INTRODUCTION: Respiratory failure (RF) with recurrent pneumonia in the ICU can have devastating consequences for the patient. Search for an underlying cause should always prompt thinking of the common and then not so common causes, especially in the post operative thorasic patient. Known complications of esophagectomy can include chylothorax and bronchopleural fistula (BPF). Having both complications in the same patient leading to recurrent aspiration of the chyle into the bronchial tree, recurrent pneumonia and persistent RF is very rare.
CASE PRESENTATION: A 65 year old man with a history of hypertension, was suffering from dysphagia secondary to a fungating growth in the distal esophagus extending into the gastroesophageal junction. Pathology revealed poorly differentiated adenocarcinoma on biopsy, with no metastasis. Preoperatively, the patient received neoadjuvant treatment consisting of chemotherapy, and external beam radiation. Ivor-Lewis esophagectomy with split-stomach fundoplication was performed.His post-operative course was complicated by fever, persistent right-sided pleural effusion, and pulmonary infiltrates on chest radiography and computed tomography. RF persisted and mechanical ventilation (MV) support was required. Multiple tube thoracostomies were performed for the persistent pleural effusion. Bronchoscopy was performed, which revealed two small-sized BPF. The larger fistula, measuring 4–5 mm in diameter, located on the posterior wall of the proximal left mainstem bronchus. The smaller fistula measured 1–2 mm in size and was located proximal to the larger lesion. Significant secretions with active influx of fluid from the pleural space into the tracheobronchial tree through the fistulas were found. Comparative analysis of bronchial wash and pleural effusion showed similar analysis. Rigid bronchoscopy with contrast bronchography confirmed the communicating BPF. Fibrin glue was injected into the lesions and subsequently an ultraflex covered stent was placed in the left mainstem bronchus. Follow up bronchoscopy two weeks later revealed that the fistulas were enlarging. A larger stent was then placed. Repeat bronchoscopy two weeks later established stability of the stent with appropriate healing of fistulas.
DISCUSSIONS: BPF and chylothorax are known complications of esophagectomy. Having both in the same patient can lead to devastating consequences. Recurrent pneumonia with persistent RF and difficulty weaning from MV was the initial challenge in this patient, which prompted further investigations.BPF is a relatively rare complication, with significant morbidity and mortality. Different etiologies include infection, malignancy, trauma, and adult respiratory distress syndrome. Most commonly BPF results from operative complication following pulmonary resection. Treatment of BPF can be surgical or medical. Surgical options include direct stump closure with muscle or omental flap, thoracoplasty, or chronic open drainage. Bronchoscopy with use of sealants and/or a mechanical occlusion device is the hallmark of medical therapy especially for high risk or debilitated patients. Various different sealants can be used. Mechanical occlusion, with stents or coils, has been used either alone or in conjunction with sealants to achieve closure. BPFs > 8 mm are not appropriate for endoscopic management, those ≤;1 mm have the best success rate. High-output chylothorax may lead to life-threatening complications such as respiratory failure, immune suppression, malnutrition, and nosocomial infections. Non-operative management of chylothorax includes fat-free diet with medium-chain triglycerides to decrease the output, drainage of the effusion via tube thoracostomy, enteric rest with total parental nutrition, aggressive diuresis, and somatostatin or octreotide injections. Surgical management includes thoracic duct repair or ligation via an open or thorascopic approach, fibrin glue application, pleurodesis, pleuroperitoneal shunting, and percutaneous embolization of the thoracic duct.
CONCLUSION: BPF, a potentially treatable condition, should be suspected and investigated in the presence of chylothorax with persistent RF and pneumonia.
DISCLOSURE: Hamed Mataria, None.