Eur J Cardiothorac Surg 2006;30:950-951
© 2006 Elsevier Science NL
Colo-pleural fistula following pneumonectomy
Babajide O. Olubaniyi,
Eustace J. Fontaine,
Richard D. Page*
Department of Thoracic Surgery, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, United Kingdom
Received 20 July 2006;
accepted 1 September 2006.
* Corresponding author. Tel.: +44 151 2932456; fax: +44 151 2288573. (Email: richard.page{at}ctc.nhs.uk).
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Abstract
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Following pneumonectomy and diaphragmatic reconstruction for carcinoid tumour, a fistula developed between the pneumonectomy space and the splenic flexure of the colon. The problem was successfully treated by colon resection and thoracoplasty.
Key Words: Pneumonectomy • Diaphragm • Infection • Abdominal organs • Thoracoplasty
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1. Introduction
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After pneumonectomy a number of surgical complications can occur some of them taking many years to develop. Many of these complications are due to a fistula between the pneumonectomy space and the divided bronchus. However, the development of a communication between the pneumonectomy space and the large bowel has not been reported previously.
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2. Case report
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A 61-year-old previously healthy male presented with weight loss. CT scanning showed a 25 cm x 25 cm mass occupying the lower left hemithorax and left upper quadrant of the abdomen, involving the lower lobe of the left lung, the diaphragm, and the spleen (Fig. 1
). Bronchoscopy revealed endobronchial tumour extending from the lower lobe to involve the left main bronchus; biopsy showed atypical bronchogenic carcinoid tumour. Percutaneous biopsy of the abdominal component of the mass was unhelpful.
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Fig. 1. CT scan on initial presentation showing a huge confluent mass in lower left hemithorax and left upper quadrant of the abdomen. It proved to be a combination of an atypical carcinoid tumour affecting the left lung and a pathologically separate arterio-venous malformation arising within the spleen.
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Surgical resection was carried out via a left thoracoabdominal incision using the 5th and 8th intercostal spaces. A huge confluent infiltrating mass was removed along with the diaphragm, spleen, tail of the pancreas, greater curvature of the stomach, part of the left lobe of the liver and the left lung. The splenic flexure of the colon was adherent to the mass over an area of a few millimetres but was separated from the mass in the subserosal plane which was then repaired. Polypropylene mesh was used to reconstruct the diaphragm. The patient required re-exploration during the first post-operative night for bleeding and subsequently developed a pneumonectomy space infection one week after surgery; the latter was managed by saline irrigation for 10 days without recourse to further surgery. His recovery was otherwise uncomplicated; chest radiograph showed satisfactory early opacification of the pneumonectomy space. Histological examination of the resected specimen confirmed an atypical node negative carcinoid tumour with extension into the diaphragm and a large associated arteriovenous malformation within the spleen.
Two years following his operation when attending for review his chest radiograph showed a significant amount of air in the pneumonectomy space. At this time, he was without symptoms. Although bronchoscopy revealed a healthy bronchial stump it was assumed that the air on the chest radiograph represented a tiny fistula from the airway to the pneumonectomy space.
Six months afterwards he developed recurrent bouts of unexplained sepsis; several courses of intravenous antibiotic therapy produced only slight clinical improvement. Although CT scanning was unhelpful an indium-labelled white cell scan showed an increased uptake in relation to the base of his left pneumonectomy space. At the time it was postulated that the prosthetic material used to reconstruct his diaphragm was chronically infected and was the cause of his sepsis. Bronchoscopy remained unremarkable.
A left video-assisted thoracoscopy was carried out via the pneumonectomy space. Although extensive debris limited the view, no air leak was in evidence from the stump of the left main bronchus on tracheal ventilation. Despite a further period of irrigation of the pneumonectomy space the drainage fluid cleared but remained infected after two weeks. Culture yielded coliforms and anaerobe species. At the conclusion of irrigation, on attempting to fill the pneumonectomy space with antibiotic-containing fluid he developed profuse watery diarrhoea. Prior to this occurrence there was a complete lack of gastrointestinal symptoms. Water soluble contrast instilled into the pneumonectomy space demonstrated a fistulous connection to the splenic flexure of the colon (Fig. 2
).
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Fig. 2. Fistulogram following injection of contrast in to the pneumonectomy space, demonstrating a communication between the space and the splenic flexure of the colon. Contrast passes freely to outline the descending colon.
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The pneumonectomy space drain was left in-situ. Via an abdominal approach the colon was mobilised and the diseased portion excised. Apart from the fistula, which was intimately connected to the underside of the diaphragmatic mesh, there were no other abnormalities. A primary anastomosis was carried out and omentum used to separate it from the mesh, which was otherwise not disturbed. There was no evidence of a recurrence of the original tumour. The patient's recovery was uneventful but his pneumonectomy space remained chronically infected despite continued drainage. Four months after abdominal surgery the pneumonectomy space was explored. The diaphragmatic reconstruction was intact without evidence of a residual fistula although the mesh was completely covered with dense fibrous tissue. Although there was a concern that it would be a focus for a future infection it was decided not to remove the mesh because of the risks this would involve. In order to obliterate the pneumonectomy space a latissimus dorsi flap and limited left thoracoplasty were required. He recovered well and remains without symptoms over a year later.
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3. Discussion
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Colo-pleural and colo-bronchial fistulae occurring as complications of colonic pathology have been described previously, in relation to locally invasive primary colonic carcinoma [1,2], diverticular disease [3], Chron's colitis [4] and strangulated diaphragmatic hernias [5]. We believe that our case is the first description of a communication between the colon and a pneumonectomy space. The fistula's late presentation after the original surgery presumably explains the lack of specific symptoms, given that the infection in the space was chronic in nature due to protective inflammatory scarring in response to the infection. Its aetiology is explained by the fact that the original pathology was adherent to the colon and the area of dissection was left in apposition the mesh used for diaphragmatic reconstruction. Interposing the greater omentum between the colon and the mesh at the time of the original surgery could conceivably have prevented it, as would the use of Gortex rather than polypropylene for diaphragmatic reconstruction. The lack any impact on colonic function due to the fistula and its direct communication to the pneumonectomy space explains the absence of lower gastrointestinal symptoms.
The case demonstrates the variable nature of problems that can occur after pneumonectomy, and that appropriate surgical intervention can lead to a favourable outcome, especially in subjects with excellent background health as in our patient.
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References
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- Papagiannopoulos K, Gialvalis D, Dodo I, Darby MJ. Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum. Ann Thorac Surg 2004;77:324-326.[Abstract/Free Full Text]
- Domej W, Kullnig P, Petritsch W, Melisch B, Schaflinger E, Smolle-Juttner FM, Schalk V, Ratschek M. Colobronchial fistula: a rare complication of Chron's colitis. Am Rev Respir Dis 1990;142:1225-1227.[Medline]
- Sinha M, Gibbons P, Kennedy SC, Matthews HR. Colopleural fistula due to strangulated Bochdalek hernia in an adult. Thorax 1989;44:762-763.[Abstract/Free Full Text]
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Abstract
1. Introduction
