|Year : 1983 | Volume
| Issue : 2 | Page : 108-110A
Nephrobronchial fistula. Closure by thoraco-abdominal approach and the use of free fascia lata graft. (A case report).
NK Sachdeva, LK Shah, SS Vaidyanathan, NN Das, MS Rao
N K Sachdeva
|How to cite this article:|
Sachdeva N K, Shah L K, Vaidyanathan S S, Das N N, Rao M S. Nephrobronchial fistula. Closure by thoraco-abdominal approach and the use of free fascia lata graft. (A case report). J Postgrad Med 1983;29:108-110A
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Sachdeva N K, Shah L K, Vaidyanathan S S, Das N N, Rao M S. Nephrobronchial fistula. Closure by thoraco-abdominal approach and the use of free fascia lata graft. (A case report). J Postgrad Med [serial online] 1983 [cited 2023 Jan 31 ];29:108-110A
Available from: https://www.jpgmonline.com/text.asp?1983/29/2/108/5541
Fistula between the urinary tract and the lung is a rare occurrence. Only 69 cases have been reported so far. The common causes of nephrobronchial fistula are pyonephrosis, perinephric abscess, and renal tuberculosis. With the advent of antibiotics and prompt treatment of urinary tract infection, this entity secondary to inflammatory disease of the kidney is becoming almost extinct in the developed nations. However, in our country, calculus pyonephrosis and perinephric abscess are being encountered frequently because of the sociomedical reasons viz. the health education of the mass is below par and there is a delay in seeking medical care especially in the rural areas. A case of nephrobronchial fistula in a patient with calculus pyonephrosis who was initially taking indigenous drug treatment for about six months is presented.
A 38 year old female was admitted with the complaints of fever, pyuria, and right flank pain of six months' duration. She developed cough with expectoration during the past two months. A tender, fluctuant lump was palpable in the right lumbar region. Crepitations were audible over the base of the right lung. Her haemoglobin was 9.3 G%, and her total leucocyte count was 21,400/mm3, with P-84%, L-12%, M-3% and E-1%. Blood urea was 27 mg%, and serum creatinine was 1 mg%. Urine analysis revealed many pus cells per high power field. X-ray chest revealed pneumonitis in the lower zone of the right lung [Fig. 1]. X-ray abdomen showed staghorn calculus and soft tissue mass in the right upper quadrant. Excretory urography revealed normal left pyelocalyceal system but non-visualisation on the right, even in the delayed film [Fig. 2]. Based on our previously reported experience of a case, the presence of ipsilateral chest lesion in this patient with pyonephrosis raised the possibility of a co-existent nephrobronchial fistula. During induction of anesthesia, purulent secretions were seen exuding from the tracheobronchial tree. Due to technical reasons a double lumen endobronchial tube (to block spill-over infection to opposite lung in the lateral operating position of the patient) could not be used. The anesthesiologist kept constant vigilance and sucked away the purulent material at frequent intervals.
The perinephric abscess was first drained through a subcostal incision in order to relieve the tension and stop exodus of pus into the chest. Pyelolithotomy was performed which facilitated subsequent performance of a sub-capsular nephrectomy. Two fistulous tracts were seen in the right dome of the diaphragm. An attempt was made to close them with a muscle graft taker from the transversus abdominis but this procedure was only partly successful. Therefore, thoracotomy was performed through the right ninth intercostal space. The lower lobe of the lung was separated from the diaphragm and the fistulous ends in the right lower lobe were closed with 3-0 prolene. The defect in the diaphragm was then repaired with fascia lata graft taken from the right thigh. Intercostal drainage was provided and the thoracotomy wound was closed. The loin wound was approximated around a sump drainage connected to a collapsed asepto syringe for negative suction. Ventilatory support was provided for 8 hours in the immediate post-operative period. Pus from the perinephric abscess and sputum yielded Pseudomonas aeruginosa sensitive to gentamicin and carbenicillin. She developed wound infection which responded to the above antibiotics. Histopathology of the kidney revealed completely hyalinised glomeruli. Hyaline casts were present in the dilated tubules. Intense interstitial inflammation was present which had progressed to lymphoid follicle formation with germinal centres in some areas. The pelvis contained inflammatory exudate. There was no evidence of malignancy or xanthogranulomatous pyelonephritis.
Nephrobronchial fistula, if unsuspected and appropriate precautionary measures not instituted during operation, could result in a fatal outcome. This entity should be suspected in a patient with pyonephrosis, respiratory symptoms and ipsilateral pleuropulmonary lesion in the chest X-ray. Although it may be possible in the majority of cases to close the fistulous communication with the lung through the lumbar incision, it would be desirable to resort to thoracotomy in case the former is not successful. Further, thoracotomy offers the added advantage of providing the opportunity to achieve airtight closure of the bronchopulmonary end of the fistula. This particular step would considerably reduce the postoperative morbidity by diminishing the chances for development of pleuropulmonary complications. Free graft of fascia lata has been used extensively for closure of tissue gaps in various regions. This procedure enabled us to achieve satisfactory closure of the rent in the diaphragm.
Use of a double lumen endobronchial tube would avert spill-over of the purulent material to the contralateral bronchial tree during. surgery. In the absence of this facility, constant vigilance on the part of the anesthesiologist to suck away the purulent material would help in its prevention to some extent and possibly avert any major pulmonary complication as exemplified in this case. These patients who undergo prolonged operative procedure in the `kidney position' are susceptible to the development of `down lung syndrome'. They are benefited by elective ventilatory support in the immediate post-operative period in an intensive care unit. It should be admitted that the decrease in mortality of urological surgery has been brought about in such situations not only by refinement in urological operative technique and instrumentation but also by simultaneous advances in supportive facilities such as anesthesiology, clinical biochemistry, etc. Hopefully, with improvement in health education and health care facility in the rural areas, these patients will be treated at an early stage for urinary tract infection and renal calculous disease and will not be allowed to progress to form pyonephrosis and subsequently nephrobronchial fistula which could prove a complicated and even fatal problem.
|1||Manchanda, K. S., Kumar, V. and Bhatnagar, V.: Understanding of diseases and treatment-seeking pattern of childhood illnesses in rural Haryana, India. Trop. Geogr. Med., 32: 70-76, 1980.|
|2||Rao, M. S., Bapna, B. C., Rajendran., L. J., Shrikhande, V. V., Prasanna, A., Subudhi, C. L. and Vaidyanathan, S.: Operative management problems in nephrobronchial fistula. Urology, 17: 362-363. 1981.|
|3||Rubin, S. A. and Morettin, L. B.: Nephrobronchial fistula: an uncommon manifestation of inflammatory renal disease. J. Urol., 127: 103-105, 1982.|