Acquired tracheo-oesophageal fistula.CP Shah, ME Yeolekar, FK Pardiwala
Dept of Medicine, KEM Hospital, Parel, Bombay.
Acquired tracheo-oesophageal fistula is rare. The most common causes are tuberculosis and malignancy. Here we report a patient who had come with dysphagia and aspiration pneumonia with paratracheal lymphnodes on X-ray chest and was diagnosed to have a tracheo-bronchial fistula on barium studies. Transtumoral intubation by pull-through method was carried out.
Keywords: Adult, Antitubercular Agents, therapeutic use,Case Report, Deglutition Disorders, etiology,Human, Intubation, Intratracheal, Male, Tracheoesophageal Fistula, complications,diagnosis,etiology,therapy,Tuberculosis, Lymph Node, complications,
Tracheo-oesophageal fistulas are divided into con-genital and acquired. The latter is rare and can occur secondary to malignancy, Trauma, surgery, contagious diseases and pulmonary infections,,. We report here a case of tracheo-oesophageai fistula and discuss the causes and approach for its correction.
A 44 years old male patient presented with low grade lever with evening rise of 10 weeks duration, cough with mucopurulent expectoration (4 weeks duration) and dysphagia which was more for liquids (2 weeks duration) associated with loss of appetite and weight. He was taking treatment regularly for psoriasis for the last 15 years. He did not have a history of tuberculosis in the past. Previous barium studies of oesophagus and stomach showed aspiration of barium and hence he was diagnosed to have defective deglutition. However, his ear, nose and throat examination was inconclusive. No neurological cause was detected. Therefore, he was referred to us for his dysphagia.
On clinical examination, he was found to be averagely built and poorly nourished with normal vital parameters. He was pale and had psoriatic lesions all over the body, but had no evidence of lymphadenopathy. Respiratory system examination revealed infrascapular rales, more on the right side than the left. The other systems wore normal.
In view of dysphagia, presence of violent coughing on swallowing and barium studies of esophagus and stomach done elsewhere showing aspiration of barium, the patient was investigated to exclude an acquired tracheo-oesophageal fistula.
The patient had a normal hemogram with an ESR of 35 mm at the end of first hour. His blood sugar, renal and liver function tests were normal. Sputum examination for acid fast bacilli was negative. Electrocardiogram was within normal limits. The X-ray chest was suggestive of aspiration pneumonia. Repeat barium studies for oesophagus showed barium in the bronchial tree. At the level of carina there was a fistulous communication between oesophagus and left main bronchus. On upper gastrointestinal endoscopy at 25 cm on the anterior wall there was a diverticulum with fistulous opening. The biopsy was taken which showed non-specific inflammation.
Anti -tuberculosis treatment was started empirically considering tuberculosis as the most obvious and common cause in our setting. Over a period of time symptomatic improvement was noticed but dysphagia for liquids persisted. Hence we referred the patient to surgeons who did a trans-tumoural intubation by pull through method; following which marked symptomatic improvement was observed. The patient was discharged tour weeks after intubation.
The acquired tracheo-oesophageal fistula can be secondary to 1. malignancy from esophagus or adjacent structures by either direct invasion or can be metastatic; 2. traumatic due to blunt or penetrating trauma from endoscopy, tracheostomy or endotracheal intubation; 3. post-operative following vagotomy for hiatus hernia. pulmonary resection and aortic aneurysm: 4. miscellaneous causes like diverticuli, esophagitis, ulcers due to caustic injury, and 5. Contagious diseases like tuberculosis, syphilis or histoplasmosis infecting lymphnodes or pulmonary infections like empyema and lung abscess, aortic aneurysm,,.
Recent reports implicate lymph node involvement The patient had a normal hemogram with an ESR by tuberculosis as the cause of acquired tracheo - oesophageal fistula,,,.
Malignant tracheo-oesophageal fistulas are reported by Godeau, et al in association with leiomyo sarcoma of esophagus. These fistulas can also occur by direct spread in Hodgkin's diseaseg. Incidence of malignant tracheo-oesophageal fistula is about 0.9 to 13 %.
Acquired tracheo-esophageai fistulae can be diagnosed clinically by features such as cough which is brought about by swallowing but can be mild.
X-ray chest can reveal aspiration pneumonia and lymphriodes. Barium studies of esophagus can reveal barium into the bronchopulmonary system. Endoscopic visualisation of fistula in the esophagus can be useful as was done in our case. Bronchoscopy will help to locate the exact site of the fistula.
Treatment of acquired tracheo-esophageal fistula mainly consists of anti -tuberculosis treatment because tuberculosis would be the commonest cause in our country. Injection of histocryl can be tried to close the fistula. Surgical treatment of acquired tracheoesophageal fistula consists of radical surgery and palliative surgery.
Radical surgery consists of combination of pneumonectomy or pericardial patching of the fistula with oesophagectomy and restoration of gastrointestinal continuity using the stomach. Mortality reported was however very high.
Palliative surgery consists of either bipolar exclusion or trans-tumoural intubation. The latter can be done by either pull through method or push through method. In pull through method surgery is required so that the Moussean-Boubin or Celestin tube can be pulled through via a gastrostomy. This was the procedure, which was undertaken in our patient. Celestin tube is made up of latex rubber with a nylon reinforced spiral and radio opaque marker. They come in two adult sizes and one paediatric size. Mousseau-Boubin tube is made up of neoplex.
Introduction of fibreoptic endoscopy has made the push through method very easy. In push through method, the esophagus is dilated and the tube is introduced. PVC and latex tubes were used by Earlern and Cunhamelo. The largest series of intubation by push through method comes from South Africa where mortality in malignant tracheo-esophageal fistula was 25% for 184 patients but long-term survival was not known.