Bronchocutaneous Fistula Research Articles

Clinical presentation and treatment of a bronchocutaneous fistula with intrathoracic abscessation in a yearling

SummaryThis case report describes the clinical presentation, surgical treatment, post‐operative management and outcome of a bronchocutaneous fistula with intrathoracic abscessation in a yearling horse. The animal was presented with a history of several months of persistent coughing and a cutaneous fistula located over the right ventral hemithorax. The yearling had purulent discharge similar in character from both nares and draining out of the fistula. A bronchocutaneous fistula with intrathoracic abscessation was diagnosed by endoscopic examination of the cutaneous fistula. The treatment initially consisted of cyanoacrylate applied topically to the affected bronchi under endoscopic guidance, which was not successful. The fistula was successfully sealed with a diode laser used to create local inflammation at the site. One week after the second intervention, the patient's clinical signs resolved and the fistula was completely sealed 10 weeks following intervention. Follow‐up at 16 months revealed that the patient was doing well and clinically normal.

ВОЗМОЖНОСТИ ДИАГНОСТИКИ И ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ОСЛОЖНЕНИЙ ВИРУСНОГО ПОРАЖЕНИЯ ЛЁГКИХ ПРИ COVID-19

The article presents description of our own observation of a clinical case of severe viral infection caused by SARS- CoV-2 complicated by bilateral polysegmental pneumonia, complete bronchocutaneous fistula in a patient born in 1961. Brief information about the features of pathogenesis, clinical presentation, differential diagnosis and surgical treatment of pulmonary complications of this pathology according to modern literary data is presented. The study of the given clinical case indicates that the most important component of differential diagnosis of lung lesions with SARS-CoV-2 virus is laboratory diagnosis and high-resolution multispiral computed tomography. Pneumothorax and pyopnevothorax are a severe complication of COVID-19. However, in persistent bronchopleural fistula, it is necessary to continue active surgical treatment when it is clinically possible, performing minimally traumatic interventions.

Bronchocutaneous fistula from metastatic cervical cancer with COVID-19

A 38-year-old woman with a history of stage IVA squamous cell cancer of the cervix presented with pain and an enlarging wound in her central chest. Approximately 20 months earlier...

SUCCESSFUL BRONCHOSCOPIC REPAIR OF A CHRONIC BRONCHO-CUTANEOUS FISTULA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: A broncho-cutaneous fistula is a pathologic communication between the bronchus, pleural space, and subcutaneous tissue. Positive pressure ventilation, pneumonectomy, and thoracotomy are known causes of broncho-cutaneous fistula formation. Although broncho-cutaneous fistulas are benign, they can be disturbing to the patient and can lead to further serious pulmonary infections. Occlusion of the air leak is essential for adequate healing of the fistula. CASE PRESENTATION: We report a case of a sixty-one year-old-male with a past medical history of diabetes, chronic liver disease and chronic pancreatitis, who was admitted to the intensive care unit due to sepsis secondary to a large left lower lobe empyema. In addition to antibiotics, he required a left-sided thoracotomy, three cavity washouts and ultimately an Eloesser flap in order to achieve complete evacuation of the empyema. After a long hospitalization the patient was discharged home. Five years later the patient was referred by general surgery to our interventional pulmonology service with a chief complaint of air leaking through his non-healing thoracic wound but no other symptoms. A computerized tomographic scan of the chest demonstrated post-surgical changes of the left thoracic wall, which raised concern for a broncho-cutaneous tract formation. The patient was scheduled for an elective bronchoscopy and a broncho-cutaneous fistula was found in the lateral basal segment of the left lower lobe using methylene blue. After localization of the fistulous tract, the entrance to the affected segment was tattooed and two endobronchial valves were placed, Figures 1, 2. The patient was discharged home and complete resolution of the symptoms was reported in the subsequent follow-up visits. Additional imaging studies and a bronchoscopy two months later confirmed the successful closure of the bronco-cutaneous tract. DISCUSSION: Although surgery remains the mainstay treatment of broncho-cutaneous fistula, it may be a high-risk procedure in patients with poor health status or active infection. In these cases, bronchoscopy with various closure methods has been proposed as an alternative treatment. Identification of the broncho-cutaneous fistula can represent a major challenge, as bronchoscopy alone does not consistently identify the anatomic defect. Thus, using a combination of fiberoptic bronchoscopy and a liquid colorant such as methylene blue can be a useful method of diagnosis. Once the location is identified, several devices including histo-acril glue, valves, and stents, can be used to seal the leak. CONCLUSIONS: Endoscopic repair of broncho-cutaneous fistulas is a great therapeutic option in patients where a surgical approach is not possible or represents a very high risk to the patient. Timely and adequate management of these anatomic abnormalities is key in the prevention of serious complications such as severe pulmonary infections. Reference #1: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128(6):3955–3965. Reference #2: Varoli F, Mariani CL, Fascianella A. Methylene blue in bronchial fibroscopy. Minerva Medica. 1984;75(36):2099–2100. Reference #3: John SK1, Jacob S, Piskorowski T. Bronchocutaneous fistula after chest-tube placement: A rare complication of tube thoracostomy.Heart Lung. 2005 Jul-Aug;34(4):279-81. DISCLOSURES: No relevant relationships by Cinthya Carrasco Barcenas, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Rita Medrano Juarez, source=Web Response No relevant relationships by Brittany Rosales, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response No relevant relationships by Andres Yepes-Hurtado, source=Web Response

UNIQUE CASE OF ENDOBRONCHIAL VALVE IN TB BRONCHOPLEURAL FISTULA

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: A bronchopleural fistula (BPF) is a pathological connection between bronchial tree and the pleural space. BPF is a well-known complication of pulmonary tuberculosis (PTB). Endobronchial valve (EbV) are conventionally used to treat persistent air leaks (PAL) in the setting of non-surgical bronchopleural fistula. EbV are not routinely used in BPF secondary to active PTB. We describe a unique case where EbV was used to treat BPF secondary to active cavitatory pulmonary tuberculosis CASE PRESENTATION: A 30-year-old Spanish-speaking female, emigrated from Honduras 5 years ago presented to the emergency department with worsening productive cough and anorexia for two months. On admission patient was noted to be in respiratory distress and saturating 88% on room air. She once cachectic had poor inspiratory effort and bilateral rhonchorous breath sounds. Chest imaging was significant for bilateral upper lobe thick walled cavitatory lesions. Mycobacterium tuberculosis without rifampin resistance was detected, and patient was started on antituberculous therapy. On day 7 patient developed acute respiratory distress secondary to large right-side pneumothorax requiring chest tube placement. Patient required mechanical ventilation for hypercarbic respiratory failure, felt secondary to significant air leak. Bronchoscopy with balloon occlusion was performed, BPF with air leak was identified in right upper lobe with complete disappearance of air leak on occlusion of all three segments of right upper lobe (RUL). On day14 patient underwent endobronchial valve placement with complete occlusion of RUL. The hypercapnia, hypoxia improved, and patient stabilized clinically. Unfortunately, patient had complicated ICU course with failure to thrive and venous thromboembolism. On day 35 family requested terminal extubation and comfort care. DISCUSSION: There is very limited literature on utility and safety of EbV in patients with BPF and PAL secondary to active cavitatory PTB. Since their first description in 2005 by Snell (1), EbV have been in use for more than a decade now. The main indication of EbV is non-surgical management of BPF and PAL. PAL have been associated with significant morbidity, mortality and prolonged hospital stay(2). There is recent literature in multidrug resistant tuberculosis where EbV was used safely to treat cavernous tuberculosis with improved cavity closure and bacteriological conversion (3). In our patient the main reason for EbV placement was to improve minute ventilation and hypercapnia secondary to PAL. Endobronchial valve placement stabilized the clinical status in our patient without any associated adverse events. CONCLUSIONS: We need more literature and randomized controlled trials to evaluate safety and long-term complications of EbV in pulmonary tuberculosis associated BPF. Our case highlights that EbV could be a safe option for BPF in patients with active pulmonary tuberculosis. Reference #1: Snell, G., Holsworth, L., Fowler, S., Eriksson, L., Reed, A., Daniels, F.. (2005) Occlusion of a broncho-cutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 80: 1930–1932. Reference #2: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–65. Reference #3: Denis Krasnov, Yana Petrova, Sergei Skluev, Irina Felker, Vladimir Krasnov, Nikolay Grischenko. Endobronchial valve in complex treatment of patients with destructive pulmonary TB/HIV co-infection.European Respiratory Journal 2016 48: PA775; https://doi.org/10.1183/13993003.congress-2016.PA775 DISCLOSURES: No relevant relationships by Sean Dikdan, source=Web Response No relevant relationships by Boyd Hehn, source=Web Response No relevant relationships by MRINALINI VENKATA SUBRAMANI, source=Web Response

Intraoperative Flow Volume Data From Mechanical Ventilator as a Surrogate for Successful Closure of Refractory Bronchocutaneous Fistula With Intrabronchial Valve Placement

Intraoperative Flow Volume Data From Mechanical Ventilator as a Surrogate for Successful Closure of Refractory Bronchocutaneous Fistula With Intrabronchial Valve Placement

Getting the Wind Knocked out of Your Chest: A Case of Endobronchial Valve Placement for Bronchocutaneous Fistula Following Thoracoplasty for Pulmonary Tuberculosis and Aspergillosis

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Bronchopleural fistula (BPF) is cause for significant morbidity and mortality following pulmonary resection, complicated pleural infection or pneumothorax. Several methods exist for the treatment of BPF ranging from conservative methods to more invasive surgical correction. Endobronchial valve (EBV) placement is a promising minimally invasive technique for poor surgical candidates. CASE PRESENTATION: A 61-year-old male was diagnosed with pulmonary tuberculosis following a trip to Mexico in 2013 and initiated on RIPE therapy, later converted to Rifampin and Isoniazid after sputum clearance. His course was complicated by pulmonary aspergillosis and empyema with significant left upper lobe (LUL) destruction requiring thoracoplasty with Eloesser flap. Several months later he was hospitalized for sepsis and found to have a BPF for which he underwent muscle flap closure. Upon follow-up, he was noted to have a large extrapulmonary air pocket that varied with inspiration. A large BPF between the LUL and lingula was confirmed by bronchoscopy. He was deemed to be a poor repeat surgical candidate due to suboptimal nutritional status and debility so a less invasive intervention was favored. In December 2014 the patient underwent bronchoscopic placement of a removable 7.0mm Spiration® IBV valve. At one month follow up there was significant reduction in the extrapulmonic air accumulation (shown). DISCUSSION: Endobronchial valves were first designed for bronchoscopic lung volume reduction in patients with severe emphysema and air trapping. More recently they were approved by the FDA under the Humanitarian Device Exemption for use in persistent air leaks (PAL) following lung resection. Off-label use for BPF or PAL secondary to suppurative lung infection or spontaneous pneumothorax have become increasingly popular owing to the minimally invasive technique. One-way EBV's work by blocking airflow distal to the valve promoting atelectasis and healing of the BPF while permitting clearance of airway secretions without affecting valve migration. CONCLUSIONS: This is a novel report of the successful use of one-way EBV for a large proximally located BPF after definitive closure was attempted with a muscle flap. Further trials are needed to establish guidelines regarding indications for use, optimal duration and prognosis after placement in such situations. Reference #1: Giddings, O. et al. Endobronchial valve placement for the treatment of bronchopleural fistual: a reivew of the current literature. Curr Opin Pulm Med. 2014. 20:347-51. DISCLOSURE: The following authors have nothing to disclose: Amber Oberle, Khalil Diab, Lorenzo Zaffiri, Aliya Noor Endobronchial valve (EBV) placement for bronchopleural fistulas or persistent air leaks after spontaneous pneumothorax, suppurative chest infection and failure of conventional therapy is currently regarded as off-label and not approved by the FDA. EBV's were originally designed for bronchoscopic lung volume reduction in patients with severe heterogeneous emphysema but have not been FDA approved for this indication. In 2006, The FDA did approved the use of EBV's under the Humanitarian Device Exemption program for patients with persistent air leaks after lung parenchymal resection.

Bronchocutaneous Fistula as a Rare Complication of Tube Thoracostomy

Bronchocutaneous Fistula as a Rare Complication of Tube Thoracostomy

“Pseudocavitation” in Thymic Carcinoma During Treatment with Sunitinib

A 45-year-old man with stage IVA thymic carcinoma was enrolled on a phase II study of sunitinib (50 mg daily)1A Phase 2 Study of Sunitinib in Patients with Advanced Relapsed or Refractory Thymoma or Thymic Carcinoma with at Least One Prior Line of Platinum-Based Systemic Chemotherapy. NCT01621568. www.clinicaltrials.govGoogle Scholar 4 weeks after disease progression on first-line chemotherapy with cisplatin, doxorubicin, cyclophosphamide, and belinostat.2A Phase 1/2 Study of PXD101 (Belinostat) in Combination With Cisplatin, Doxorubicin and Cyclophosphamide in the First Line Treatment of Advanced or Recurrent Thymic, Malignancies. NCT01100944. www.clinicaltrials.govGoogle Scholar Molecular profiling of the tumor revealed only a p53 gene mutation (c-Kit was wild type).3Pilot Trial of Molecular Profiling and Targeted Therapy for Advanced Non-Small Cell Lung Cancer, Small Cell Lung Cancer, and Thymic Malignancies. NCT01306045. www.clinicaltrials.govGoogle Scholar Baseline chest computed tomography, before sunitinib, showed a mediastinal mass with compression of the proximal right main pulmonary artery (Fig. 1A) and direct invasion of pericardium. Three weeks after initiation of sunitinib, the patient reported increased left shoulder pain, cough, nausea, vomiting, and a palpable soft and fluctuating lesion measuring 2 cm in size overlying the sternum. A new computed tomography scan (Fig. 1B–D) showed an increase in the size of the mediastinal mass, which now included air (Fig. 1B–D, asterisk), air-fluid levels (Fig. 1B, D, arrow), dissection in the anterior chest wall with subcutaneous air (Fig. 1C, double arrow), and a large left pleural effusion (Fig. 1B–D). Sunitinib was discontinued, and a thoracentesis was performed to remove a liter of straw-colored fluid. Considering disease progression with tumor necrosis and superimposed infection with the possibility of bronchocutaneous fistula, antibiotic therapy was started. Subsequently, the patient's clinical condition deteriorated rapidly with development of right ventricular heart failure, and he died 2 weeks later. The autopsy revealed massive neoplastic infiltration of the heart and great vessels, including the pulmonary artery and left lung, with abundant tumor necrosis, most likely related to rapid progression of disease rather than antiangiogenesis effects of sunitinib. This represents an unusual finding in a patient with an aggressive thymic carcinoma.

Is it safe to cut pacing wires flush with the skin instead of removing them?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to cut the temporary epicardial pacing wires (TEPWs) flush with the patient's skin surface prior to discharge. Altogether 105 relevant papers were identified of which 13 case reports represented the best evidence to answer the question. The author, journal, date, country of publication, complications, the culprit TEPW and relevant outcomes are tabulated. All case reports demonstrated a wide spectrum of complications. Complications from a retained TEPW mainly arise after a long dormant period. A recent case report has demonstrated the herniation of intra-abdominal contents through a diaphragmatic defect created by the abandoned epicardial pacing wires after a few decades. In multiple case reports, the migration of TEPW was the culprit of serious complications. In two case reports, the TEPWs attached to the right chambers of the heart had migrated to the pulmonary artery via the right atrium and then the right ventricle. In one case report, a similar migration of the right ventricular TEPW to the right ventricular outflow track was observed. The TEPW migration was not limited to the right side of the heart, as in one case report the right atrial TEPW had migrated to the right carotid artery via the ascending aorta. A distant extravascular migration of TEPWs to the skin surface and intraperitoneal and pelvic cavities has also been reported. Retained TEPWs have also been reported to inflict complications locally. One case report has shown a large right-sided para-cardiac mass caused by a right atrial TEPW. In two other case reports, the bronchocutaneous fistula, lobar consolidation and bronchiectasis were the manifestations of a retained TEPW. We conclude that the retention of TEPW after cardiac surgery is not necessarily safe and may cause severe complications. We recommend that TEPWs should be completely removed when possible. If TEPWs are retained, this should be appropriately documented and the surgeon should be mindful of this when the patient presents with complications postoperatively.

Chronic Bronchocutaneous Fistula Caused by Toothpick Foreign Body in a Maltese Dog

A 7-year-old, 1.76 kg Maltese dog presented with a 4-year history of a chronic pustular lesion and a wet cough. Erosive lesions were seen at the left thoracic wall. Radiology and computed tomography (CT) revealed a bronchocutaneous fistula connecting from the left cranial bronchus to the skin. On definitive surgery, a long wooden toothpick was observed within this tract, and clinical signs resolved after retrieval of the foreign body. Three-dimensional CT was useful to identify the characteristics of the bronchocutaneous fistula. However, the wooden foreign body was not apparent on CT. Here, we report the clinical, clinicopathological and diagnostic imaging findings of a chronic bronchocutaneous fistula caused by a foreign body in a dog.

Cavitary lung cancer presenting as subcutaneous emphysema on the contralateral side

Bronchocutaneous fistula is an extremely rare complication of lung cancer and is frequently seen following biopsy or radiotherapy. A 67-year old male patient was administered to our hospital due to sudden onset of shortness of breath and subcutaneous emphysema on the right side. Chest computed tomography revealed a cavitary lesion in the left upper lobe in connection with the subcutaneous emphysema on the right side through sternum and anterior chest wall. The pathological examination of the biopsy performed during tube insertion revealed a well-differentiated squamous cell carcinoma of the lung. The patient was referred for adjuvant therapy to local oncology hospital. He passed away 9 months following diagnosis.

Microwave Lung Ablation Complicated by Bronchocutaneous Fistula: Case Report and Literature Review

Microwave ablation is a developing treatment option for unresectable lung cancer. Early experience suggests that it may have advantages over radiofrequency (RF) ablation with larger ablation zones, shorter heating times, less susceptibility to heat sink, effectiveness in charred lung, synergism with multiple applicators, no need for grounding pads, and similar survival benefit. Newer microwave ablation devices are being developed and as their use becomes more prevalent, a greater understanding of device limitations and complications are important. Herein we describe a microwave lung ablation complicated by bronchocutaneous fistula (BCF) and its treatment. BCF treatment options include close monitoring, surgical closure, percutaneous sealant injection, and endoscopic plug or sealant in those who are not surgical candidates.

Treatment of a malignant peripheral nerve sheath tumor and its complications through a multidisciplinary approach

The authors report the case of a 14-year-old girl with a residual malignant peripheral nerve sheath tumor after thoracotomy, chemotherapy, and radiation therapy. The residual tumor, which involved the intercostal muscles, aorta, and neural foramina of T4-10, was completely resected through a costotransversectomy and multiple hemilaminotomies with the patient in the prone position and was stabilized using a T1-12 pedicle screw fusion. Postoperatively, the patient developed several infections requiring multiple washouts and prolonged antibiotics. Thirty months after surgery, she developed a bronchocutaneous fistula. The hardware was removed, and a vascularized latissimus dorsi free flap was placed over the lung. She continued to have an air leak and presented 3 weeks later with a 40° left thoracic curve. She returned to the operating room for a T2-L2 fusion with a vascularized fibular graft. On postoperative Day 1, she underwent a bronchoscopy and had her left lower lobe airways occluded with multiple novel one-way endobronchial valves. She is now 5 years out from her tumor resection and 3 years out from her definitive fusion. She has no evidence of residual tumor, infection, or pseudarthrosis and continues to remain asymptomatic.

Severe Local Toxicity after Lung Stereotactic Body Radiation Therapy: Lesional Abscess Leading to Bronchocutaneous Fistula Requiring Surgical Marsupialization

Severe Local Toxicity after Lung Stereotactic Body Radiation Therapy: Lesional Abscess Leading to Bronchocutaneous Fistula Requiring Surgical Marsupialization

Effective Approach for the Treatment of Bronchopleural Fistula: Application of Endovascular Metallic Ring-Shaped Coil in Combination With Fibrin Glue

The development of bronchopleural fistula is an important complication after pulmonary resections. Generally, conventional treatment methods are used in patients having bronchopleural fistulas. Recently, there has been an increase in the use of minimally invasive methods yielding better results. In our study, we applied a combination of endovascular metallic ring coil and fibrin glue. We hereby think that such an approach for a combination might be a contribution to improving the already existing minimally invasive treatment methods.

Occlusion of a Broncho-Cutaneous Fistula With Endobronchial One-Way Valves

Bronchopleural and broncho-cutaneous fistulas can be problematic after lobectomy for tumors or aspergillomas. Closure of the air leak and treatment of infection are essential to allow the fistula to heal. The initial treatment can usually proceed along standard lines, but if the fistula persists, then treatment can be problematic. This report is the first description of the use of multiple Emphasys Medical endobronchial valve prostheses (Emphasys Medical, Inc, CA) to control a previously intractable broncho-cutaneous fistula. The valves have been specifically designed for airway placement as part of a therapeutic approach to severe emphysema. The advantages of using valves in this situation are discussed.

Bronchocutaneous fistula after chest-tube placement: A rare complication of tube thoracostomy

Bronchocutaneous fistula is a pathologic communication between the bronchus, pleural space, and subcutaneous tissue. It can occur as a complication of positive pressure ventilation and pneumonectomy. Diagnosis is made by imaging studies. Treatment options are endoscopic repair, parietal pleurectomy, and pleurodesis. Our patient is a 53-year-old woman who had a difficult chest-tube placement for complicated parapneumonic effusion. Computed tomography scan revealed a fistulous tract from the bronchus to the skin at the site of the original chest tube, and chest x-ray film revealed a subcutaneous fistulous air tract in the lateral chest. It is usually an acquired condition; congenital bronchocutaneous fistula is rare. We report a case of bronchocutaneous fistula after chest-tube placement.

Novel management of a large chronic bronchocutaneous fistula after lobectomy

We describe the successful use of silicone stent for the treatment of chronic bronchocutaneous fistula in a patient with a large stump opening of 20 mm in diameter. A literature review of bronchoscopic treatment of bronchopleural fistula (BPF) is also discussed here.

Bronchocutaneous fistula in a dog.

A dog with a bronchocutaneous fistula is described. Contrast enhanced computed tomography was useful for diagnosis and treatment of the fistula in this dog.