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

Abstract

The case presented describes the migration of a surgical swab across the left hemidiaphragm over four years. The patient had at least two episodes of haemoptysis in that period and was misdiagnosed and treated for Pulmonary Tuberculosis. When the proper diagnosis was made and a lobectomy was planned for removal of the swab, the act of anaesthesia revealed a major bronchoabdominal fistula that was resolved by simply isolating that lung with an endobronchial tube. According to our search, such a left-sided broncho-abdominal fistula has, to date, not been described in the literature.

Bronchoabdominal fistula – a severe complication of non‐perforated appendicitis

“…BAF has been described in the literature following retention of a surgical swab following a trauma laparotomy 6 and following an infected subdiaphragmatic bile leak, post laparoscopic cholecystectomy 7 . This is the first reported case of a BAF following appendicectomy.…”

“…The optimal management strategy for BAF remains uncertain, partly because of the unusual and rare nature of the condition. In stable patients, conservative approaches may be used including time‐synchronized occlusion of intercostal drains, the use of double lumen endotracheal tubes with differential lung ventilation, high frequency oscillatory ventilation or high frequency jet ventilation 6,7 . In this case surgical debridement and ECMO was required due to the inability to mechanically ventilate the patient because of the severity of the underlying lung injury from a combination of factors including necrotising pneumonia, barotrauma, oxygen toxicity and the BAF.…”

“…4 The third case describes a chronic subphrenic abscess that eroded into the splenic flexure and diaphragm resulting in a colobronchial fistula 4 years after laparotomy for perforated appendicitis. 5 BAF has been described in the literature following retention of a surgical swab following a trauma laparotomy 6 and following an infected subdiaphragmatic bile leak, post laparoscopic cholecystectomy. 7 This is the first reported case of a BAF following appendicectomy.…”

“…In stable patients, conservative approaches may be used including timesynchronized occlusion of intercostal drains, the use of double lumen endotracheal tubes with differential lung ventilation, high frequency oscillatory ventilation or high frequency jet ventilation. 6,7 In this case surgical debridement and ECMO was required due to the inability to mechanically ventilate the patient because of the severity of the underlying lung injury from a combination of factors including necrotising pneumonia, barotrauma, oxygen toxicity and the BAF. Delayed presentation of acute surgical pathology has recently been shown to be more common in rural New Zealand and has likely contributed to the advanced presentation of pathology in this case.…”