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

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.
Figure1.
CTScanofthe
abdomenshowing
alargeintra
peritoneal
septatedcystic
massintheleft
upperabdomen.

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.

Figure2.Intraoperativeimageshowingthedefect(arrow)ontheleftdiaphragm

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

display chronic inflammatory changes in the lung parenchyma with no malignant

disease identified.
Figure3.
Specimenof
theresected
lungshowing
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 patients 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 highfrequency 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
4

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 patients 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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