Esophagobronchial fistula and mediastinal tuberculosis

Long-term results of surgical treatment in benign bronchoesophageal fistula

OBJECTIVES

Benign bronchoesophageal fistula is a rare complication resulting from various diseases. The objectives of the study are to report our surgical experience in patients with benign bronchoesophageal fistulas and to evaluate the long-term results of surgical management.

METHODS

Between 1995 and 2005, a total of 14 patients (mean age, 52.5 years; male/female = 6:8) underwent operations for benign bronchoesophageal fistulas. The etiology of the fistulas included traction esophageal diverticula in 7 patients and tuberculous lymphadenopathy in 6. Primary repair of the fistula was performed in all patients and a concomitant lobectomy in 6.

RESULTS

There was no in-hospital mortality. Postoperative complications occurred in 1 patient (empyema resulting from a leakage at the repair site). Postoperative esophagography revealed a leakage at the repair site in 1 patient. There was 1 late death with a mean follow-up of 43.9 months. The cause of death was aspiration pneumonia resulting from recurrent fistula. Two of 8 patients who did not undergo a lobectomy had persistent bronchiectasis, whereas none of those who underwent a concomitant lobectomy had any recurrent pneumonia or bronchiectasis. The overall survival was 100% at 5 years and the mean survival time was 124 months (95% confidence interval, 106.5-142.2 months).

CONCLUSIONS

We conclude from these data that early detection and definitive surgical repair of benign bronchoesophageal fistulas can yield high success rates with excellent early outcomes and good long-term results.

CT and MRI appearance of a fistula between the right and left main bronchus caused by tracheobronchial tuberculosis

Tuberculosis of the trachea and main bronchi is a relatively rare disease seen predominantly in elderly patients. We present a case of a fistula between the right and left main bronchus owing to tuberculosis. We describe the CT and MRI appearances.

Benign tracheoesophageal fistula: results of surgical therapy

Acquired fistulas between the trachea and the esophagus (TEFs) are unusual, serious and still challenging clinical entities. Between 1980 and 1997, 31 patients with acquired benign TEF were evaluated and treated in our department. The definitive treatment was undertaken when patients were weaned from the ventilator. Dissection of the fistula and closure of the tracheal and esophageal defect was performed in 26 patients. Esophagogastroplasty plus closure of the tracheal defect and omental interposition was performed in two patients. Tracheal resection and reconstruction plus of the sternocleidomastoid muscle interposition was carried out in one patient with circumferential tracheal damage. In two patients, no surgical treatment was carried out. One patient died after surgical treatment. In 23 patients, long-term follow-up was excellent, with normal post-operative function of both the esophagus and the airway. Two failures of treatment occurred which required definitive tracheostomy plus T-tube. Management of TEFs can be safely carried out after weaning patients from the ventilator.

Sepsis syndrome induced by tuberculous perforation of the esophagus

Perforation of the esophagus induced by tuberculosis with no evidence of HIV infection is an extremely unusual presentation of the disease. We report on a 41-year-old man presenting with an esophageal perforation who developed a sepsis syndrome characterized by multiple organ dysfunction. The perforation was covered endoscopically with a tube, the patient recovered from cardiovascular, renal and pulmonary dysfunction under intensive care treatment, including antimycobacterial therapy. In response to endoscopic and medical treatment the size of the lesion decreased and disappeared 56 days after diagnosis. The patient could be discharged 2 months after admission and remained asymptomatic after a 12 month follow-up examination.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.