Retained drains causing a bronchoperitoneal fistula: a case report

Abstract

IntroductionBronchoperitoneal fistulas are extremely rare. We present a case where retained surgical drains from a previous surgery resulted in erosion and fistula formation. This condition required an extensive surgical procedure and advanced ventilator techniques.Case presentationA 24-year-old African-American man presented to our Emergency Department with a one-week history of fever, dyspnea, cough, and abdominal pain. A computed tomography scan of his chest and abdomen revealed bilateral lower lobe pneumonia and two retained Jackson-Pratt drains in the right upper quadrant. He was taken to the operating room for drain removal, a right hemicolectomy, debridement of a duodenal injury, a Roux-en-y duodenojejunostomy, and an end ileostomy. He subsequently became increasing hypoxemic in the intensive care unit and a bronchoperitoneal fistula was diagnosed. He required high-frequency oscillatory ventilation followed by lung isolation, and was successfully resuscitated using these techniques.ConclusionTo the best of our knowledge, this is the first known case report of a bronchoperitoneal fistula caused by retained surgical drains. This is also the first known report that details successful management of this condition with advanced ventilatory techniques. This case highlights the importance of follow-up for trauma patients since retained surgical drains have the potential to cause life-threatening complications. When faced with this condition, clinicians should be aware of advanced ventilatory methods that can be employed in the intensive care unit. In this case, these techniques proved to be life-saving.

Bronchoperitoneal and Enterocutaneous Fistula Development Following a Colorectal Anastomosis Leak

“…The patient ultimately required a laparoscopic esophagojejunostomy with gastric exclusion and primary repair of the diaphragm defect. Additionally, iatrogenic injuries from biliary procedures and even retained surgical drains have been noted to result in bronchoperitoneal fistulas [2,4].…”

“…Ventilator management in this patient cohort is particularly challenging. There are several reports of novel ventilator strategies used to treat patients with bronchopleural fistulas, which may be applicable to bronchoperitoneal fistulas [2,4,6]. In general, the goal of ventilation therapy is to minimize air flow across the fistula.…”

“…If mechanical ventilation is necessary, then decreased air flow through the fistula can be achieved with a high-frequency, low-tidal volume approach or by equalization of the airway pressure and the interpleural pressure [7]. Multiple cases utilized high-frequency oscillatory ventilation to minimize air leaks, barotrauma, and peak airway pressure [2,8]. This approach may facilitate healing in both bronchoperitoneal and bronchopleural fistulas.…”

“…As most bronchoperitoneal fistulas originate from a benign or malignant mass eroding through the diaphragm, it would be prudent to remove the offending agent. Four of the case reports reviewed ultimately required operative management to obtain source control, debride nonviable tissue, or repair the diaphragm [1][2][3]5]. Surgical treatment also permits inspecting the abdomen for additional injuries.…”

“…Bronchoperitoneal fistulas are rare entities that pose significant challenges to critical care and surgical teams. These fistulas most commonly occur due to erosion by a subdiaphragmatic abscess or mass and place the patient at significant risk for pneumonia, sepsis, acute respiratory distress syndrome (ARDS), and prolonged mechanical ventilation [1][2][3]. Although bronchoperitoneal and bronchopleural fistulas have been well described as complications after biliary surgery, their occurrence outside of this context is less common [4].…”