BTK Clinical Challenge Bronchopleural Fistula

Hello and welcome back to another clinical challenge in thoracic surgery with your Swedish thoracic surgery team. I'm Chloe Hansen. I'm a third year general surgery resident currently in my research year here at Swedish. And I'm joined by my esteemed attendings, Dr. Brian Louie and Dr. Peter White. Howdy do.

Hey, great to see you again. Today we will be talking about the management of bronchoparal fistulas after pneumonectomy, which is one of the most dreaded complications after lung resection due to its high morbidity and mortality. Thanks, Chloe. Let's dive right into a case. Let's just imagine you're on our service and you're called postoperatively to see one of our pneumonectomy patients who the nurses tell you has a new onset productive cough.

The patient is 65, a male, who's post op day 4, after undergoing a right pneumonectomy by a serratus anterior sparing post lateral thoracotomy, and they buttressed the, or they covered the stump with an intercostal muscle flap at the time of surgery. This is for a bulky squamous cell carcinoma of the right main stem that

extended down the bronchus intermedius.

On your way over you briefly review his past medical history, which includes a history of smoking, COPD, and until today his post operative course has been unremarkable, and the chest tube we took out on post op day two. On arrival you find the patient sitting up in bed. He's aggressively coughing in an obvious distress.

He says his coughing fit came on acutely and he's been productive of a large volume of clear reddish fluid. His blood pressure is stable, he's sat at 92 percent in room air, mildly tachycardic at about 100. What would you like to do next? Yeah, I'd be concerned about a post op complication. For this patient, I'd place him on supplemental oxygen, place him with his right side down, and then order a stat chest x ray and some labs.

So you mentioned placing him right side down. Can you explain your concern for this and, and why this specifically? specific positioning? Yeah. So due to his, the surgery he had done, my biggest concern would be for a bronchopleural fistula and the cough would be due to soiling of his left lung with the

pleural space fluid.

I placed him right side down because positioning the opposite side down would be to help prevent further soiling of the opposite lung. by using gravity to move any remaining pleural fluid away from the stump. Alright, excellent. So, you get your basic labs and AVGs, and those are all pending. Chest x ray was quickly done and demonstrates new subcutaneous emphysema of the chest wall, and when you compare it to the previous chest x ray, you notice that the intrapleural space has expanded and then there's even a little bit of mediastinal shift towards the non operative side.

So, based on this clinical presentation, chest x ray findings. Bronchopleurofiscia is clearly going to be at the top of your differential but what are the other things that you would think of as part of that potential postoperative complication differential? It's important to consider the imaging and lab findings as these will help narrow the differential.

However, broadly, I'd be worried about pneumonia, pulmonary edema with fluid overload, right heart

failure, hemothorax, and chylothorax. I'd also review the op report for whether the diaphragm or the pericardium were resected, and if so, how they were reconstructed, as herniation of either of these structures is a possible complication.

It's a bit early for this, but also an empyema within the pneumonectomy space, for those who've had any induction therapy, particularly with immunotherapy, with pneumonitis. So Chloe, you mentioned getting a chest x ray up front. What are we going to be paying particular attention to in somebody who's had a pneumonectomy?

Well, of course, we'd always look for the basics indicating a pneumonia, such as infiltrates or consolidation, as well as findings of pulmonary edema. If there's still a chest tube, we'd want to make sure that it's appropriately positioned in the pleural space without any signs of kinking or blockage. In addition to these, we would be looking at the air fluid level within the empty pleural space on the operative side.

paying close attention to whether the level is increasing or decreasing, and whether it's above or below the level of the bronchial stump. We'd also be looking at the

mediastinum to see if there's any shift either towards or away from the operative side. One of the things that we do after surgery to really make sure the nurses don't accidentally put the chest tube to suction is cut off the Nozzle on our atrium so that it's physically impossible to put them to suction Because you all don't know it could be a traveling nurse.

They may not understand Some of the effects of doing that So, before returning to our case, as the title hints, we're really talking about bronchopleural fistulas after a pneumonectomy. So, can you just take a step back and tell us, well, what is a bronchopleural fistula and how do they typically present?

Yeah, it's as it sounds basically, a direct communication between the bronchus and the pleural space. It occurs in about 1 12 percent of patients after pneumonectomy and about 0. 5 1 percent after lobectomy and sublobar resection. This is fairly morbid, with mortality ranging from about 25 to

70 percent, with treatment usually involving multiple stage procedures.

The majority of patients present within three months after surgery, most within the first 12 days. Late onset BPF can be more difficult to diagnose and is generally seen in the setting of empyema. Chloe, that's a very important point. Let's highlight some of the differences between early and late BPF. As we've said early BPF typically is defined as occurring within the first seven days after surgery, and as the result of a surgical dehiscence of the airway, early broncho, pleural fistulas, prompt surgical intervention as it can be life-threatening from tension pneumothorax, asphyxiation, or soilage of the contralateral lung and pneumonia.

On the other hand, a late BPF generally presents after 30 days and usually the signs and symptoms are infectious and an empyema is considered. These occur more frequently in immunocompromised patients with multiple core morbidities. And although we mentioned tension pneumothorax as

part of what can be seen, we've actually never seen it clinically ourselves.

It's reported in books and also in papers. And so we mentioned it, but as always, that should be a clinical diagnosis as opposed to an image finding. So if you really think someone has a tension, do a good physical exam and make sure that the chest space is decompressed to treat that. Alright, so Chloe, what are some of the specific risk factors for developing a ronchoplural fistula?

There are anatomic, technical, and patient specific growth factors. Starting with anatomic, the right pneumonectomy is associated with a 4 5 times higher incidence of BPF than a left pneumonectomy for a couple reasons. A right pneumonectomy stump has minimal mediastinal coverage of the bronchial stump compared to a left sided stump, which often retracts underneath the aorta and into the mediastinum.

The right main sim bronchus is oriented more vertically than the left, allowing secretions to pool more easily in the right stump. Finally,

the blood supply to the right and the left bronchus differs. The right bronchus relies on local branches traveling through the SubCal space from the trachea, often disrupted by dissection and lymph node harvesting, whereas the left bronchus received direct branches as it passes behind the aorta.

So then thinking through the anatomy, a lot of the technical risks also go along with that. Such as devascularization of the bronchial stump as you dissect through the lymph nodes surrounding it, or leaving a bron, a long bronchial stump like we talked about, the pooling of secretions can lead to a secondary infection.

Although the right side is at higher risk, the left side is at higher risk of leaving a longer stump just because of where it sits underneath the aorta and a little bit more difficulty with mobilization. Also, we'd want to look at closure under tension can be a risk factor and technically speaking the right side is a little bit larger and so then higher tension when it's closed.

And lastly, if there's any residual

tumors, you want to be really careful about where your resection margin is. As if you end up closing it with tumor within the actual stump, obviously that can inhibit wound healing. And Peter, one of the things that we haven't addressed is a main factor in, or a main risk factor in development of BPF is the need for post operative mechanical ventilation.

And this increases the risk of BPF by almost 20%. Another big risk factor is infectious, such as tuberculosis, which can affect healing. And additionally, some of the classic risk factors for poor wound healing are also are also key for bronchopleurofacial, including COPD, as our patient has, diabetes, age over 60, which our patient has, a smoking history, malnutrition, chronic steroid use, preoperative infection or empyema, and preoperative chemotherapy or radiation.

So, in this case, our patient had a pretty classic presentation of an early bronchopleural fistula with coughing up large volumes of serous or seropurulent fluid, as well as the associated respiratory distress. What

are some of the other presenting signs or symptoms that we'd be looking at? Going along with cough, respiratory distress may be from a tension pneumo, which we talked about.

That would also present with increased sub q emphysema, dyspnea, shortness of breath, and a significant mediastinal shift away from the operative side. There may be fever and leukocytosis with aspiration pneumonia. Or an increasing air leak or amount of pleural air after lung resection. Contrast that with signs and symptoms of chronic broncho pleural fistulas, which can include weight loss, malaise, anorexia, productive cough, fever, leukocytosis, and ima, and kind of basically a progressive clinical decline, right?

So a prompt diagnosis and then protection of the remaining non-operative side. Is essential with an acute BPF or chronic BPF, as we discussed earlier, as there's a major risk of aspiration of that fluid into the remaining lung. You know, not only this timing impact presentation, but also the size of the fistula.

Larger fistulas

tend to present with more dramatic symptoms, and this is more likely when you might get this rare tension pneumothorax scenario. But most often, the fistulas are small deficits in the bronchial stump that present with the cough that's productive with serous, serous or bloody cough.

fluid, sometimes purlins. Then you get the fever. I mean, you might get some hemoptysis and you might get the subcutaneous emphysema. Chloe, how do we investigate a possible BPF? Yeah, the main modalities are chest x ray, chest CT, and bronchoscopy. If we still don't have a diagnosis, CT bronchoscopy or a NUC Med test such as a VQ scan or a SPECT CT can be used.

Well let's go back to the chest x ray and remind our listeners of the classic findings on of chest x ray for BPF. What do those include, Chloe? As we know, tension pneumo should be a clinical diagnosis, but we can also see this on chest x ray imaging and can be pathognomonic for BPF after lung resection, especially after pneumonectomy.

Additionally, it's classic to see a new air fluid level in a previously opacified pneumonectomy space, or when the air fluid level is lower than prior, especially when it's below the bronchial stump. When comparing levels though, you gotta be careful to compare chest x rays with similar upright positions.

We can also see sub q or mediastinal emphysema, a shift, or a development of multiple new air fluid levels. I know that all patients with a suspected bronchopleural fistula should undergo bronchoscopy, but I haven't personally seen what that looks like. Dr. Wooley, what would I expect to see? Well, Chloe, you know, bronchoscopy, at bronchoscopy, we'd be looking for the fistula itself, and that could range from a large hole, or it could be something very pinpoint, and so, you might see bubbles coming back through the fistula site.

Sometimes we'll do saline lavage to see if we can see the bubbles. And we want to establish the exact location of the size of the fistulas, because we're trying to figure out, A, what are the causes, such as

assessing for length of the remaining bronchial stump, stump tissue quality, and whether there are ischemic changes.

And in the case of chronic bronchopleurofistula, we might be looking for purulence, recurrent cancer as potential reasons. And sometimes for really small ones, as we said, it can be really tough to see on bronchoscopy. For non pneumonectomy bronchopleurofistulas, which really isn't the focus today, but you could.

Do sequential balloon occlusion to help narrow down the location, or if you're at the time of surgery and you can't find it, you could instill intrabronchial methylene blue, or you do similar to an air leak test and you have them inflate that side looking for air bubbles under saline. And then finally, a CT chest with IV contrast should always be obtained.

This is going to help you look and whether there's empyema or heterogeneous products within the chest wall like blood. And then you can visualize air bubbles around the bronchial stump as well. And sometimes with larger fistula tracts, you can actually see that communication with the pleural

space.

You'll also want to look at the anatomic relationship of the fistula and the adjacent structures because in the hylum it can be quite confusing, especially when you go back and there's a lot of scar tissue and floral rind. Peter, I want to go back to your, you know, the very difficult to find fistulas where you do the bronchoscopy and you don't see an obvious hole.

You look at the staple line and you wonder if there's something there. But the patient has all the correct symptoms, but it doesn't look like that. In that situation, we have at times taken the patient to the OR, done a VATS on the side of the pneumonectomy, cleaned out the space, and under positive pressure ventilation, filled the space to see if we could find air bubbles through positive pressure ventilation to get a better sense and to make the diagnosis that way.

Now that's generally only done when we don't see a hole so that we can figure out what's going on. Then lastly, we should highlight the fact that it can take one to four months for the pneumonectomy space to fill up. And so within that time frame, just the presence of

an airspace may be expected. But later than that, any airspace may be a sign of a late BPF.

So returning back to our case. So we clearly have a strong suspicion this patient has an early bronchopleural fistula. They have all the clinical signs as well as findings. Now that you are there at the patient and you have that suspicion, what are going to be your next steps? Yeah, so breaking it down into six steps we need to number one, protect the contralateral lung from spillage.

We need to, number two, provide a rapid diagnosis with the modalities that we talked about before. Number three, obtain adequate pleural drainage. Four, start broad spectrum antibiotics. Five, have a plan for nutritional support. And six, if still ventilated, we need to optimize their mechanical ventilator settings.

Exactly, you have to start with controlling the life threatening conditions while avoiding downstream issues. As you had performed, the first step is positioning the patient with the affected lung side down to

avoid flooding the contralateral good lung with likely infected pleural fluid and protecting their good lung.

Then pleural drainage and antibiotics are mixed. A bedside chest tube with either a balanced drain atrium or half filled water in our atrium has the same effect. Remember, the post pneumonectomy chest tube should never be placed to suction as the resulting mediastinal shift can have severe effects on venous return, cardiac infection, and hemodynamics.

Right, and this is something that we always grill our trainees on. So if you did have to place a bedside chest tube on someone who's previously had a pneumonectomy, Where would you actually place it? Is it going to be the standard location? No, so always above the thoracotomy incision site. This is because the diaphragm will elevate as part of the normal thoracic remodeling and staying above the incision keeps you out of the peritoneum.

And the patient should be either supine or seated during placement and not lateral to continue to protect the good contralateral lung and keep the

pneumonectomy site in a more dependent position. Right. And then we send fluid studies and cultures as this helps narrow down our antibiotic use. 80 percent of patients with a BPF will also have a concomitant empyema and so you've got to treat that.

And then as they heal from the bronchopleural fistula, nutrition is really important. And so a lot of them may require enteral access for tube feeds if they're otherwise sick and clearly if they're intubated then you can continue to keep their nutrition that way. And then also, if they're intubated, we really want to minimize the number of pressure done to that side.

Sometimes you can do selective intubation of the non operative side in order to minimize those pressures, but regardless, you're going to want to make sure that your peak pressures are low to avoid pressure against the stump. And then, really, we've got to return quickly to the OR but sometimes that's just not possible because you've got to really take care of those life threatening issues first before you can do anything more definitive.

Okay, so now we've handled the acute event, we've started antibiotics, sent pleural fluid studies,

we have a good nutritional plan. Our patient does not require positive pressure ventilation. So let's talk about our surgical plan. Peter, what are some of the considerations for surgery? Yeah, so with an early BPF, we've got a contaminated pleural space, but not necessarily an empyema.

So we really want to get back to the operating room as quickly as we can, because that's going to make our life easier, and better for the patient. So we'd start with a single lumen endotracheal tube, we do our bronchoscopy, we look at our stump as we described before, assessing anatomy, So, the next thing that we do is we put a double lumen endotracheal tube down the left side.

I would personally intubate over a bronchoscope to really ensure that there isn't an accidental twist, because you don't want that extension down the left side to actually injure your stump. And then if we were doing a left sided pneumonectomy, we would actually want to flip that and do a right sided double lumen tube for the same reason to give us isolation.

You might think, well, why couldn't you

just main stem a tube? Well, then you don't have the ability of doing differential pressures on one side versus the other without doing a lot of tube manipulation. And then the surgery can be broken down into drainage of the pleural space, closure of the fistula, buttress of that bronchus, and then potentially obliterating the space either in the same setting or in a staged setting.

Peter, this is contrasted against patients with a late BPF, who will have an empyema, inflammation and a pleural rind, which obscures the hyaluronatomy and makes those even more technically challenging. Primary closure there is generally not an option for these patients, unless there is a long bronchial stump, and we'll address that scenario later on.

So on bronchoscopy, we've got a five millimeter stump, so great, it's less than the one centimeter that we'd want. We see a one millimeter defect, inferior aspect of the stump. You've got some bubbling there, clearly it's a fistula, but no concern for stump ischemia. So Brian, what are going to be your

steps to the operation, and what is your plan for stump coverage?

Well, Peter, as you mentioned, the stump coverage is going to be critical here. And for me, vascularized muscle flap, Or a rotational pedicle to mental flap, bringing the momentum up from the abdomen, which I use is going to be dependent on what is still available for use, and whether or not somebody has used the intercostal muscle flap already, as we have said in this case.

But if not, I still favor a double intercostal muscle flap with resection of the intervening rib. And then after that, trapezius, all can be used as muscles from the chest. Though, omentum, I think, still works very well. And particularly for chronic BPFs and stump coverage, omentum works excellent. The latissimus is often divided in a thoracotomy and is generally not available to use.

Peter, do you have a different thought than I do? Pretty similar. I personally always take down an intercostal muscle

to cover on the right side. Some other people don't. And we know that at the time you could take down pleura or pericardium or pericardial fat. Even thymus or azygous vein could all be used as part of that initial coverage.

But really, those are much less robust and for a reoperative stump, I do the exact same thing that you said. It really needs to be a highly vascularized flap. And then for this patient, probably serratus muscles since that's spared at the time of the original thoracotomy or omentum would probably be my second step.

The reason why we mention it now is because you've got to have this plan because if you're going to harvest omentum, you're keeping them supine, harvesting the omentum first. Okay. Before going to the chest. So you really want to have an idea of what you're going to use before you get started. If I've done a latissimus sparing posterior lateral thoracotomy, which I often do outside of mesothelioma, well then the latissimus muscle may be a really great option.

Not only is it well vascularized,

it also has a lot of bulk, and so it helps obliterate that space in addition to providing coverage. I know I've heard about pedicle diaphragm flaps and they're described and written about, but I've never actually seen one. You know, Peter, we've read about them and we've done one where we've pedicle the diaphragm and then brought it up and used it as coverage.

You need to have enough length to get the diaphragmatic pedicle up to the up to the stump. And then you've got to close the diaphragm. But it's certainly an option that is available. After having planned our coverage and reopening the thoracotomy, then, we're cleaning out the pleural space using irrigation and carefully identifying hyalur structures.

Alright, so all these structures are really stuck together in the hyalums. Chloe, which one would you be most worried about when you're digging down in that deep, dark space trying to find the bronchial stoma? Well, thinking through the structures we go vein, artery, and bronchus from front to back. So, it's probably the bronchus.

Yeah, exactly. So, you've got a staple line

right next to the PA staple line. It can be densely adherent, really tough to identify, and a wrong move there can be a life threatening complication. So, you've got to be really, really careful as you're trying to find that stump. Always paying attention to where that PA may be.

Yeah, so once I identify the bronchial stump, I would try and find the exact site of the BPF. And this is where positive pressure on the tracheal side of the double lumen and intertracheal tube with some saline in the pleural space is helpful to see the bubbles because it's not obviously going to be clear even this early.

Then if we're able to, we'll carefully debride away any infected endocrotic tissue to try to avoid any further dissection around the carina and affect the blood supply further. So then, Chloe, in terms of closure, so now we've got it exposed, we've dissected it out, how are we going to close that stump and what other considerations might you have?

Our first consideration would be to identify the stump length. While this

patient has a short stump, if it's left long and may be the reason for the fistula, then we would dissect, elevate, and re staple across the base of the right main stem bronchus. Right, but it needs to be about a centimeter and a half for that option to be really undertaken.

This could be done with an endo GIA or TA stapler. And remember, you should leave your remaining stump at least less than one centimeter from the carina. But what about a short stump? If you can't get a, or you can't get the stapler across it, what are you going to do next? I think then we could debride down to healthy tissue and then close the stump with sutures.

So we have a few options for suture closure, but in a bronchopterofistulas setting most would offer permanent polypropylene. You could also do a slowly dissolving monofilament like PDS. In the initial setting for bronchial anastomosis, you'll often times hear of 4 O Vicryl. Oftentimes soaked in mineral

oil and that's fairly routinely used, but for this you wouldn't want to use that because in an infected space, it's going to break down much faster.

And so you'd want something longer lasting and likely more permanent. And when we think about permanent suture in the airway, you always think about granuloma formation and for an anastomosis, that's definitely a consideration. But here when we're closing the stump, that's going to be less important.

Great, so, we're fortunate that we've got our fistula closed, and then after that we'll need to secure down our vascularized flap over the bronchus for coverage. And then after that, we'll try and clean up, or try and sterilize the pleural space. In this patient, if the BPF occurred very shortly after surgery and was caught quickly with minimal contamination, thorough debridement and irrigation may be sufficient.

In cases where there is greater contamination, sterilization can be accomplished by packing with betadine, antibiotic soap gauze with several exchanges or creating a thoracostomy window with dressing changes or closure over irrigation catheters after the fish

shell has been repaired. Chest tubes and other irrigation catheters can be placed and irrigated either continuously or several times daily with antibiotic solution.

And we won't really go into much here, but there are reports of endoscopic closures for BPFs using stents and glues. Effectiveness is somewhat limited and really would only consider them if I felt the patient couldn't tolerate an operation or maybe as some sort of bridge towards a definitive repair.

One of the things that I just wanted to talk about was although there is a fairly set guideline for timing of what's considered early versus late BPF, In reality, if you're not catching this within the first couple days after surgery, maybe day two or day three, there is so much inflammation, scarring, and obscuring that actual hilum that it becomes so risky and unsafe to try and dig out that stump that a lot of times you're now treating them much more akin to a late BPF where

it's mostly about providing appropriate clearance of infection and then a delayed coverage and less about finding the stump and then providing a second closure.

So let's change the case up a little bit. We've been on the right side so far, but what happens if it's on the left side? Although we know the risk is less, it still happens. And so how would this change our management? Well, you know, Peter, the left side certainly can be more difficult to access, especially since the stumps, if you have shortened them or cut them at the appropriate length, should retract underneath the aorta.

A long stump is going to be more likely given more challenges with the section and mobility of the left main stem bronchus. If the stump is long on either side, closure can be attempted by immediate sternotomy, which allows exposure of the carina in a previously non operated field between the superior vena cava and the aorta.

While I've only done this a limited number of times, it's an invaluable exposure, especially for a chronic BPF with empyema. Right. And then on the left side, once

it's closed, generally you don't need a separate flap coverage as it withdraws so far under the aorta and all of the surrounding mediastinal tissues.

But if we're already in the chest, I would still try and bring around some of the tissues together, like either pericardium or pericardial fat, just to try and isolate that stump away from the infected pleural space. Alright, so, irrigated, debrided, closed our fistula, we've buttressed it with our vascular tissue.

So, what might be stopping us from deciding, okay, we're just going to close the chest and be done? Well, Peter, as we've hinted throughout this this podcast the challenge is, is there, is it infected? How infected is it? So, it's about chest contamination. Early recognition of the BPF and surgery may have limited this, and a primary closure with tube thoracostomy may be appropriate.

However, in a setting with empyema or significant contamination, we'd want to either clear the infection first, or have a way for continued drainage of the infection until we're

confident the BPF is fully healed. Most failures of chest closure are going to be from persistent or recurrent BPF, so delay of the closure for a week helps confirm BPF closure.

Yeah. So we'll talk about it a bit more when we talk about delayed BPFs and their treatment and presentation. And this can either be done in a delayed fashion with packing, like with betadine soaked gauze, or you can end up doing a bit more morbid operation, but a claggett window or an LOS or flap. That's always a great option to allow persistent drainage to an infected chest cavity.

There is a lot of commitment from the patient as well as the patient's family to do it. But once everything's cleaned and healthy, you can come back at a later date and then decide on your obliteration of the space, and that then reduces risk of recurrent empyemas. From what I've read, it sounds like we have three main options for obliteration.

A modified Claggett maneuver where the fistula is closed and then the chest is filled with antibiotic solution and then closed.

Transmission of muscle flaps or other vascularized tissue like omentum to fill the space. And the final option is a thoracoplasty. This is where multiple ribs are resected to allow the chest wall soft tissue to collapse inward and fill the pneumonectomy space.

Of all of those, which one is still most commonly used? Nowadays, definitely vascularized flaps are the most common as they have a higher success rate and less morbidity. For larger spaces, multiple flaps may need to be used. The types of flaps available are the same as when we discussed coverage of the bronchial stump.

Although it's quite morbid for patients, if we can't control the infection, the initial repair fails, or they develop recurrent empyema, definitive therapy with an open window drainage is still a very good option to consider. We'll talk more about these in the management of late bronchopleural fistulas.

All right, so let's step back to our case, and rather than only being four days post op in an early BPF, what if it's actually been two months, and they're in your office, and they

have malaise, and they just feel terrible, they've been losing weight, they've got this cough that's now been worse and worse, that's been evolving over the span of a few weeks, and now they're telling you, oh, it just smells awful.

All right. And you look at him and you're just like, Ooh, this guy really doesn't look well. What are you going to do for that patient? This is definitely not someone you send home, even if their vitals on paper, maybe look okay. I'd send him to the ER and plan for resuscitation labs, get a CT chest with IV contrast.

Presuming his renal function is appropriate. So you get that CT chest and of course a chest x ray, but we always know they're going to get a CT as well. It shows a new air fluid level. Previously that chest space was actually pacified. You've got pleural thickening, you've got this heterogeneous material all throughout the pleural space.

You can even make out some air bubbles next to that right bronchial stone. So, we all know the diagnosis given our topic but Brian, in this setting with a delayed BPF, what would you

consider specifically? Well, you know, Peter, like the last case, we need to start protecting his remaining lung from soilage so that he doesn't develop pneumonia or pneumonitis on that side.

So draining the infected pleural space, getting him started on antibiotics and really focusing on his nutritional status are going to be the key things that we need to do. This type of patient likely needs enteral axis and tube feeds because they're so malnourished because it's been going on for a little while.

Then once resuscitated, I plan for a bronchoscopy followed by a thoracotomy to wash out his pleural space. The main goal of this surgery is simply control of the empyema infection with debridement of the cavity, washout, and good drainage with tubes. We wouldn't even think about trying to repair or even find the BPF at this point in time.

Not only would it be extremely high risk, but it also wouldn't be very successful given the severity of the infection. So we kind of mentioned this in the last case, but there is a Zurich protocol that describes doing this in this kind of exact setting. So, Brian, what is that protocol?

On that protocol, we would tend to either reopen his chest and wash it out, and then every several days, we will be back in the operating room, washing him out, debriding the chest space.

We would probably pack him with betadine soap gauze at that point in time while we try to achieve control of the infection. And we would probably continue that for at least a week. at least four or five times based on the Zurich protocol before. And once they started to develop granulation tissue and looked healthy, that's when we may consider the next step, which is either a flap, some sort of packing or closure, or a decision about a definitive window to start the process.

Yeah, so this is not the patient where you're whisking off to the operating room and doing an immediate fistula closure. It's nutrition, It's control the infection, and then at some point when all that's said and done, then like Brian said, you can talk about how are we going to close this. But Chloe what exactly is a claggett window and

LOS or flap?

We've mentioned that a few times now. Yeah, these are definitely confusing and can be scary for the junior residents on the floor managing at first. A clacket window involves cutting an oval shaped window with resection of a portion of one to two ribs, then suturing the skin to the window and to the parietal pleura.

An eloesser flap has a U shaped incision made over the most dependent portion of the space and also includes removal of segments of one to two ribs, and then the skin flaps suture directly to the parietal pleura to create an epithelialized tract. In either case, the goal is to maintain the patency of the window and make it large enough that dressing changes can easily be made to this window until the cavity is sterilized.

And then there's a modified LOS or flap, which is an upside down U, where you take the flap and you actually attach it down to the diaphragm. And for me, I've done that a few times. That's what I prefer if I've got to do a window, because I think it makes a nice epithelialized border for those dressing changes.

And this is just a reminder that placement of this window is

important. If you place it too far posteriorly, it is impossible for the patient to manage themselves. The chest cavity is a very deep space. So remember that they should be made large enough to allow a hand up and into the space for packing and removal.

And then timing of these closures is going to be dependent on the patient's response, how they've done with antibiotics, how the cavity looks and sterilization and their nutritional status. And while some really small fistulas may actually close spontaneously, once you've got this. like granulation tissue and filling of the space.

But most of them are going to require a definitive closure. And a lot of times you're waiting many months, six months or sometimes even more by the time you're actually ready and the patient's ready to close that window. And sometimes you can do vacuum assisted closure devices and wound vacs.

I've done that a few times in the hospital. It helps speed up that initial process. But then when they go home, usually it's just wet to dry dressing changes with gauze. So once they're finally healed, there's no guideline for how to monitor these patients long

term. A lot of it will be determined by their underlying disease processes and their symptoms.

And so everything really should be directed to how the patient's doing and what their clinical status is. The only thing that really governs some of this is if the patient has had a cancer, they will have ongoing cancer surveillance based on your organization or the NCCN guidelines for cancer surveillance.

Thank you very much. So, as we've heard, bronchopleurofistula after a pneumonectomy is an incredibly frustrating complication that requires a lot of time and dedication, both on the surgeon and the team, but also on the patient. It's morbid and even has a pretty high mortality, but if you follow a lot of the standard surgical principles, then hopefully we can get a lot of these patients through this devastating complication.

Yeah, you know, Peter I think the, the key things remain early on is vigilance after pneumonectomy and early diagnosis and then preventing soilage of the lung gets you to a point where you

are, you potentially can salvage some of these patients and put them back on the right course. Preoperative risk evaluation, sound surgical technique with prophylactic coverage.

It all starts before you even get there with the first operation. And that wraps it up. As always, we want to thank you for listening to another Swedish thoracic surgery clinical challenge. We hope you've furthered your knowledge and understanding of the management of bronchoparal fistulas. Now go out and dominate the day.