Pulmonary Artery Bronchial Fistula After Sleeve Lobectomy, A Case Report: A Fatal Complication Of Sleeve Lobectomy
J Abe, K Kanma, Y Saito
aneurysm, aorta, bypass surgery, cardiac, cardio-pulmonary, cardiopulmonary bypass, cardiothoracic, carotid, chest, heart, heart-lung machine, massive hemoptysis, medicine, pleural fistula, pulmonary artery bronchial fistula, sleeve lobectomy, surgery, thoracic, ulcerative bronchitis, valve, vascular, vessel
J Abe, K Kanma, Y Saito. Pulmonary Artery Bronchial Fistula After Sleeve Lobectomy, A Case Report: A Fatal Complication Of Sleeve Lobectomy. The Internet Journal of Pulmonary Medicine. 2000 Volume 2 Number 1.
A rare case of pulmonary artery bronchial fistula after sleeve lobectomy for lung cancer is described. Non-aspergillous ulcerative bronchitis was the most considerable cause of death in our case. The patient was once saved by emergency thoracotomy, but finally he died from recurrent massive hemoptysis resulting from newly formed pulmonary artery bronchial fistula. Albeit our case had quite rarely clinical course, we must have a threat for this fatal complication even when we are managing non-immunosuppressive patients.
Recently, a case of fatal massive hemoptysis resulting from ulcerative bronchitis after lung transplantation was reported1. The patient described in that article was treated with immunosuppressive drugs such as corticosteroids and was forced to be in a condition in which he was easily infected to bacteria or fungus. Aspergillus infection sometimes forms ulcerative tracheobronchitis in immunosuppressive patients2,3, and it is one of the major causes of anastomosis insufficiency in these lung transplanted patients. Ulcerative bronchitis also occur in non-immunosuppressive patients. In these cases, aspergillus infection is rarely observed. We report here our experience of massive hemoptysis owed to non-aspergillous ulcerative bronchitis which resulted in fatal pulmonary artery bronchial fistula after sleeve lobectomy for lung cancer.
A 69-year-old male was suffered squamous cell carcinoma developed from the intermediate trunk and referred our unit. He was performed right middle and lower sleeve lobectomy on 20 December, 1999. His postoperative course was poor because of sputum pooling around anastomosis site, and we had to remove them by bronchofiber scope several times at intensive care unit. In this examination, we found that white pseudomembrane was attached to overall anastomosis. Just two weeks after sleeve lobectomy, he had sudden massive hemoptysis. More than 2000ml of blood loss were observed until we performed an emergency thoracotomy. (Figure 1)
As the operative findings, segmental branch of pulmonary artery communicated directly to tracheobronchial tree through the bronchial anastomosis (Figure 2).
This completion pneumonectomy once saved the patient’s life, but bronchopleural fistula and pyothorax was developed three days after emergency thoracotomy. A chest tube was inserted into his right hemithorax, and he was managed with antibiotics. A culture of the pleural effusion from his chest tube revealed a multiplication of pseudomonas aeruginosa. He had a recurrent bleeding from the tracheal tube which was inserted in normal position now. Hemothorax also was observed ten days after the thoracotomy. The patient died 25 days after the first sleeve lobectomy. Newly formed pulmonary artery bronchial fistula was contemplated as the cause. The post mortem exam was not done. In the removed right upper lobe, aspergillous infection was not demonstrated. His bronchial cartilage around anastomosis was destructed by aggregated neutrophils (Figure 3) and which suggested us that his anastomosis insufficiency did not occur merely from ischemia of bronchial wall but from a severe ulcerative bronchitis.
Though some bacterial infection was considered as the cause, normal bacterial floras were observed in his sputum samples which were taken frequently before and after the initial operation. He did not take corticosteroids or other immunosuppressive drugs, and he did not suffered human immunodeficiency virus.
Pulmonary artery bronchial fistula after sleeve lobectomy for lung cancer is rarely reported. Uncontrollable bleeding into the traheobronchial tree often causes sudden unexpected death4. Ischemia of the anastomosis is considered one of the most significant factors of ulcerative bronchitis. Prolonging airway inflammation also affect progressive ulcer formation. Recent reported cases of ulcerative bronchitis are all occurred in patients after lung transplantation. We report here this may also occur in non-immunosuppressive patients. We could not determine the causes of inflammation but at least aspergillus infection was not related in our case. Although our case was quite rare, clinicians who manage sleeve lobectomy for lung cancer should have a threat of this fatal complication.