Broncho-peritoneal Fistula in a Gynecological Malignancy

Caroline Supit, Wuryantoro Soeharto

Division of Thorax Cardiac and Vascular Surgery

Department of Surgery, Cipto Mangunkusumo Hospital

ABSTRACT

Introduction: Broncho-peritoneal fistula (BPF) is a rare disorder. This report aimed

to describe the unusual clinical presentation, diagnosis and management of a case of

BPF.

Case Presentation: Reporting a case of 45-year-old female with metastatic ovarian

cancer presented with abdominal discomfort and found to have a retrogaster abscess

one year following a surgery for gynecological metastasis. The patient underwent a

surgical removal of the abscess which the diagnosis of a broncho-peritoneal fistula

was made intraoperatively. The BPF was then repaired using a mesh, post repair the

patient was not able to breathe spontaneously. Six days later, the patient underwent a

thoracotomy and left lung wedge resection for fistula removal. Following left lung

resection, the patient was successfully extubated and capable for spontaneous

breathing.

Discussion: On previously reported cases of BPF, the clinical symptoms are recurrent

cough, shortness of breath. chronic chest infection and sepsis. However, in this patient

the only complaint was abdominal discomfort. BPF treatments are similar to other

types of broncho-intra-abdominal fistulas, which involve conservative or surgical

treatments depending on the nature of the disease. In this case surgical resection and

primary closure of the defect is the treatment of choice.

Keywords: broncho-abdominal fistula; bronchoperitoneal fistula

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Introduction

A fistula between the bronchus and peritoneal cavity is rare, with only several

cases reported in the literature. The etiology, clinical manifestation and treatment

varies. Most causes are due to sub-phrenic abscess and iatrogenic diaphragmatic

injuries.1-3 This report describes a case of broncho-peritoneal fistula following a

surgery for gynecological malignancy.

Case Presentation

A 45-year-old female presented to the outpatient clinic with a one-month

history of recurrent nausea, a mild pain of the left upper abdomen, and a previous

surgery for a stage IV ovarian cancer one year before hospital admission. The surgery

includes a total hysterectomy, bilateral salpingoophorectomy, distal pancreatectomy

and splenectomy. Histology showed a poorly differentiated carcinoma consistent with

serous carcinoma, originating from the ovary spreading to the left ovary, splenic hilar

fat, peripancreatic tissue, sigmoid serosal nodule and two splenic hilar nodes.

A palpable mass on the left upper abdomen was found during the physical

examination, the mass was mildly painful on palpation. Abdominal ultrasonography

revealed an intra-abdominal fluid collection within a thick wall, sized 6.85x7.7 cm

anterior to the left kidney and adjacent to gaster. It was confirmed by a computed

tomography (CT) scan of the abdomen, which showed a large intra-peritoneal

septated cystic mass with thick wall in the left upper abdomen, pushing gaster to the

posterior (Figure 1). A working diagnosis of retrogaster abscess was made.

Figure 1.

CT Scan of the

abdomen showing

a large intra-

peritoneal

septated cystic

mass in the left

upper abdomen.

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Upon surgical removal of the abscess, a perforation on the left posterior

diaphragm was found. During the surgery the patient had oxygen desaturation due to

air leak from the bronchus to the peritoneal cavity. The broncho-peritoneal fistula was

repaired using a polypropylene mesh and the oxygen saturation went up to 98-100%.

She was admitted to the intensive care unit (ICU) for post-operative care. Six days

after the first repair the patient underwent a thoracotomy for fistula removal because

she failed to breathe spontaneously.

A left-sided thoracotomy was performed, there was an extensive adhesion of

the left lung to the parietal pleura. The fistula was found on the left lower lobe lung

connected to the defect of the diaphragm sized 1.5 cm in diameter (Figure 2). A left

lung wedge resection was done using a stapler (Figure 3), followed by a direct closure

of the defect using non-absorbable stitches.

Figure 2. Intra-operative image showing the defect (arrow) on the left diaphragm

Subsequent to left lung resection, the patient was successfully extubated and

capable for spontaneous breathing. She was discharged from the ICU two days after

the surgery to the common ward in a stable condition and was able to perform early

mobilization. The histolopathological findings of resected specimens of the lung

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display chronic inflammatory changes in the lung parenchyma with no malignant

disease identified.

Figure 3.

Specimen of

the resected

lung showing

fistula

opening

(pinset)

Discussion

On previously limited cases reported in the literature, the most common causes

of BPF are due to sub-phrenic abscess and iatrogenic diaphragmatic injuries.1-3 Other

causes such as malignancy have also been reported.4 Previous literature associate

surgery and broncho-intra-abdominal fistulas as a complication following an

extensive surgery for malignancy.1,4-5,9-10 In present case, the proposed mechanism

relates to a complication from a previous excessive surgery for ovarian malignancy.

The unusual absence of respiratory symptoms can be explain by a sealant effect of the

abscess preventing air leak from the bronchus into the peritoneal cavity.

Based on previously reported studies, the management of BPF are similar to

other types of fistula such as gastro-bronchial fistula and broncho-billiary fistula;

these include conservative or surgical treatments depending on the cause of the

disease and the patient’s general health.1-7,11 Prior studies preferred conservative

management such as using a time-synchronised occlusion of intercostal drains and

double lumen endotracheal tubes with differential lung ventilation, and high-

frequency oscillatory ventilation (HFOV) in a patient with severe ARDS and a

broncho-abdominal fistula due to an infected sub-diaphragmatic collection.1-2,4,6

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According to Devbhandary MP, et al., the ideal treatment for a fistula includes

surgical resection and direct closure of the fistula.7 Brega PP, et al., also reported

surgical management by performing a lower lobectomy for a defect in the lower lobe

bronchus and resection and repair of a defect in the main-stem bronchus.8 In this case

the BPF was found intra-operatively during abscess removal, thus surgical resection

of the fistula and primary closure of the defect of the diaphragm is the treatment of

choice. Up today there is no specific procedure that is suitable for all the patients.

Treatment methods must be personalized to the patient’s condition.

In conclusion, slow development of a broncho-peritoneal fistula as a rare

complication of extensive surgery for malignancy can be presented with no

respiratory symptoms. In this patient, surgical resection and direct closure of defect is

the chosen method of treatment, which applied in similar situations in patients with

gastro-bronchial fistula.

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