Broncho-Abdominal Fistula: Making the Diagnosis and Managing the Patient

Abstract

The diagnosis and management of broncho-abdominal fistula in critically patients is difficult, with various treatment options including medical, surgical, ventilatory strategies and drainage systems. We report the case of a 58-year-old male patient who presented acutely with systemic sepsis 41 days after undergoing an elective laparoscopic cholecystectomy. The patient underwent a 34-day course of intensive care treatment during which the diagnosis of a broncho-abdominal fistula was made using a simple technique previously undescribed in the critical care literature. The case was subsequently managed successfully following the introduction of high frequency oscillatory ventilation (HFOV) as the principal mode of respiratory support. We describe the unusual presentation, the method of diagnosis and the subsequent management of this case using HFOV.

Hypoxic respiratory failure in acute appendicitis: A bronchoperitoneal fistula as the presenting symptom of appendicitis in the setting of pediatric COVID-19

“…This case was a rare presentation of a perforated appendicitis complicated by a bronchoperitoneal fistula. Previously, the literature has reported cases of bronchoperitoneal or broncho-abdominal fistulas from subphrenic abscesses including as a sequela of appendicitis [ 23 ], cholecystectomy [ 24 ], colorectal anastomotic leak [ 25 ], gastric leak status post laparoscopic sleeve gastrectomy [ 26 ], and as a sequela of retained drains [ 27 ]. In each case, the presence of an intra-abdominal collection eroded through the diaphragm and eventually though the pleura and into an airway.…”

Post-laparotomy haemoptysis due to broncho-abdominal fistula caused by retained abdominal surgical swab

“…7 Management strategies adopted to treat such cases have been drawn from experience of treating broncho-pleural fistulae (BPF), which are more common and better understood. 7 Strategies used successfully include differential lung ventilation using double-lumen endotracheal tubes, high-frequency oscillatory ventilation (HFOV), highfrequency jet ventilation (HFJV), and extra-corporeal membrane oxygenation (ECMO). The case presented by Cook et al was initially managed by conventional pressure-controlled synchronised intermittent mandatory ventilation (P-SIMV).…”

“…Subsequent use of HFOV halted the gas loss completely within four days, and the patient recovered on conservative treatment without needing surgery. 7 The use of sampling tracers such as Xenon-133 or methylene blue were previously used to diagnose BAF. Cook et al also reported the ingenious use of nitrous oxide (N 2 0) and a standard anaesthetic gas analyser attached to the abdominal drain to diagnose postoperatively the communication between bronchus and abdominal cavity in the intensive care unit, thereby using N 2 0 as the tracer.…”

“…Cook et al also reported the ingenious use of nitrous oxide (N 2 0) and a standard anaesthetic gas analyser attached to the abdominal drain to diagnose postoperatively the communication between bronchus and abdominal cavity in the intensive care unit, thereby using N 2 0 as the tracer. 7 This test can easily be performed in resourcelimited settings. In our case, the BAF was clinically obvious, with abdominal distension occurring soon after intubation and initiation of ventilation.…”

“…6 Broncho-abdominal fistula (BAF) is similarly rare with a search yielding two reports involving single cases and one other report involving three cases. [7][8][9] All aforementioned BAF cases refer to the right hemi-diaphragm being breached by biliary pathology. No case of BAF has thus far been related to the migration of a surgical swab from the abdomen into the left thorax.…”