Delayed bronchial perforation after bulla cauterization with soft coagulation system

Background Soft coagulation is widely used for hemostasis because of its significant advantage in inducing tissue coagulation and denaturation without carbonization. However, a few cases of airway damage have been reported at the site, where soft coagulation was directly applied. Case presentation We encountered an unusual case of delayed perforation of the intermediate bronchial trunk observed on 24 days after cauterization of the right S6 bulla adjacent to the bronchus. Chest computed tomography revealed a large fistula between the intermediate bronchial trunk and the cauterized bulla in the right S6. Bronchoscopy showed a large fistula at the membranous portion of the intermediate bronchial trunk. We presumed that the bronchial perforation resulted from thermal damage to the intermediate bronchial trunk during bulla cauterization and the bronchial perforation induced infection in the bulla. Resection of the infectious bulla and the intermediate bronchial trunk, followed by end-to-end bronchial anastomosis and a pedicled intercostal muscle flap coverage, was performed. Conclusions The severe airway damage resulting in perforation developed even without direct contact between the electrode tip and the bronchial wall, provoking the need for special attention to the duration of cauterization and location, where it is used.

Bochdalek Hernia and Partial Diaphragmatic Agenesis: Pedicled Intercostal Muscle Flap and Mesh Repair in a Young Adult with Sickle Cell Disease

Congenital Bochdalek hernia (BH) in an adult is rare and has an unusual presentation. They are confined to the pediatric age group with an incidence of 1:3,000 live births. It rarely persists asymptomatic until adulthood. Surgical repair by thoracic, abdominal, or thoraco-abdominal approach is the treatment of choice with diaphragmatic reconstruction in associated diaphragmatic agenesis. With only 10 cases of BH with partial diaphragmatic agenesis reported to date, we discuss the rarity, unusual presentation, and management of BH in a young adult with sickle cell disease that has not been reported in the literature.

A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer

Background Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection. Case presentation A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient’s postoperative course was uneventful, and he was discharged on the 354th day. Conclusions We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

Successful treatment of bilateral empyema with bilateral fistulae using free intercostal muscle flap

Background Bilateral empyema is rare and can be life-threatening. Few cases have ever been reported about bilateral empyema with fistula on both sides. We herein report a case of bilateral empyema with bilateral fistulae that was treated with a 2-stage operation. Case presentation The patient was a 40 year-old man with uncontrolled diabetes mellitus, severe emaciation and remarkably decayed teeth. On his admission, computed tomography showed bilateral pneumothorax and pleural effusion. Thoracentesis revealed a cream-colored purulent pleural effusion from both sides of the pleural cavity. Bilateral empyema with fistulae on both sides due to a ruptured lung abscess was diagnosed. 7 days after his administration, we performed the first surgery. There were 3 fistulae in the right lateral basal segment (S9), right posterior basal segment (S10), and left posterior basal segment (S10). At the first operation, the S9 fistula was directly sutured; however, the right S10 fistula could not be closed because the surrounding tissue was fragile. The left lung fistula was deep and crater-shaped; it was closed with the suturing of a plugged free muscle flap. At the second operation, the right S10 fistula was closed with the superimposition of a pedicled intercostal muscle flap. Conclusion Patients with bilateral empyema tend to be with poor general condition and, therefore, less invasive treatments are required initially. Closure of fistulae is an essential process for the treatment of empyema with fistulae. We could manage the fistulae using several techniques with 2-stage operation. Although the efficacy of using a free intercostal muscle flap to close the fistula has not been adequately verified, it is simple and less invasive and, thus, might be a useful option in cases where the patient is too ill to undergo a more invasive operation or when the surgical approach should be done in a short time

Homograft Treatment for Infected Frozen Elephant Trunk Prosthesis

A 46-year-old male received total arch replacement with frozen elephant trunk for acute non-A/non-B aortic dissection. Two months later, he underwent emergency reoperation for contained rupture of the left common carotid ostium at its insertion on the aortic arch. Three months after the reoperation, he developed tracheoesophageal fistula and infection of the prosthesis in the region of the aortic arch and the proximal descending aorta. Second reoperation was performed with replacement of the aorta with a composite of three aortic homografts, and the fistula was permanently closed with a direct suture and intercostal muscle flap

The role of indocyanine green fluorescence in bronchopleural fistula prevention

A 57-year-old woman with non-small-cell lung cancer qualified for pneumonectomy. At the start of the surgery, a pedicled intercostal muscle flap was harvested. Indocyanine green fluorescence revealed ischemia in the distal part of the flap. After pneumonectomy, the ischemic portion of the muscle was removed and the well-perfused proximal part was sutured to the bronchial stump. Reassessment with indocyanine green showed good perfusion of the flap. The postoperative period was uneventful, but follow-up bronchoscopy revealed bronchial suture line dehiscence with the muscle flap separating the bronchial lumen from the postpneumonectomy space. The bronchial stump healed spontaneously by secondary intention.

Benign gastrobronchial fistula following oesophagectomy in a patient presenting with respiratory failure

Benign gastrobronchial fistula (GBF) is a rare but potentially life-threatening complication of oesophagectomy for malignancy. We present a case of GBF post Ivor-Lewis surgery manifesting as pulmonary sepsis and type II respiratory failure. Clues to the diagnosis were persistent hypercapnia despite high minute ventilation, aspiration of gastric content through the endotracheal tube and accumulation of air in the nasogastric drainage bag. Flexible bronchoscopy confirmed the diagnosis. Surgical exploration identified necrosis of the proximal stomach as causative factor. Despite reconstruction of the oesophagogastric anastomosis and interposition of an intercostal muscle flap, the patient developed a new episode of type II respiratory failure. Bronchoscopy revealed in situ recurrence of the fistula. Patency of the fistula was proven through application of methylene blue with subsequent gastroscopy. A conservative, symptom-based, management was conducted. The patient died 6 hours later.