Pleural Fistula Research Articles

Bevacizumab-induced esophageal pleural fistula during maintenance therapy without radiation in lung cancer

BackgroundEsophageal pleural fistula (EPF) is a rare but fatal complication associated with bevacizumab use; however, cases reports of EPF caused by bevacizumab have not been previously published.Case presentationA 66-year-old male patient diagnosed with stage IV lung adenocarcinoma on April 24, 2020 received 6 cycles of platinum-containing dual chemotherapy combined with bevacizumab followed by three cycles of bevacizumab monotherapy. Five days before admission, he experienced chest tightness, dyspnea, and right chest pain. Bed-side X-ray examination revealed a massive right hydrothorax, and food was found in the extracted pleural effusion. EPF was further confirmed by upper gastrointestinal radiography after oral administration of iohexol. The patient underwent jejunostomy as the distal esophagus could not be identified on gastroscopy, and eventually died of septic shock on January 16, 2021.ConclusionsIt is necessary to pay attention to EPF during bevacizumab use in patients with or without risk factors.

An experience of the treatment of a patient with chronic pancreatitis with pancreatic pleural fistula complicated by lung abscesses

Pancreatic pleural fistula is one of the rare and difficulty verifying complication of chronic pancreatitis. We present a rare medical case of a patient with chronic pancreatitis complicated by pancreatic pleural fistula with the formationof multiple lung abscesses. At the same time, the success of the treatment of the patient was due to the staged treatment and the participation of a multidisciplinary team of specialists.

S3476 Workup of a Suspected Pancreaticopleural Fistula in a Young Male

Introduction: Pancreatic fistulas are an abnormal connection between the pancreas and an adjacent or distant structure or organ. These can be characterized as internal or external depending if the pancreatic duct communicates with the skin or not. The most common cause of an internal pancreatic fistula is pancreatitis associated with chronic alcohol. Pancreatopleural fistulas develop by leakage of pancreatic exocrine secretions through the openings in the diaphragm. Here we present a case, where there was concern for a pancreatopleural fistula. Case Description/Methods: A 31-year-old male with past medical history of chronic recurrent pancreatitis complicated by enlarging pseudocysts and portal vein thrombosis was transferred to our facility from outside hospital for hemorrhagic pancreatic pseudoaneurysm status post IR embolization. He had been bleeding from the hemorrhagic pseudoaneurysm at the previous hospital and had been treated with an initial IR embolization procedure for this 4-5 days before arriving at our facility. He underwent repeat IR embolization procedure with repositioning of the malpositioned coil 6 days after admission and subsequently underwent EGD with endoscopic ultrasound and cysgastrectomy for treatment of his associated pancreatic pseudocyst 12 days after admission. Pleural effusion seen on Xray was thought to be secondary to pancreatic fluid accumulation. Thoracentesis was subsequently performed due to patient complaints of dyspnea and analysis showed > 12,000U/L of amylase and black fluid concerning for a pancreatic pleural fistula (Figure A). Patient had a repeat X-ray the following day with accumulation of the pleural effusion (Figure B). Patient was started on TPN and Octreotide for treatment. Repeat thoracentesis yielded amber colored fluid and a CT chest, abdomen and pelvis did not show evidence of fistula formation. It was determined that the initial thoracentesis performed on the patient was actually placed into the pancreatic pseudocyst due to severe elevation of the hemidiaphragm. The patient was ultimately discharged with plans to follow-up with general surgery as an outpatient for possible pancreatectomy. Discussion: We believe that our findings during the care of this patient are important for Gastroenterologists as they provide an excellent opportunity to review both the common and obscure complications of pancreatitis. entity that can occur in patients with acute pancreatitis and is characterized by small, left sided pleural effusions.Figure 1.: Figure A. Thoracentesis fluid obtained from patient concerning for a pancreatic pleural fistula. Figure B. Repeat chest x-ray showing re-accumulation of large left-sided pleural effusion.

S1549 An Ominous Connection Causing Recurrent Pleural Effusions

Introduction: Fistulation is a rare complication of chronic pancreatitis. Pancreaticopleural fistula (PPF) typically presents with thoracic symptoms. Pathogenesis is related to pancreatic duct obstruction causing leakage of pancreatic fluid, and if persistent can lead to fistula formation. Due to its predominant thoracic over abdominal symptoms, the diagnosis and treatment of PPF are usually delayed. The following case is an example of the potential need for repeat testing to confirm the diagnosis of PPF as well as a multidisciplinary approach to treatment. Case Description/Methods: A 66-year-old white woman presented to the emergency department with 10 days history of worsening dyspnea, orthopnea, and chest tightness. Her medical history was notable for alcohol-induced chronic pancreatitis. On physical examination, she was tachycardic with diminished breath sounds bilaterally. Chest CT angiogram revealed bilateral pleural effusions. Diagnostic right sided thoracentesis revealed exudative fluid pattern, but negative for infection and malignancy. Symptoms initially improved after therapeutic thoracentesis, but pleural effusions shortly recurred requiring repeat thoracenteses. Pleural effusions laboratory findings on thoracenteses are listed in Tables 1 and 2. MRCP showed an irregular tubular tract extending cephalad from the pancreas toward the right diaphragmatic crus and appeared to communicate with the right hydropneumothorax (Figure 1). ERCP was performed which showed diffuse dilatation of the pancreatic duct (Figure 2). Patient underwent therapeutic stenting to the ventral pancreatic duct (Figure 3). She had complete resolution of symptoms and pleural effusions on 2 months follow-up chest CT. Discussion: Pancreatic pleural fistula is a rare complication of chronic pancreatitis and can be a challenging diagnosis as symptoms tend to overlap with other causes of dyspnea, hypoxia and pleural effusions. MRCP is the most sensitive imaging modality, followed by ERCP and CT to visualize pancreatic duct anatomy and guide further therapeutic management. Conservative medical management with bowel rest and somatostatin analog are shown to be effective in patients without pancreatic ductal obstructions. In cases with recurrent pleural effusions despite conservative management, ERCP with therapeutic stenting to alleviate pancreatic ductal obstructions is strongly indicated with high success rate. Owing to its rarity and complexity, a multidisciplinary approach to PPF is warranted to provide the best care possible.Figure 1.: Tables and Figures.

A case report of Pancreatico Pleural Fistula presenting as recurrent right pleural effusion

Chronic Obstructive Pulmonary Disease (COPD) is characterized by irreversible airflow limitation in the lungs. COPD frequently coexist with Heart Failure (HF) but most patients go undiagnosed because of similarity of symptoms. Data on prevalence of COPD in HF are discrepant and scarce.

Pleurography (thoracography) for pleural fistulas: A case series.

BackgroundPleurography (PG) has been described previously but has not gained popularity. PG can determine the exact air leak points in the lung, which is important for treating pneumothorax and pleural fistulas. We believe that the usefulness of PG should be reassessed, and here we describe the method, air leak detection rate, and common complications.MethodsFrom the 1210 cases of pleural fistulas that were treated at our institution between March 2015 and October 2018, 275 patients with recurrent primary pneumothorax or secondary spontaneous pneumothorax were selected for this study. PG was performed in 127 patients with persistent air leakage during exhalation. In addition, 35 patients with postoperative complications of air leakage persisting for 7 days or longer were included.ResultsAir leak points were detected in 119 patients (73%), in the apex of the lung in 65 cases, in the basal segment in 13 cases, and in the middle lobe or lingular segment in 9 cases. There were 8 cases of hilar lesions, 12 cases of S6 lesions, 8 cases of upper lobe lesions other than apex, and 4 cases of upper mediastinal lesions. Complications within 30 days were observed in 10 cases (6.2%), with 8 grade 2 cases involving fever, 1 grade 3 case involving infection, and one grade 1 case with abdominal distension.ConclusionsThe incidence of grade ≥3 adverse events after PG was 0.6%, which is considered acceptable. Our findings suggest that PG is a safe examination method to identify air leaks before surgery for pleural fistulas.

ОСОБЕННОСТИ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ПАНКРЕАТИКОПЛЕВРАЛЬНЫХ СВИЩЕЙ

The analysis of features of diagnosis and treatment of pancreaticopleural fistulas according to the materials of publications and own clinical observation of a 44-year-old patient with fistula between a false pancreas cyst and both pleural cavities is presented. Diagnosis in the debut of this disease was complicated by the prevalence of pleural pulmonary pathology, lack of characteristic clinical signs of pancreatic lesion and lack of references to them in the anamnesis. The sudden color change of pleural exudates from straw yellow to red-brown and comparison of the results of blood serum and pleural fluid analysis for amylase content allowed suspecting pancreatogenic origin of bilateral hydrothorax, which served as a basis for instrumental examination of the pancreas. The nature and prevalence of the process in the pancreas, abdominal cavity and the presence of pancreaticopleural fistula with bilateral hydrothorax were established by ultrasound and multispiral computer tomography of the thoracic and abdominal cavities; specification - by magnetic resonance imaging in the modes of T1-BI, T2-BI and magnetic resonance cholangiopancreatography(MRCP). Conservative treatment of acute inflammation of the pancreas in combination with puncture method of sanation of pleural cavities led to the elimination of pancreatic pleural fistula and bilateral hydrothorax. The choice of the method for the rehabilitation of pleural cavities should be justified by the nature, volume, rate of exudates accumulation and its infection. Magnetic resonance cholangiopancreatography (MRCP) is being used routinely to determine the expediency, possibility and the choice of method and volume of surgical treatment of pancreas pathology.

An Audit of Management of Chronic Pancreatitis with Pancreatic Ductal Disruption Resulting in Ascites and Pleural Effusion

Introduction: Pancreatic Ductal Disruption (PDD) may remain a localised collection to form pseudocyst or dissect into adjacent organs or rupture freely into the peritoneal cavity or pleural cavity resulting in massive or high-volume ascites or pleural effusions. The management of pseudocyst is well known among general and gastrosurgeons, but ascites and plural effusion remain difficult decisions. Depending on the availability of resources total parenteral nutrition, octreotide, pancreatic duct stenting are used with varying success. There are no guidelines as to which intervention is preferable in different clinical scenarios. Aim: To audit the clinical characters and management of patients with pancreatic ascites and pleural effusion. Materials and Methods: This study was done at the Department of Surgical Gastroenterology, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India. Fifty two patients with pancreatic ascites or pancreatico pleural fistula in the background of chronic pancreatitis satisfying both inclusion and exclusion criteria were identified and studied from the prospectively maintained database of patients with chronic pancreatitis in the period from September 2010 to September 2020. The patients were classified as conservatively managed, endoscopic main pancreatic duct stenting or surgery. Statistical analysis was done using windows excel. The results were expressed as percentage, mean and Standard Deviation (SD). Results: Five patients with ascites and two patients with pleural effusion responded completely to conservative measures (13.4%). In one of them ascites recurred at two months and one had left pleural effusion recurrence at one month. Fifteen patients died while on conservative management (68.2% mortality). Among eight patients undergoing endoscopic pancreatic duct stenting, ascites/pleural effusion resolved in six (75% success rate) and remained asymptomatic during mean follow-up of 12 months. Two patients who were not improving after stenting were lost to follow-up. Twenty-two patients underwent surgery namely lateral pancreatojejunostomy with resolution of symptoms. Two patients undergoing surgery died in postoperative period due to sepsis and chest infection (9.1% mortality). At a mean follow-up of 14 months they remained symptom free. Conclusion: Conservative management alone has high mortality. Early aggressive management can aim to stop leak either by pancreatic duct stenting or surgical lateral pancreatojejunostomy will help reduce mortality and morbidity.

Surgical treatment of wounded persons with complicated thoracic damages

Objective. To improve the results of complex surgical treatment of wounded and injured persons with thoracic trauma, complicated by bronchopleural fistulas, pleural empyema and defects in the thoracic wall soft tissues, basing on introduction of the proposed procedure of vacuum therapy in combination with bronchoscopic obturation of certain bronchus.
 Materials and methods. Analysis of results of the complex surgical help delivery for 54 wounded persons with defects of the thoracic wall soft tissues, broncho-pleural fistulas and pleural empyema, caused by the combat thoracic trauma, on ІІІ and ІV levels of medical support while conduction of the Antiterrorist operation/Operation of the Joined Forces (the main group) and 73 injured persons with thoracic trauma of the peace period (the comparison group) in the 2014 - 2019 yrs period was conducted.
 Results. Improvement of complex surgical treatment of the wounded and damaged persons with thoracic trauma and defects of the thoracic wall soft tissues have permitted to reduce the complications frequency by 6.7%, and lethality - by 9.2% in the main group.
 Conclusion. There was proposed a procedure of vacuum therapy, ultrasound cavitation together with bronchoscopic bronchial obturation for its fistula, which have proved its efficacy in complex surgical treatment of severely wounded persons with the gun-shot thoracic damages and presence of combination of pleural empyema, bronchial fistula and defects of soft tissues.

OUTCOMES OF OPEN THORACIC SURGICAL DECORTICATION IN PATIENTS WITH TUBERCULOUS EMPYEMA

Objective: To analyze the outcome of open surgical decortication of tuberculous empyema patients at their late presentation.
 Study Design: Cross sectional study.
 Place and Duration of Study: Patients (n = 128) with tuberculous empyema were subjected to decortication for one and half year starting from July 2017 to December 2018. Pre, intra, and post-operative characteristics of all patients were studied thoroughly with a 6-month follow up evaluation of the surgical outcomes.
 Results: Preoperative conditions were as follows: 6.25% patient had Broncho pleural fistula, 90.9% patients were diagnosed with cough, 34.7 with night sweating, 64.2% chest pain and 79.6% chest tightness. Decortication was performed in all cases, with debridement of necrotic tissue and repair of air leaks in some patients. 70 (54.7%) patients went through right side decortication, whereas 56 (43.7%) patients went through left sided decortication and 2 (1.56%) patients had bilateral. Mortality was 2 (1.56%), 1 patient died of septicemia while 1 of pulmonary embolism. Whereas morbidity was 9 (7%), 3 patients had wound infection, 4 had incomplete lung expansion, 1 patient each had prolonged air leak and post-operative bleeding.
 Conclusions: Delayed referral for surgery causes irreversible changes in the lung, and prolonged disease condition, which causes increased thickness of the pleura and injury to the underlying lung with a delayed recovery. Open decortication gives satisfactory results.

Low 25-OH vitamin D level are associated with increased postoperative acute kidney injury, broch pleural fistula after lung transplantation

Background: Vitamin D (Vit D) deficiency is found in over two-thirds of lung transplantation (LT) candidates, which is greater than in general population. In addition to bone metabolism, low serum level of 25-hydroxyvitamin D[25(OH)D] is known to be associat ed with higher incidence of infections, cancer, and cardiovascular disease. So, it is important to investigate association between Vit D level and post LT complications. Methods: In this single-center study, we reviewed 237 LT patients from January 2013 to July 2019 at Severance Hospital, Seoul, Korea. Thirty-nine patients were excluded due to missed level of preoperative Vit D. Enrolled patients were divided into Vit D defi ciency group (range, 0-10 ng/mL), Vit D insufficiency (range, 10-30 ng/mL), and Vit D sufficiency group (>30 ng/mL). Analysis of variance and chi-square tests were used for comparing variables. Results: Forty-nine patients (24.7%) were Vit D deficiency, 128 patients (64.6%) were Vit D insufficiency, and 21 patients (10.6%) were Vit D sufficiency. There were no significant differences between three groups with respect to age, sex, comorbidities, and primary lung disease. Low Vit D level was associated higher occurrence of postoperative acute kidney injury (AKI; deficiency vs. insufficiency vs. sufficiency, 10 [22.2] vs. 11 [9.5] vs. 1 [5.0]; P<0.05). Prevalence of broncho pleura fistula was higher in Vit D sufficiency group: deficiency vs. insufficiency vs. sufficiency, 0 (0.0) vs. 14 (10.9) vs. 0 (0.0); P=0.016. We further evaluate postop erative broch pleural fistula (BPF) in Vit D increase and Vit D decrease group within 6-month follow-up, and Vit D decrease group show high prevalence of BPF: decrease vs. increase, 9 (12.3) vs. 1 (1.1); P=0.002. Low Vit D level was also associated with post operative anxiety, but it was not statically meaning. Conclusions: Low 25-OH Vit D level is associated with increased incidence of post LT complications such as AKI, BPF, and anxi ety. Also, Vit D decrease during postoperative period showed higher incidence of BPF.

IT LOOKED BLOODY BUT WASN'T: A CASE OF SALMONELLA EMPYEMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Non-typhi Salmonella was isolated from sample of pleural empyema of an immunocompromised patient. The patient was treated with prolonged antibiotic course, thoracotomy with decortication, and chest tube placement; endured complications including chest tube induced pleural cutaneous fistula, subcutaneous emphysema, pneumomediastinum, and persistent hydropneumothorax with trapped lung. Pulmonary salmonellosis is a rare infection that generally occurs with history of gastrointestinal symptoms or enterocolitis and should be considered in patients with immunodeficiency, sickle cell anemia, and lung cancer. CASE PRESENTATION: 57-year-old man with PMH of RA and recurrent right sided pleural effusion (PE) presented with right sided pleuritic chest pain. The patient was septic with a leukocytosis of 15.8 10E3/uL. CT chest showed moderate sized, loculated PE with adjacent passive atelectasis [Figure 2]. A thoracentesis was performed with 650 cc bloody fluid drained. Pleural fluid was exudative with glucose less than 10, pH 6.83, and LDH 1175. A chest tube was placed and pleurolysis initiated. He subsequently underwent right thoracotomy decortication with findings of extensive adhesions, trapped middle and lower lobe lung, and thick chronic rind with no dissection plane. Fluid culture speciated to Salmonella group D and ABX were narrowed to ceftriaxone. He was successfully treated with a 65-day course. DISCUSSION: Salmonella is a gram-negative non-spore forming anaerobic motile bacilli of the Enterobacteriaceae family. Clinical presentation of a Salmonella infection depends on the serotype and ranges from sepsis to gastroenteritis. Non-typhi salmonella organisms often produce a localized reaction, most commonly intestinal infections.1 There have been rare cases of pleuropulmonary infections, which are abrupt in onset without gastrointestinal symptoms in two-thirds of cases and incidence is highest in immunosuppressed patients.2 Pathogenesis is unclear, however it is suggested that Salmonella may rest dormant in the reticuloendothelial system. Blood spread may be a consequence of reactivation however due to low bacterial load, blood cultures are often negative.3 Due to Salmonella organisms’ propensity for prolonged infection a 4 to 12-week course of ABX should be anticipated and include a third-generation cephalosporin or fluoroquinolone. CONCLUSIONS: In patient with relapsing infections, drainage of empyema is likely necessary, with the possibility of decortication. Patients without known preexisting conditions should also undergo further testing for associated immunodeficiency including HIV and malignancy as well as investigation for focal gastrointestinal tract infections and fistulas.Lastly, in the setting of an immunocompromised patient with exudative pleural effusions or empyema, non-typhi Salmonella should be considered as a causative agent and investigated as early as possible. Reference #1: Abuhasna S, Al Jundi A, et al. Non-typhoidal Salmonella group D bacteremia and urosepsis in a patient diagnosed with HIV Infection. Journal of Global Infectious Diseases. 2012;4(4):218. Reference #2: Pathmanathan, S., Welagedara, S., Dorrington, P. et al. Salmonella empyema: a case report. Pneumonia 6, 120–124 (2015). Reference #3: Saeed N. Salmonella pneumonia complicated with encysted empyema in an immunocompromised youth: Case report and literature Review. The Journal of Infection in Developing Countries. 2016;10(04):437-444. DISCLOSURES: No relevant relationships by Sarah Luber, source=Web Response no disclosure on file for David Sharpe; No relevant relationships by Abigayle Sullivan, source=Web Response

S1567 Pancreatico-Pleural and Enteric Fistulas: A Rare Complication of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

INTRODUCTION: Pancreatico – pleural and enteric fistulas (PPEF) are rare complications of pancreatitis, where a tract is created draining pancreatic fluid into the pleural cavity and/or bowel. Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a 5-10% risk of pancreatitis. CASE DESCRIPTION/METHODS: A 66-year-old female with past medical history of hypertension and asthma presented for abdominal pain with nausea and vomiting. One-day prior she underwent an ERCP. She was treated conservatively for post-ERCP (pERCP) pancreatitis. Subsequently she was admitted for pancreatitis three times over a period of 3 months. Vitals were within normal limits. Physical examination was significant for diffuse abdominal tenderness and normoactive bowel sounds. Laboratory data was significant for a lipase of 2858, and a WBC of 12.39. Otherwise, complete metabolic panel, and CBC were normal. Initial computerized tomography (CT) showed acute pancreatitis with a large pseudocyst (Figure 1). Interval CT showed pancreatic duct dilation, a pancreatico-enteric fistula tract and a new left pleural effusion with air within the fluid suggestive of a pancreatico-pleural fistula (Figure 2). The patient was managed conservatively. At 3-month follow up, the patients symptoms had resolved, and a repeat CT showed resolution of pancreatitis, fistula and pleural effusion (Figure 3). DISCUSSION: Magnetic resonance cholangiopancreatography is the diagnostic imaging of choice for visualizing pancreatic fistulas. Thoracentesis with a lipase-rich pleural fluid can help aid in the diagnosis.Modalities of treatment are endoscopic stenting of the disrupted pancreatic duct, conservative management with octreotide (to suppress pancreatic exocrine function) with or without chest tube drainage, or surgical intervention with distal pancreatectomy and pancreatico-jejunostomy in those with complete ductal obstruction. Thirty to 60% of patients can be managed successfully with conservative management. Sphincter of oddi dysfunction, young age, repeated cannulation attempts with sphincterotomy, and history of pancreatitis are risk factors for pERCP pancreatitis. Prophylactic rectal indomethacin and pancreatic stenting in patients at high risk of pERCP pancreatitis have been shown to decrease incidence rates. PPEF uncommonly arise together and require a high index of suspicion. The diagnosis can be made via imaging, endoscopy or with a thoracentesis. Management is usually conservative, but endoscopic or surgical procedures may be warranted.Figure 1.: CT abdomen and pelvis showing acute pancreatitis with a pancreatic tail/body large pseudocyst (Green arrow).Figure 2.: Interval CT Chest, abdomen and pelvis showing dilated pancreatic duct (Blue arrow), resolving pancreatic pseudocyst(White arrow), pancreatico-enteric fistula tract (Red arrow), and a new left pleural effusion with air within the fluid (Yellow arrow) suggestive of a pancreatico-pleural fistula.Figure 3.: A 3-month Interval CT abdomen, pelvis and chest showing complete resolution of acute pancreatitis and fistula tract (Panel A), and resolution of pleural effusion (Panel B).

Our Experience on The Use of Dimexid (Dimethyl Sulfoxide) in The Effective management of Lung abscess

A lung abscess is a localized area of pulmonar parenchymal necrosis caused by an infectious anism Primar lung abscesses occur in immunocompromised patients. Secondary lung abscesses occur in patients with an underlying pulmonary disease. Systemic broad spectrum antibiotics, pulmonary physiotherapy, postural drainage and interventional or surgical drainage and surgical pulmonary resection in selected cases, are main modalities in the management of lung abscesses. A distressing fact is the long course of recovery and complications encountered in the management of lung abscesses. Severe complications like massive haemoptysis, endobronchial spread, rupture into the pleural space, pyopneumothorax, empyema, broncho pleural fistula, septic shock and respiratory failure have been reduced with advances in treatment, as mentioned above. Dimexid Dimethyl Sulfoxide possesses strong anti inflammatory, analgesic, antioxidant and antimicrobial actions it changes the sensitivity of microflora resistant to antibiotics.

Unilateral upper lung-field pulmonary fibrosis radiologically consistent with pleuroparenchymal fibroelastosis after thoracic surgery: Clinical and radiological courses with autopsy findings.

Pleuroparenchymal fibroelastosis (PPFE) is a rare idiopathic interstitial pneumonia characterized by pleural and parenchymal involvements predominantly in the upper lobes. Unilateral upper-lung field pulmonary fibrosis (upper-PF) radiologically consistent with PPFE was recently reported in patients with a history of open thoracotomy and presented with impaired thoracic movements in the operated side with unknown mechanisms. This retrospective study aimed to elucidate the clinical and radiological courses and pathological findings of unilateral upper-PF. All the consecutive patients diagnosed as having unilateral upper-PF between March 2012 and April 2018 were included. Radiological images and clinical courses before and after the diagnosis were thoroughly reviewed. Fourteen patients were included. Unilateral upper-PF was diagnosed after a median of 4.8 years from the open thoracotomy or video-assisted thoracic surgery for treating lung or esophageal cancer, or bronchiectasis. Before or at diagnosis, 12 (85.7%) of 14 patients developed aberrant intrathoracic/extrathoracic air suggestive of pleural fistula, although the degree was slight. Of note, the upper-PF lesion apparently deteriorated once aberrant air emerged in all the patients. After diagnosis, the upper-PF lesion transformed into cystic lesion in 9 patients, 4 of whom eventually developed pulmonary aspergillosis. The prognosis was poor, with a median overall survival of 49.3 months. The autopsy in one patient demonstrated findings consistent with PPFE and chronic pleuritis. Unilateral upper-PF developed after thoracic surgeries and had many clinical, radiological, and pathological characteristics in common with idiopathic PPFE. Our results indicate that the commonly observed aberrant air may be correlated with disease development and progression.

A Bullet Injury to the Liver Complicated by Biliary Broncho Pleural Fistula and IVC Thrombosis: Case Presentation and Review for Management Guidelines

This is a case report of a 20-year-old male who presented to our hospital after sustaining a gunshot to the left upper abdominal quadrant with an exit right below the right scapula. On investigation, he was found to have a large right sided hemothorax and an extensive laceration in the liver. A right chest tube drain was inserted, initially drained blood and days later started draining bile. Consequently, the patient started coughing up bile and diagnosis of a biliary-broncho-pleural fistula was made. ERCP with sphincterotomy and stenting of a left hepatic duct injury was subsequently performed. The patient also developed an IVC thrombus that was discovered incidentally on follow up imaging and was treated with anticoagulation

Clinical Effect of Pedicled Pericardial Fat Flap in Prevention of Bronchial Pleural Fistula in Bronchial Sleeve Lobectomy

背景与目的支气管袖式肺叶切除是中心型肺癌重要的手术方式，它是最能体现“最大程度切除肿瘤，同时最大程度保留肺功能”的肺癌手术原则。支气管胸膜瘘是支气管袖式肺叶切除最严重的手术并发症，严重威胁患者的生命安全。本文将总结带蒂心包脂肪垫包裹支气管吻合口在预防支气管袖式肺叶切除术后支气管吻合口瘘的临床效果。方法回顾性分析四川大学华西医院肺癌中心2016年1月-2019年5月期间行支气管袖式肺叶切除术，并用带蒂心包脂肪垫包裹支气管吻合口的39例中心型肺癌患者临床资料，观察该组患者术后并发症，尤其是支气管吻合口相关并发症发生情况。结果该组患者手术后恢复良好，均于术后6 d-14 d内出院；30 d内无支气管胸膜瘘发生，无因胸腔内出血再次行手术病例，无严重心律失常，无严重肺部感染及呼吸衰竭发生；术后继续随访期间，术后6个月发生重度吻合口狭窄导致术侧残余肺不张1例。结论支气管袖式肺叶切除的肺癌患者，术中用带蒂心包脂肪垫包裹支气管吻合口，可有效预防术后吻合口瘘相关并发症的发生，从而提高手术安全性。

Repair of diaphragmatic biliary pleural fistula in a hydatid cyst with pericardial patch: A case report

Intrathoracic complications are rare events in postoperative recurrence of hepatic hydatid cysts; however, they are serious causes of mortality. In this report, we aimed to present a case of diaphragmatic defect developing as an intrathoracic complication after recurrence, which we repaired using a pericardial patch. Based on the literature, we encountered no use of pericardial patches in such cases.

Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax.

To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points. We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis. The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis. Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.

Successful Right Atrium-Pulmonary Artery ECMO in an Infant With Severe Necrotizing Pneumonia and Bilateral Bronchopleural Fistula

We report an infant with necrotizing pnuemonia and bilateral broncho pleural fistula, who failed on conventional and high frequency ventilation and was managed successfully on Veno-venous Extra Corporeal Membrane Oxygenator (V-V ECMO) with a unique configuration for 12 days, and weaned off successfully.