Search

Eleven of 48 (23%) patients diagnosed as having lung abscess or empyema presented diagnostic problems in the localization of infected material. All 11 patients were found eventually to have empyemas, all but one of which was complicated by bronchopleural fistulas. Difficulty in distinguishing abscess from empyema on a chest roentgenogram delayed diagnostic and therapeutic thoracentesis from 1 to 12 days. Pleural effusions were noted in all but one of the patients who did not initially have a bronchopleural fistula. In addition, once the bronchopleural fistula became established, the extension of the air-fluid level to the chest wall, the tapered borders of the air-fluid pocket, and the extension of the lesion across fissure lines were noted, in retrospect, to be suggestive of pleural localization. Delay in the evacuation of empyema fluid can lead to chronic complications and increased morbidity. Early identification and treatment of pleural effusions may avoid these diagnostic and therapeutic problems.

The fiberoptic bronchoscope was used percutaneously to visualize the track of a bronchopleurocutaneous fistula and to obtain tissue and microbiologic specimens for examination. The bronchoscopy turned out to be a very simple procedure and patient discomfort was minimal. The findings aided in the successful management of this patient.

The case of a 43-year-old man with congenital esophagobronchial fistula is presented. The patient had had bouts of coughing on swallowing liquids for 5 months. A barium swallow examination and bronchography showed an esophagobronchial fistula communicated between the middle third of the esophagus and right lower bronchus. An orifice of the fistula at the apex of an esophageal diverticulum was revealed by esophagoscopy. The clinical, operative, and histological features are discussed as well as the basis for a diagnosis of congenital origin.

Enterobronchial fistula is a rare condition. The authors describe a 47-year-old man who had a fistula between the small bowel and tracheobronchial tree, 8 years after resection of an adrenal carcinoma. The report illustrates the difficulties in diagnosis and the surgical treatment. In particular, the use of hyperosmolar, water-soluble contrast medium in radiologic investigations is to be avoided and the use of a double-lumen endotracheal tube is mandatory if a general anesthetic must be given. Despite its rarity, enterobronchial fistula can be diagnosed through a carefully taken history, confirmed safely by roentgenography and cured surgically.

A patient with prior GBF and new-onset hemoptysis was diagnosed as having recurrent GBF by measurement of bronchial secretion pH. This is a previously unreported means of diagnosing this process. Bronchoscopic findings were substantiated by upper GI contrast study and surgical findings.

This report deals with a patient with a congenital bronchoesophageal fistula, type "H", which was diagnosed only at age 43. This is an extremely rare defect and, if not recognized shortly after birth, it usually will stay unrecognized despite the fact that it causes recurrent pneumonias or localized bronchiectasis. The diagnosis of such a case is difficult and usually only possible with the help of a variety of diagnostic tests. The deciding factor is the recognition of the congenital defect. The subsequent surgical treatment including resection of the canal and closure of the fistula is a relatively simple operative procedure.

Bronchopleural fistula, although reduced in incidence in recent years, remains a grave complication of pulmonary disease and of pulmonary resection. In a series of 77 patients treated for bronchopleural fistula over a 13 year period, 49 of whom had postresection fistulas, only 44 (57.1 percent) were cured of the fistula and 15 (19.5 percent) died. Prevention assumes great importance. Key factors in prevention are avoidance of pulmonary resection in tuberculous patients with positive sputum; overzealous dissection of the bronchus; a long bronchial stump; tumor in the bronchial stump; contamination of the pleural cavity; and too little tissue left behind to fill the pleural space. Treatment should be surgical. In none of the six patients treated conservatively was the fistula obliterated. Seventy-one patients were treated surgically, and 133 operations were needed to effect fistula obliteration in the 44 patients (62 percent) in whom this was achieved. Adequate surgical drainage has always been the sine qua non of effective treatment, and yet this alone brought about closure of the fistula in only nine patients. Early resuture of the bronchial stump succeeded in only two of five patients. Thoracoplasty combined with drainage effected closure in seven of 11 patients. The highest rate of fistula closure with the lowest mortality occurred among the 20 patients who underwent myoplasty, usually combined with a limited thoracoplasty. In this group, the fistula was obliterated in 16 patients, with one death.

The authors describe a simple, yet reliable technique for confirmation of a bronchopleural fistula. It is based on detection of radioactivity in the pleural space after the washout phase of the 133Xe ventilation study. This method demonstrated the pathological communication while bronchoscopy, bronchography, and methylene blue testing did not.

A 62-year-old woman had symptoms of cough provoked by ingestion of liquids and radiologic changes compatible with repeated bouts of aspiration pneumonitis. A left bronchoesophageal fistula was easily demonstrated by barium esophagogram and fiberoptic bronchoscopy. Division of the fistula resulted in immediate disappearance of the symptoms, gradual resolution of the radiologic abnormalities, and marked improvement in the results of pulmonary function tests. The fistula appeared to be of congenital origin, but the reason that symptoms developed so late in life remains obscure.

Between 1972 and 1982, 15 episodes of tuberculosis-related bronchopleural fistula (BPF) were observed in 13 patients at a municipal hospital in New York City. All 13 had a history of inadequate treatment for pulmonary tuberculosis, and seven had one or more associated chronic debilitating conditions. Past pleural inflammation with resultant fibrothorax appeared to be the source of the late BPF formation in at least seven patients, while rupture of a cavity during active disease was likely in four. Clinical presentation ranged from life-threatening tension-pneumothorax to incidental discovery, a long-term wasting illness being the most common form. Diagnosis was not difficult. Antituberculosis chemotherapy and tube suction were generally employed in treatment, with further surgical drainage procedures done when necessary and possible; open window thoracostomy was usually successful (four of seven BPFs closed, one stable for years), as were one case each of pleuropneumonectomy and decortication. When surgery was not feasible, long-term tube drainage was a useful alternative.

Fistulas between the pancreas and bronchial tree are uncommon examples of internal pancreatic fistulas. We describe a case of pancreaticobronchial fistula in which the diagnosis was made by bronchoscopy and biochemical analysis of respiratory secretions. Endoscopic retrograde cholangiopancreatography was confirmatory and guided treatment by internal drainage of the pancreatic duct. Ten other cases were found in the Western literature that emphasize the principles of diagnosis and treatment.

Congenital bronchoesophageal fistulas usually present in infants and may occur with or without esophageal atresia. Twenty cases of congenital bronchoesophageal fistula in adults have been reported in the English literature. Another case of this rare developmental anomaly is presented here. The radiographic, endoscopic, surgical, and pathologic findings are discussed with a review of the literature.

A review of all the bronchopleural fistulas which developed following pulmonary resection in the Department of Cardio-Vascular and Thoracic Surgery of The London Hospital between 1953 and 1973 is presented. During this period 3150 pulmonary resections were performed for various conditions and 86 fistulas occurred, an incidence of 2-7 per cent. The aetiology, diagnosis and treatment of these fistulas are discussed.

The adult respiratory distress syndrome (ARDS) is a frequent feature of acute pancreatitis. Amylase and lipase values were determined in samples of bronchial secretions in two patients with endotracheal intubation and under supportive ventilation for severe hypoxemia occurring during the course of acute pancreatitis. A pancreatico-bronchial fistula was suggested in both cases. In one case, an endoscopic retrograde pancreatography was performed and demonstrated a fistula between the pancreatic body and the left bronchial tree. Arterial pH values decreased following pancreatography. Splenopancreatectomy was performed in one case, and necrosectomy associated with left pulmonary lobectomy in the other. Documented cases of pancreaticobronchial fistulas have been rarely reported to date. A retrospective study of 10 patients with ARDS was made among 32 patients undergoing laparotomy for objectively recognized necrotizing pancreatitis. A pancreatico-bronchial fistula could be incriminated in three cases. This 30 p. 100 prevalence has to be re-evaluated in the light of serial determinations of amylase and lipase levels in patients with ARD and endotracheal intubation in the course of pancreatic disease. In these patients, high levels of amylase and lipase in bronchial secretions, the use of iso-osmolar X-ray colloids could be helpful in protecting the alveolar membrane against osmolar injury during pancreatography.

A 39-year-old heavy drinker was admitted to Saga Medical School Hospital on February 21th, 1987. He had suffered from dyspnea, chest pain and lumbago three weeks prior to admission. His chest X-ray showed right hydropneumothorax and right lower lobe atelectasis and his CT scan showed a cystic lesion in the mediastinum. His laboratory data showed a high level of amylase in serum, urine and pleural effusion. A fistula connecting the pancreas to right pleural cavity was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP). In addition, bronchoscopy showed complete obstruction of the right lower bronchus (B7). These bronchoscopic findings and hydropneumothorax on his chest X-ray suggested the leakage of pancreas juice through the pancreatico-pleural fistula injured the lung tissue directly and produced a bronchopleural fistula. In this case, hyperalimentation and drug therapy using protease inhibitor resulted in successful closure of the fistula and reexpansion of the collapsed lung.