Benign esophagorespiratory fistula: a case series and a novel technique of definitive management

A rare cause of esophagopleural fistula due to intensity-modulated proton therapy: a case report and review of literature

Esophagopleural fistula (EPF), initially described in 1960, is an abnormal communication between the esophagus and the pleural cavity which can occur due to congenital malformation or acquired due to malignancy or iatrogenic treatment. The most common presenting symptoms are of a respiratory infection, such as fever, chest tenderness, cough and imaging findings consistent with pleural fluid consolidation. In this report, we present a 59-year-old man who exhibited shortness of breath, productive cough, and significant weight loss for 2 weeks. His medical history was significant for smoking-related lung disease and pulmonary squamous cell carcinoma (SCC). His SCC (T4N0) was diagnosed 6 years prior to this presentation and was treated with chemoradiotherapy. The cancer recurred a year ago and he was treated with intensity-modulated proton therapy (IMPT) and consolidation chemotherapy. During admission, he was found to have an EPF by CT scan after initially failing antibiotic treatment for suspected complicated pneumonia and pleural effusion. Multiple attempts of esophagopleural fistula closure were made using endoscopic self-expandable metallic stents and placement of an esophageal vacuum-assisted closure device. However, these measures ultimately failed and, therefore, he required an iliocostalis muscle flap (Clagett window) procedure for closure. Esophageal pulmonary fistulae should be suspected whenever patients have undergone thoracic IMPT and may present with acute pulmonary complications, particularly pneumonia refractory to antibiotic treatment. This case reviews the current literature, potential complications, and treatment options for esophagopleural fistulas.

Repair of Adult Benign Tracheoesophageal Fistulae With Absorbable Patches: Single-Center Experience

BACKGROUND

This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique.

METHODS

Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed.

RESULTS

An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n = 6), mediastinal radiotherapy (n = 1), and a complication of lung resection (n = 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower.

CONCLUSIONS

Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

Surgical repair of mechanical ventilation induced tracheoesophageal fistula

PURPOSE

To evaluate the outcomes of surgery to repair tracheoesophageal fistula (TEF) caused by mechanical ventilation.

METHOD

Case series and review of all cases reported in English literature. Only reports of TEF following mechanical ventilation and containing description of surgical repair and outcomes were included.

RESULTS

A total of 41 studies comprising 143 patients met the inclusion criteria. Most studies had incomplete information on important variables such as co-morbidity and fistula size. Tracheal resection anastomosis (TRA) was the most common approach, performed in 91 (63.6%) patients (including three newly reported here). Lateral approach repair (LA) was done in 45 (31.5%) patients. The former had a higher incidence of pre-existing tracheal stenosis [53 (89.8%) vs. 7 (35%) cases; p < 0.001]. Flap interposition to augment the repair was done in 49 (53.9%) and 40 (88.9%) cases, respectively (p < 0.001). Successful and durable healing of the fistula were achieved in 90 (98.9%) cases in TRA and 39 (88.6%) cases in LA.

CONCLUSION

In carefully selected cases of TEF caused by mechanical ventilation, TRA is the most preferred approach, delivering successful healing in almost all cases. Where TRA is not indicated or preferred, LA appears to be a good alternative. Future studies should explicitly report all of the known co-variables, so that the exact indications for choosing a particular surgical approach could be better elucidated.

Gastrointestinal CMV Disease and Tuberculosis in an AIDS Patient: Synergistic Interaction between Opportunistic Coinfections

The AIDS pandemic has made diseases such as tuberculosis, CMV disease, and other opportunistic infections more prevalent; these diseases may even be found to be associated among themselves, and the natural history of each disease may present in an unusual manner. We report the case of a 41-year-old man with HIV (CD4 of 144 cells/dL) and HCV with hematochezia due to tuberculosis in the ileocecal valve and descending colon and CMV tissue invasive disease in the esophagus and descending colon. Coinfection among tuberculosis and cytomegalovirus in the gastrointestinal tract was described only once in a patient with a recent diagnosis of HIV that affected the distal ileum and ascending colon. We will discuss the peculiarities of the case and the behavior of the immune system in the face of simultaneous opportunistic infections. This is a challenging scenario that has scarce publications and is of great clinical importance.

[The possibilities for the prevention of incompetent tracheorrhaphy]

The present review of the literature is focused on the methods designed for the prevention of incompetent tracheorrhaphy. The main cause that dictates the necessity of strengthening the sutures is the risk of the development of the complications during the postoperative period following the surgical interventions. The incompetence of the tracheal anastomoses is known to occur in 3.6-26.3% of the patients which leads to the development of such complications as neck phlegmon, mediastinitis, and pleural empyema. The mortality rate amounts to 18.2%. The authors describe the methods employed for the prevention of incompetent tracheorrhaphy following the circular resections and suturing of the linear traumatic defects. The advantages and disadvantages of individual methods are discussed.

Successful Surgical Closure of an Esophagobronchial Fistula Caused by a Foreign Body in the Esophagus of a Female Octogenarian with a Delayed Diagnosis: A Case Report

Esophagobronchial fistula (EBF) caused by an esophageal foreign body is rare in adults. All surgical interventions in the reported cases were performed via right thoracotomy. We have successfully treated an 88-year-old woman with EBF caused by a thick 2 × 2 cm piece of cake decorating paper that was swallowed accidentally. There was a 2-month interval between ingestion of the foreign body and correct diagnosis. The bronchial opening of the EBF was on the cephalic wall of the proximal left main bronchus (LMB), so we planned a primary repair of the bronchial wall with sutures via left thoracotomy. We performed a division of the fistula and primary closure of the openings on the esophageal and bronchial walls and covered the suture sites with an intercostal muscle flap and pericardial fat, respectively. The patient resumed oral intake on postoperative day 11 and was subsequently transferred to other hospital for rehabilitation.

Esophagorespiratory Fistulas: Survival and Outcomes of Treatment

GOAL

The purpose of this study was to characterize outcomes of esophagorespiratory fistulas (ERF) by etiology and initial treatment strategy.

BACKGROUND

ERF is a morbid condition for which optimal treatment strategies and outcomes are still in evolution.

STUDY

Medical records and images were reviewed for all patients diagnosed with ERF at Mayo Clinic in Rochester, MN, between September 1, 2001 and January 1, 2012. Fistulas were classified as malignant or benign. Treatment strategies were classified as surgical or nonsurgical (typically esophageal stent placement). Technical and clinical success, survival, and survival free of second intervention were assessed.

RESULTS

A total of 123 patients with acquired ERF were identified, of whom 65 (53%) were malignant and 58 (47%) benign. Initial treatment strategy was nonsurgical in 88 (72%) patients and surgical in 35 (28%); lower Charlson comorbidity scores were associated with increased likelihood of surgery. Technical and clinical success was seen in a majority of patients treated both surgically and nonsurgically. Patients with malignant ERF treated surgically survived longer than patients undergoing nonsurgical treatment (hazard ratio=5.6, P=0.005). In contrast, those with benign ERF had similar overall survival regardless of whether they received initial surgical or nonsurgical treatment; reintervention was more common in those who underwent nonsurgical treatment (hazard ratio=2.3, P=0.03).

CONCLUSIONS

We conclude that survival in malignant ERF is better with surgical intervention in selected patients. Surgical and nonsurgical techniques achieve similar survival in benign ERF, but reintervention is more common in those treated endoscopically.

Outcome and safety of tailored surgical treatments of nonmalignant esophagotracheobronchial fistula: report of fourteen patients

Introduction

Acquired benign esophageal tracheobronchial fistulae are clinically rare. In this paper, we summarize our experiences in surgical treatment of 14 consecutive patients with acquired benign esophageal tracheobronchial fistula.

Methods

This series included patients who underwent surgery between January 2002 and June 2015 at our institution. We retrieved and analyzed data on demographics, operative characteristics, and surgical outcome of the patients.

Results

Bronchofiberscopy revealed the membranous trachea openings of fistulae and gastroendoscopy further showed lesions in the anterolateral wall of the esophagus. Thoracotomy, division of the fistulous tract, and closure of the esophagus and trachea and other procedures were performed. All operations were uneventful, and there was no perioperative and postoperative complication or death. Symptoms disappeared after surgery in patients. The median length of hospital stay was 53 (range 31–270) days. The patients were followed up for a median of 33.5 (range 15–168) months. No recurrence was reported.

Conclusion

Our results suggest that acquired benign esophageal tracheobronchial fistulae have a broad spectrum of anatomic pathologies and exhibit markedly varied clinical manifestations, and a surgical approach tailored to the condition of individual patients is recommended.

Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer

Background

Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.

Case presentation

A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.

Conclusion

A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.

Effect of cauterizing esophageal mucosa in "double-patch" treatment for acquired benign tracheoesophageal fistula/bronchogastric stump fistula

BACKGROUND

The management of acquired benign tracheoesophageal fistula (TEF) and bronchogastric stump fistula (BGSF) is a challenge. This study aimed to assess the "double-patch" technique with or without esophageal mucosa in treating nonmalignant TEF and BGSF.

MATERIALS AND METHODS

We established a dog model with TEF by incising the esophageal and tracheal membranes and suturing them together. The dogs were divided into three groups (n = 12 per group). Groups A and B received a double-patch 7 d later. The esophageal mucosa of the patches was cauterized in the group A dogs, kept intact in group B dogs, and group C dogs did not receive surgical intervention. Tissue healing was measured using hydroxyproline levels.

RESULTS

Morphologic and histopathologic changes of the esophagus were assessed by gross observation of the specimens, hematoxylin and eosin staining, tracheal stenosis index, and hydroxyproline levels. On day 56 after surgery, group A showed a tracheal stenosis index comparable with that of group C (0.140 ± 0.009 versus 0.138 ± 0.014, P = 1.00), whereas group B showed a higher stenosis index (0.170 ± 0.007) than group C (P = 0.029). The hydroxyproline levels were higher in group A than in B and C on day 7 (P = 0.029), and this difference was statistically significant on days 14 and 56 (all P < 0.001).

CONCLUSIONS

The use of an esophageal "double-patch" technique without mucosa showed faster and more stable recovery than patches with mucosa in the repair of acquired nonmalignant complicated TEF and BGSF.

A novel surgical method for acquired non-malignant complicated tracheoesophageal and bronchial-gastric stump fistula: the "double patch" technique

BACKGROUND

To manage the acquired benign complicated tracheoesophageal fistula (TEF) and bronchial-gastric stump fistula (BGSF) are clinical technical challenge. The purpose of this study is to retrospectively review a surgical "double patch" technique in treating nonmalignant complicated TEF and BGSF, and then clarify the long-term curative effect of the technique.

METHODS

Clinical records of 30 patients with non-malignant complicated TEF and BGSF treated by "double patch" technique in Tangdu Hospital between August 2004 and August 2014, were analyzed and summarized retrospectively.

RESULTS

Thirty patients (19 males and 11 females) underwent "double patch" surgical repair of acquired benign complicated TEF and BGSF. The median age of the patients was 40.2±21.1 years. The most common causes were the following: TEF [22], BGSF [8]. Post-intubation injury [6], trauma [5], foreign body and stents [10], complications from prior esophageal surgery [8], and caustic ingestion [1]. The follow-up was completed for 24 months in all the patients (100%). The operative mortality was 0% (0/30). Twenty-six patients (86.7%) recovered uneventfully while four patients (13.3%) exhibited some major complications in the perioperative and postoperative periods. One patient (3.3%) developed recurrence of tracheal fistula in situ, two patients (6.7%) showed pneumonia, and one patient (3.3%) developed fistula esophageal anastomosis. All the 30 patients resumed oral intake finally.

CONCLUSIONS

The double patch technique is an effective and safe method to repair the acquired non-malignant complicated TEF and BGSF.

Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report

Background

Mucormycosis is a rare and life-threatening invasive fungal infection. Pulmonary mucormycosis commonly occurs in patients with severe neutropenia. Typically, pulmonary mucormycosis causes tissue necrosis resulting from angioinvasion and subsequent thrombosis, so most cases can occur with necrotizing pneumonia and/or hemoptysis. Some complex cases may invade adjacent organs, such as the mediastinum, pericardium, and chest wall. However, to the best our knowledge there is little known regarding bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia. We present a case report about this unusual presentation.

Case presentation

A 51-year-old Korean man was diagnosed as having acute myeloid leukemia and received induction chemotherapy. After prolonged severe neutropenia, he complained of coughing with aspiration. Imaging showed a bronchoesophageal fistula with extensive necrotizing pneumonia in the middle and lower lobes of his right lung. Bronchoscopy showed near total tissue necrosis in the middle lobe of his right lung, creating an orifice. A bronchial scope was passed through and was able to be connected with his esophagus; a bronchial wall biopsy was performed. Esophagoscopy revealed a large linear defect of his esophageal wall 30 cm from the incision that may have connected with the bronchus. A bronchial biopsy showed typical hyphae with necrotic tissue, indicating pulmonary mucormycosis. He was given amphotericin B, and a wide excision of lung and esophagus was planned. However, he suddenly died due to massive hemoptysis.

Conclusion

Here we present an extremely rare case of bronchoesophageal fistula with severe necrotizing pneumonia due to pulmonary mucormycosis.

Benign esophago-pulmonary fistula complicating achalasia: case report and literature review

The achalasia, a common benign disease of esophagus, plays an important role in esophago-respiratory fistula, which has not yet been well recognized. In present study, a case is reported of a patient with benign esophago-pulmonary fistula secondary to a longstanding achalasia. To our knowledge, this is the fifth patient of English literature presenting benign esophago-pulmonary fistula associated with achalasia, we performed Heller's myotomy as well as fundoplication through trans-abdominal route and colon replacement of the esophagus through retro-sternal procedure, but with the thoracic esophageal fistula as well as the right lung left being intact. The patient is going on well in the follow up.