 7% (95% CI [0.03-0.14]) and chylothorax was 4% (95% CI [0.02-0.09]). Overall, neoadjuvant chemoimmunotherapy in NSCLC results a high incidence of grade 1-2 TRAEs but a low risk of increasing the incidence of ≥3 grade TRAEs and wound complications. These results need to be confirmed by more large-scale prospective randomized controlled trials and studies.

Clinical characteristics and outcomes of pleural aspergillosis: a review of 13 cases.

Aspergillus pleurisy is a rare complication of invasive pulmonary aspergillosis (IPA), associated with a poor prognosis. The morbidity and mortality of this condition have not been thoroughly studied, and recent research on this topic is limited. The current study included 13 patients diagnosed with Aspergillus pleurisy, with the majority presenting concomitantly with a bronchopleural fistula. Among these patients, nine had a history of thoracic surgery, including lung transplantation and lobectomy. Four patients refused further treatment and were discharged against medical advice, while one patient succumbed to massive hemoptysis 2 years after discharge. This case series provides essential insights into Aspergillus pleurisy and evaluates the therapeutic strategy based on a limited cohort.

Costal cartilage as a promising technique for large bronchial fistula closure in fistulous empyema: a case report

BackgroundThere is no high level of evidence for the treatment of fistulous empyema. We report here a promising technique for closure of a bronchopleural fistula using costal cartilage as a bronchial embolus.Case presentationThe patient is a 79-year-old man. A computed tomography scan diagnosed a fistulous empyema associated with perforation of lung abscess of right middle lobe. After thoracoscopic curettage of the right empyema cavity, right middle lung resection and intercostal muscle flap coverage over the bronchial stump were performed. Seven months after the surgery, a bronchopleural fistula developed. Bronchoscopy revealed fistulas in the middle lobe bronchus and B3b. After the open window thoracostomy, the empyema cavity was cleaned up. The empyema cavity remained from the anterior to the lateral thoracic region of the second to fourth ribs. A part of the second through fourth ribs that formed the ceiling of the pleural empyema cavity was removed to create space for skin and thickened parietal pleura to fill the cavity. The costal cartilage obtained from the rib resection was trimmed and harvested to fit into the diameter of the bronchopleural fistula. The free costal cartilage was sutured and fixed with five stitches with 3-0 PDS. The visceral pleura was covered with the thickened parietal pleura and skin and fixed airtight. To maintain a tight seal, a Blake® silicone drain was inserted between the visceral pleura and the thickened parietal pleura, and a suction reservoir was utilized to sustain negative pressure. The drain was removed on the 21st day. As of 21 months postoperatively, the skin and thickened parietal pleura flap has maintained its integrity, and there has been no evidence of pus or recurrence of air leaks.ConclusionIn the case of a fistulous empyema extending anteriorly, costal cartilage can be easily harvested, making it a promising option as a lid for fistula closure.

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series.

Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation. All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized. Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery. Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BackgroundChronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.Case presentationThis paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.ConclusionsAfter a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

Closure of open window thoracostomy due to MRSA pyothorax by EWS bronchial occlusion and modified extraperiosteal air plombage: a case report.

Refractory pyothorax caused by methicillin-resistant Staphylococcus aureus (MRSA) is a challenging clinical condition; complications such as bronchopleural fistulae can further hinder its treatment. To avoid a fatal state caused by aspirating pneumonia, open window thoracotomy is not only sometimes performed, but subsequent closure of the window can also be difficult. In this report, we describe the case of a patient with MRSA pyothorax with bronchopleural fistula in whom a successful closure of window thoracostomy was achieved by utilizing Endobronchial Watanabe Spigot (EWS; Novatech, La Ciotat, France) bronchial occlusion and a modified extraperiosteal air plombage technique. A 66-year-old man underwent an open window thoracotomy for pyothorax with bronchopleural fistula with MRSA infection at the age of 59. After 7 years, he was referred to our department for the closure of the window. Initially, we occluded the right B6a + b by EWS under bronchoscopy. Subsequently, we dissected the intercostal muscles between the 3rd, 4th, 5th, and 6th ribs to collapse the pyothorax cavity and ensure the coverage of the fistula of lung including the hypertrophied parietal pleura and soft tissues of the chest wall. We filled the extrapleosteal space with a pedicled anterior serratus muscle flap to compress the parietal pleura. Postoperatively, lung expansion was satisfactory, and there has been no recurrence for 6 years since the window closure surgery. We were able to achieve closure and healing in a patient who underwent open window thoracostomy for MRSA bronchopleural fistula by applying EWS and modified extraperiosteal air plombage technique.

Embolization coils in treating postoperative bronchopleural fistula: a systematic review.

This study aims to comprehensively evaluate embolization coils in treating postoperative bronchopleural fistula (BPF). A systematic review based on PubMed, Embase, and The Cochrane Library studies was conducted. All cases receiving embolization coils in treating postoperative BPF were included. The primary outcome was the efficacy of embolization coils in achieving closure of postoperative BPF. 20 patients from 9 studies were included in this systematic review. A median number of 3 (range: 1-10) embolization coils with sealants obtained a complete closure rate of 80% in patients with postoperative BPF with sizes ranging from 2 to 3.1 mm. Three patients with BPF over 3 mm and one with multiple organ failure failed this treatment. Two cases of coil migration were reported without causing respiratory failure or fistula recurrence. Embolization coils might be considered a safe and effective bronchoscopic treatment for small postoperative BPF of less than 3 mm in size. More extensive and rigorous studies are needed to further evaluate and confirm the optimal use of embolization coils in the context of an alternative to surgical repair.

Применение фибринового клея в лечении больных с эмпиемой плевры и бронхоплевральным свищом

Применение фибринового клея в лечении больных с эмпиемой плевры и бронхоплевральным свищом

Management challenges of tension bullae in the emergency department: a case report and literature review

Background: Patients with chronic obstructive pulmonary disease (COPD) are at risk for tension bullae, potentially leading to tension pneumothorax. Distinguishing tension bullae from tension pneumothorax in acutely dyspneic COPD patients is essential but challenging. A case was presented where chest tube placement in a tension bulla provided initial benefit but resulted in a bronchopleural fistula. Case Presentation: A middle-aged male with COPD presented to the Emergency Department with severe dyspnea. History, bedside ultrasound, and chest radiograph suggested tension bulla or tension pneumothorax. CT was done which confirmed tension bulla. Despite bullectomy being the preferred treatment, clinical deterioration necessitated urgent chest tube placement, leading to rapid improvement. However, two days later, a bronchopleural fistula developed, requiring thoracotomy. Conclusion: Emergency physicians must be aware of tension bullae as a rare cause of acute dyspnea in COPD. This case underscores the need for specific management protocols, potentially including smaller diameter catheters for stabilization before definitive surgical treatment.

Thoracoscopy in a country with limited resources in sub-Saharan Africa: a first series of cases from Togo

Objectives: Video-assisted thoracoscopic surgery is experiencing significant growth nowadays. However, in Africa, it is slow to develop. The objectives of this study were to describe the indications and results of thoracoscopy in low and incomes country as Togo. Materials and Methods: A retrospective descriptive cross-sectional study was conducted on patients who underwent exploration and therapeutic procedures by video-assisted surgery from June 2019 to November 2020 and from January 2022 to September 2023 (39 months) in Lomé. Results: Sixteen patients underwent thoracoscopy during the study period. The mean age was 46.06 +/- 23 years. Patients over 45 years old represented 56.2%. The male-to-female ratio was 2.2. Six patients underwent preoperative pleural biopsies. Videothoracoscopy was diagnostic in 10 patients and therapeutic in 6 patients. It was performed under general anesthesia with or without selective intubation in the majority of cases (14/16). Two ports were used in the majority of cases (8/16). Biopsies were performed in 11 patients and intraoperative pleural talc pleurodesis in 4 patients. Pleural debridement was performed in 2 patients. Conversion to thoracotomy was done in 5 patients. The average drainage duration was 4 days. The average length of hospital stay was 5 days. Morbidity and mortality were marked by one case of bronchopleural fistula. Conclusion: Video-assisted thoracoscopic surgery is in its early stages in Togo. Preliminary results are encouraging for its development in Togo.

Treatment of Bronchopleural Fistula with Watanabe Spigots

Treatment of Bronchopleural Fistula with Watanabe Spigots

Point of care lung ultrasound diagnosis of concomitant lung abscess and pleural empyema due to a bronchopleural fistula

Point of care lung ultrasound diagnosis of concomitant lung abscess and pleural empyema due to a bronchopleural fistula

Right Lower Sleeve Lobectomy: Detailed Technique and Perioperative Patient Management.

This report reviews our experience with right lower sleeve lobectomy and describes our technique and approach to perioperative patient management. We retrospectively reviewed 11 patients who underwent right lower sleeve lobectomy for lung cancer. Surgical techniques and perioperative management were also investigated. Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest portion was anastomosed using continuous sutures; interrupted sutures were used for the more superficial portions. The truncus intermedius and right middle lobe bronchus should be anastomosed in a natural position. Anastomosis patency was confirmed using intraoperative bronchoscopy. Separation of the right upper and middle lobes and pericardiotomy at the inferior edge of the superior pulmonary vein are useful for mobilizing the right middle lobe. Death during hospitalization and treatment-related death did not occur. One patient developed pneumonia, and another developed a bronchopleural fistula. We reported our technique of right lower sleeve lobectomy and our approach to perioperative patient management. Sharing knowledge is essential to completing this rare surgery.

Ruptured Pulmonary Hydatid Cyst with Multiple Small Bronchopleural Fistula Formations: A Case Report

Hydatid disease is a zoonosis caused by Echinococcus granulosus. It manifests as cystic lesions, most commonly found in the liver and lungs, and rarely in other parts of the body. The disease occurs when a human host accidentally ingests contaminated food containing eggs from canine waste products. Since the clinical characteristics of this disease are nonspecific, radiological investigations play a crucial role in diagnosis. Diagnostic challenges arise due to atypical imaging features of complicated hydatid cysts. A 40-year-old female patient presented with fever, breathlessness, chest pain, and an unproductive cough persisting for eight days. Upon examination, she was in hypovolaemic shock, and an intercostal drainage tube had been inserted in the left sixth intercostal space. The chest radiograph revealed a dense, homogeneous opacity in the left hemithorax, partially compressing the left lung medially. An High-resolution Computed Tomography (HRCT) thorax showed a thick-walled cavity with an air-fluid level and layered membranes in the dependent part of the cavity, indicating a water lily sign in the left lower lobe of the lung, suggesting a ruptured hydatid cyst. The patient underwent cystectomy with suturing of a small bronchopleural fistula. Computed Tomography (CT) is the preferred imaging modality, especially for assessing associated complications and ruling out differentials in cases of ruptured pulmonary hydatid cysts.

Enhancing treatment approaches for postpneumonectomy empyema: exploring the role of video-assisted thoracic surgery.

Postpneumonectomy empyema (PPE) poses a substantial postoperative risk, even in the absence of a bronchopleural fistula, often necessitating surgical intervention for resolution. To evaluate the efficacy of video-assisted thoracic surgery (VATS) in managing PPE, supported by a comprehensive review of pertinent literature. Six studies were included in this analysis, encompassing 63 PPE cases treated with VATS. Patient ages ranged from 16 to 74 years, with prevalent bacterial strains identified within the Staphylococcus and Streptococcus genera. Hospital stays extended up to 94 days, with 4 patients requiring thoracostomy for infection management. Postoperatively, 1 patient succumbed to complications. VATS holds promise as a viable therapeutic modality for definitive PPE management. In instances of bronchopleural fistula or persistent empyema, consideration should be given to open revision procedures.

Pneumonectomy for severe post-tuberculosis bronchiectasis: A successful of case report and review of the long-term outcome.

Limited clinical intervention studies highlight the absence of evidence-based international guidelines for effectively managing post-tuberculosis lung disease, emphasizing bronchiectasis. The aim of this study was to describe a case of left pneumonectomy for severe post-tuberculosis cystic bronchiectasis and to provide a review of the post-surgical mortality rate, complications, survival rate, and the patient's quality of life following the pneumonectomy procedure. A 36-year-old Indonesian male smoker presented with worsening breathing difficulties and fever. The patient had a history of pulmonary tuberculosis six years ago and reported negative tuberculosis tests after completing TB treatment. However, lung function of the patient progressively declined over the years. Bronchoscopy, chest X-ray, and high-resolution computerized tomography (CT) scan revealed infected cystic bronchiectasis and identified a prominent left lung collapse with calcification in the left pleura. The patient underwent left pneumonectomy through left posterolateral thoracotomy under general anesthesia. The patient was discharged after seven post-operative days with no eventful course. No further complications were found after a one-year post-surgery follow-up, and the patient returned to normal activities, improved fitness, and was fitter in daily life. Based on the literature review, post-surgical mortality rates of pneumonectomy are acceptable, with bronchopleural fistula, cardiac arrest, and thoracic hemorrhage being common causes. Yet, the chances of a complete cure are high. Complications can occur in approximately one-third of patients, including arrhythmia, pulmonary infection, fever, and wound infections. The overall 5-year survival rate following pneumonectomy is generally favorable. Regarding the quality of life, pneumonectomy can have mixed effects. While it could improve symptoms and quality of life, it may impair the quality of life for certain patients, particularly elderly patients and those with lower preoperative quality of life. Although the post-surgical mortality rate, complications, and long-term survival rates of pneumonectomy are generally satisfactory, the expectation of improved post-surgical quality of life should be discussed with the patient prior to surgery.

Treatment of a four-year-old child with destructive pneumonia

BACKGROUND: Treatment of patients with destructive pneumonia remains one of the most difficult problems in pediatric surgery. Modern possibilities of antibacterial and intensive care, minimally invasive endoscopic intraluminal technologies, as well as surgical techniques have reduced the number of adverse outcomes up to 4%. The type of surgical intervention and the time of its performance depend on the disease form, child’s general state, local changes in the bronchi and pleural cavity, as well as on technical capabilities of the clinic.&#x0D; CLINICAL CASE DESCRIPTION: The article presents a clinical observation of the complex treatment of a 4-year-old patient with destructive pneumonia complicated by a bronchial fistula. Intensive and antibiotic therapy stabilized the child’s condition, eliminated manifestations of multiple organ failure, and drained the pleural cavity to resolve tension pyothorax. The programmed thoracoscopy provided an adequate sanation of the pleural cavity, assessed dynamics of the inflammatory process and allowed to position drains under visual control. The fistula of the lower lobe bronchus was closed with a valve bronchoblocker after elimination of the local erosive and ulcerative lesion. A clinical success of such management was manifested with inflammatory process remission, bronchopleural fistula closure, pleural empyema removal. Due to this, deblocking was done three months after discharge from the hospital. At the control examination, the patient had no fistula, most part of the affected lung was preserved, post-inflammatory changes in the pleural cavity were minimal.&#x0D; CONCLUSION: The favorable outcome after treatment of children with destructive pneumonia depends on personalized and multidisciplinary approach. Minimally invasive endoscopic techniques do contribute to the effective elimination of complications, to effective functional restoration of the affected lung and to better recovery of patients.

Anastomosis Complications after Bronchoplasty: Incidence, Risk Factors, and Treatment Options Reported by a Referral Cancer Center.

Sleeve lobectomy with bronchoplasty is a safe surgical technique for the management of lung cancer and endobronchial localization of extrapulmonary cancers. However, anastomotic complications can occur, and treatment strategies are not standardized. Data from 280 patients subjected to bronchoplasty were retrospectively analyzed, focusing on surgical techniques, anastomotic complications, and their management. Multivariate analysis was performed, and Kaplan-Meier curves were used to determine survival. Ninety percent of 280 surgeries were for lung cancer. Anastomotic complications occurred in 6.42% of patients: late stenosis in 3.92% and broncho-pleural fistula in 1.78%. The median survival was 65.90 months (95% CI = 41.76-90.97), with no difference (p = 0.375) for patients with (51.28 months) or without (71.03 months) anastomotic complications. Mortality at 30 days was higher with anastomotic complications (16.7% vs. 3%, p = 0.014). Multivariable analysis confirmed pathological stage (N+) as a risk factor for anastomotic complications (p = 0.016). Our mortality (3.93%) and morbidity rate (41.78%) corresponded to recent series results. In our experience, surgery is preferred to avoid life-threatening complications in bronchopleural fistulas. Bronchoscopic balloon dilatation is preferred for benign strictures. The nodal stage is related to complications (p = 0.0014), reflecting the aggressiveness of surgery, which requires extended radical lymphadenectomy.

Preventive Esophagomyobronchoplasty as a Reliable Prophylaxis of Bronchial Stump Failure and Bronchopleural Fistula after Pneumonectomy in Lung Cancer

Introduction. At present, bronchial stump failure after pneumonectomy ranges from 1% to 20%, and mortality — from 20 to 75%. In past decades, various methods of preventive bronchoplasty have been introduced and improved in order to reduce the incidence of the bronchial stump failure and bronchopleural fistula. However, the existing methods fail to prove their predominant effectiveness to be suggested as a “gold standard” for prevention of the bronchial stump failure during pneumonectomy. A method introduced by the authors enables an additional tissue mobilization with uncontrolled circulatory disturbance of the “biological flap” to be avoided. Aim. To evaluate the results and effectiveness of preventive esophagomyobronchoplasty in clinical practice. Materials and methods. The suture of “preventive esophagomyobronchoplasty” of the bronchial stump after pneumonectomy in lung cancer was developed and introduced into the clinical practice of the Thoracic Surgery Unit. The study involves a statistical analysis of bronchial stump failures as well as bronchopleural fistulas before and after the introduction of preventive esophagomyobronchoplasty. Results and discussion. A retrospective analysis of 224 clinical observations proves a zero probability of such complications after pneumonectomy as bronchial stump failure and bronchial fistula in case of preventive esophagomyobronchoplasty. The incidence of pleural empyema does not exceed 1.3%. Notably, pleural empyema implies longer duration of stay, additional examination, expensive drugs, as well as direct threatening life of a patient. Conclusion. Since 2015, when the new method of bronchial stump formation has been introduced into clinical practice, the rate of complications in the form of bronchial stump failure was reduced from 10.5% to 0%.