Thoracoscopic management of a communicating bronchopulmonary foregut malformation in a 23-month-old child

Left interval thoracoscopic pneumonectomy for type II communicating bronchopulmonary foregut malformation in a 17-month-old girl

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Type II CBPFM: no main bronchus and underdeveloped lung connected to the oesophagus.

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No incidence is reported but there are less than 30 cases in the English literature.

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Typical presentation of CBPFM is by 2 years old with chronic cough and pneumonia.

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CBPFM was approached dorsally; all trocars were placed along the erector spinae.

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Intensive conservative management contributed to successful thoracoscopic surgery.

Introduction

Communicating bronchopulmonary foregut malformation (CBPFM) is a rare congenital anomaly comprising a spectrum of airway anomalies connected to the oesophagus or stomach. Our management of a case of CBPFM is presented to improve knowledge of its treatment.

Presentation of case

A 17-month-old Japanese girl presented with fever (39.1 °C) and persistent cough. She was noted to be poorly developed (7.5 kg: −2SD). Chest X-ray radiography was suggestive of pneumonia involving the left lung; WBC was 41600/μL and CRP was 12.9 mg/dL. Computed tomography, upper gastrointestinal series, and bronchoscopy identified a fistula between the oesophagus and the left lung and severe left pulmonary artery hypoplasia, typical of type II CBPFM. Her left thoracic cavity was small with sclerotic lung tissue. We customised management by commencing a trial of intensive duodenal tube feeding without oral ingestion. She gained weight and her pneumonia improved enough to enable thoracoscopic left pneumonectomy through an unconventional dorsal approach, necessary because of the location of her CBPFM. Surgery was successful and tolerated well with unremarkable postoperative recovery. Currently she is asymptomatic and growing well.

Discussion

We used minimally invasive surgery (MIS) to resect an anomalous bronchus and perform a left pneumonectomy after two weeks of intensive conservative management, including nil-by-mouth to optimise her condition for surgery.

Conclusion

Our case provides further evidence that CBPFM can be treated successfully by MIS (interval thoracoscopic pneumonectomy), especially after a period of intensive conservative management. Interval surgery should be considered actively prior to major surgery in smaller children if indicated.

Congenital bronchopulmonary foregut malformation: systematic review of the literature

BACKGROUND

Congenital bronchopulmonary foregut malformation (CBPFM) is a rare congenital malformation involving both the digestive and respiratory system. Early diagnosis is difficult, and delayed recognition may result in considerable complications. The aim of the study was to identify and analyze the clinical characteristics and radiological features of CBPFMs.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Ovid database, EMBASE were searched for relevant publications to identify all published case-reports of CBPFM since 1992. Data about the demography, clinical presentation, pathology, imaging features, treatment and prognosis were collected.

RESULTS

Sixty-one cases were included in our study. Cases were aged from 1 day to 59 years with the majority aged 3 years or younger. The most common type was group III (37.7%), followed by group II (29.5%)group I (27.9%) and group IV (4.9%). The presentations included respiratory distress (32.8%), cough/choking following food intake and other presentations associated respiratory infection. Thirty-eight cases (62.3%) were diagnosed by upper gastrointestinal series (UGI). Misdiagnosis was common. Eight cases (13.1%) of the included cases died.

CONCLUSIONS

Early recognition and extensive delineation of the anatomy of CBPFM are important to correct these anomalies successfully. UGI is the first choice to confirm the abnormal bronchus communicating with the esophagus. Resection of abnormal pulmonary tissue, lobe or even unilateral lung is preferred. Reconstruction procedures are feasible in selected patients.

Esophageal lung diagnosed following the primary repair of esophageal atresia with tracheo-esophageal fistula in a neonate

Communicating bronchopulmonary foregut malformations are a diverse group of congenital anomalies characterized by a fistula between the respiratory and alimentary systems. Among these malformations, the association of an esophageal lung with esophageal atresia (EA) and tracheo-esophageal fistula (TEF) is extremely rare. We report the case of a neonate with esophageal lung detected following the primary repair of EA with TEF. Despite the rarity of esophageal lung with EA and TEF, it should be considered to develop in infants with abnormal findings on chest radiographs and an unusual preoperative and/or in the postoperative clinical course of EA and TEF. Swallowing study with water-soluble contrast medium is the investigation of choice to demonstrate the anatomic connection, if EA and TEF were already primarily repaired. If not, although the use of preoperative CT may be debatable in neonates due to the associated radiation exposure, in selected cases such as our patient, preoperative CT can be useful for early preoperative diagnosis.