Ann Thorac Surg 1999;68:1058-1059
© 1999 The Society of Thoracic Surgeons
Case Reports
Bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess
Stephan M. Stockberger, Jr, MDa,
Kenneth A. Kesler, MDb,
Lynn S. Broderick, MDa,
Thomas J. Howard, MDc
a Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
b Division of Thoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
c Division of General Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
Address reprint requests to Dr Kesler, Division of Thoracic Surgery, Department of Surgery, Indiana University, 545 Barnhill Dr, Emerson Hall #212, Indianapolis, IN 46202
e-mail: kkesler{at}iupui.edu
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Abstract
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We treated a case of bronchoperitoneal fistula secondary to a Klebsiella pneumoniae subphrenic abscess. This fistulous communication and the surgical procedure used to treat it are described.
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Introduction
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Fistulous communications between the bronchi and the peritoneal cavity are distinctly rare. However they can occur secondarily to neoplasms or biliary tract infection [1–6]. We recently treated a patient with a bronchoperitoneal fistula, whose presentation was dramatic and life threatening.
The patient was a 46-year-old white woman who had a laparoscopic cholecystectomy 4 months before admission. A bile leak was noted at the time of operation and therefore a drain was placed in the subhepatic space. She continued to drain approximately 300 to 400 mL of bile daily and was subsequently transferred to our institution for further evaluation and therapy. A percutaneous transhepatic cholangiogram disclosed complete occlusion of the common bile duct at the level of surgical clips consistent with inadvertent ligation. A percutaneous transhepatic biliary drainage catheter was then placed via a right lateral subcostal approach followed by choledochojejunostomy. The biliary drainage catheter was removed 4 weeks after biliary reconstruction.
Three days later, she developed a cough productive of initially clear sputum which became green with a feculent odor. She also had temperature increases up to 102°F. Chest radiograph on admission to the hospital showed an extensive right lower lobe infiltrate containing a focal lucency (Fig 1). The patient was therefore readmitted for treatment of presumed right lower lobe pneumonia, and her sputum cultures were positive for Klebsiella pneumoniae.
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Fig 1. Chest radiograph on the day of admission shows elevation of the right hemidiaphragm and airspace disease in the right lower lobe. A pulmonary abscess was found within the right lower lobe, which is manifest as a focal lucency containing an air or fluid level (arrows).
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Two days after readmission the patient had an acute episode of respiratory distress requiring endotracheal intubation and positive pressure ventilation. A spiral computed tomographic scan was obtained which demonstrated a 5.5-cm cavity in the right lower lobe that was in communication with a 3.5-cm defect in the dome of the right hemidiaphragm. A new large subphrenic air collection, bilateral lower lobe pulmonary airspace opacities, and small bilateral pleural effusions were also demonstrated (Fig 2).
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Fig 2. Spiral computed tomographic scan sagittal reconstruction shows the abscess in the right lower lobe (curved black arrow), defect in the right hemidiaphragm (open black arrows), and loculated subphrenic air (open white star), which developed radiographically after positive pressure ventilation was initiated. No pneumothorax is seen.
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Because of the patient’s ventilator positive pressure requirements and computed tomographic findings suggestive of a bronchoperitoneal fistulous communication, exploratory thoracotomy was performed. A chronic subphrenic abscess was found to be burrowing into the basilar segments of the right lower lobe through a central diaphragmatic defect. The surrounding lung parenchyma and pleural space appeared normal except for adherence of the basilar segments to the dome of the diaphragm. The subphrenic abscess was debrided through the diaphragmatic defect. Cultures of this abscess grew K pneumoniae. Right middle and lower lobectomies with a five-rib (ribs 6 through 10) thoracoplasty were done, which afforded complete obliteration of the subphrenic abscess space as well as pleural space after bilobectomy. She was weaned from mechanical ventilation on the 15th postoperative day and discharged on the 22nd postoperative day. The patient is well 2 years postoperatively (Fig 3).
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Fig 3. Chest radiograph obtained 3 months postoperatively shows rib deformity secondary to the thoracoplasty and elevation of the right diaphragm. The lungs are clear.
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Comment
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Fistulous communications between the biliary tree and pleura are associated with neoplasms and have been found with suppurative biliary tract obstruction or percutaneous biliary drainage procedures [1–6].
Although the infectious process could have originated in the right lower pulmonary lobe, in this case we suspect that an undetected subphrenic Klebsiella abscess eventually eroded through the diaphragm. This process then involved the lung creating a bronchoperitoneal fistula which was dramatically radiographically demonstrated after positive pressure ventilation. The history of multiple previous biliary tract procedures before her current illness and the intraoperative findings of a chronic subphrenic infectious process support this theory.
Although there was no evidence of pleural space infection, the bilobectomy procedure left a large potential space in continuity with a chronic subphrenic abscess cavity. Although muscle interposition might have obliterated enough space to avoid postoperative infectious complications above and below the diaphragm, a limited lower thoracoplasty accomplished this easily and successfully.
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References
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Boyd D.P. Bronchobiliary and bronchopleural fistulas. Ann Thorac Surg 1977;24:481-487.[Abstract]
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Bilfinger T.V., Oldham K.T., Lobe T.E., Barron S., Hayden C.K. Successful percutaneous drainage of pyogenic liver abscess complicated by bronchobiliary fistula. South Med J 1987;80:907-909.[Medline]
-
Ibarra-Perez C. Thoracic complications of amebic abscess of the liver. Chest 1981;79:672-677.[Abstract/Free Full Text]
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Stark P. Bronchoenteric fisulae in lymphoma. AJR Am J Roentgenol 1981;136:615-617.[Free Full Text]
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Savage P.J., Donovan W.N., Kilgore T.L. Colobronchial fistula in a patient with carcinoma of the colon. South Med J 1982;75:246-247.[Medline]
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Cunningham L.W., Grobman M., Paz H.L., Hanlon C.A., Promisloff R.A. Cholecystopleural fistula with cholelithiasis presenting as a right pleural effusion. Chest 1990;97:751-752.[Abstract/Free Full Text]
Accepted for publication November 5, 1998.
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Abstract
Introduction
