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Ann Thorac Surg 1996;61:1875-1876
© 1996 The Society of Thoracic Surgeons
Departments of Cardiothoracic Surgery Anaesthesia St John's Medical College Hospital Sarjapur Road, Bangalore 560034 India
To the Editor:
We read with interest the articles on congenital bronchoesophageal fistula in adult patients by Rämö and associates [1] and Kim and colleagues [2]. In these studies a preoperative diagnosis was made in all but 2 cases.
Our patient was a 34-year-old man with a 10-year history of cough with expectoration, diagnosed to have right lower lobe cystic bronchiectasis. He was taken up for a right lower lobectomy on August 16, 1995. During induction of anesthesia, positive-pressure ventilation via the right channel of a cuffed 39F Carlens double-lumen endotracheal tube (Rusch, Germany) resulted in esophageal and gastric dilatation. At this time the presence of an additional bronchoesophageal fistula was suspected [3, 4], operation was deferred, and he was extubated.
The next day a contrast study using urografin 76% (Schering) showed a type II bronchoesophageal fistula (Fig 1
) [1], which over the years had damaged the right lower lobe, resulting in a cystic pulmonary change. With a revised cause of his cystic lung pathology he was taken up for operation again on August 21, 1995.
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Histologic examination of the fistula showed an epithelium-lined tract with muscularis mucosa, and the lobectomy specimen showed nonspecific chronic bronchiectasis with extensive squamous metaplasia and parenchymal fibrosis. There was no evidence of any granulomatous disease, which is commonly seen in our part of the world. The postoperative recovery was uneventful, and a contrast study on the tenth day showed a normal esophagus with no leak.
The diagnosis of congenital bronchoesophageal fistula in the adult rests on the history of chronic respiratory complaints, absence of an acquired cause such as trauma, foreign body, tumor, granulomatous disease, syphilis, or necrotizing esophagitis, and histologic evidence of an epithelium-lined tract with muscularis mucosa [4]. In the presence of recurrent pulmonary suppuration, such as pneumonia, bronchiectasis, and abscess without an obvious cause, the possibility of a congenital bronchoesophageal fistula should be suspected and an early diagnosis made with a pulmonary-friendly contrast medium to prevent serious lung damage.
References
Department of Thoracic Cardiovascular Surgery Helsinki University Central Hospital Haartmaninkatu 4 00290 Helsinki, Finland
To the Editor:
We read with great interest Saldanha and associates' letter. Doctor Saldanha and his collegues present a case of congenital bronchoesophageal fistula that was diagnosed during the induction of anesthesia for elective pulmonary operation. This is a good example of variable symptoms and findings caused by these fistulas, even though the diagnostic value may be limited.
We reported recently in this journal our series of 9 patients with this anomaly [1]. In these patients no one was diagnosed to have a respiratory–esophageal fistula while starting positive-pressure ventilation during anesthesia. Two patients did not have preoperative diagnosis before scheduled thoracotomy, but we could not find any observations of gastric dilatation during the induction of anesthesia in any of our patients. This may be due to a suggested congenital valve-like structure between the esophagus and the airways, which may have hidden this anomaly until old age. On the other hand, the suggested valve may act as a one-way valve, ie, only from the esophagus to the respiratory channel. This might explain the usual symptoms after drinking fluids or eating, but under positive-pressure ventilation the valve would close rather than stay open. However, the shape of the fistula also may enable it to function primarily toward either airways or esophagus depending on pressure conditions.
Congenital bronchoesophageal fistula is a rare disease; we had only 9 of these patients in 33 years. Regardless of the cause of a respiratory–esophageal fistula certain symptoms, such as coughing after ingestion of liquids, should raise a suspicion of a fistula and therefore lead to more specific examinations in patients of all age groups. As shown in our patients [1], Kim and associates' report [2], and also in Saldanha and associates' case, esophagography-even repeated if necessary-is the most sensitive and specific method of preoperative diagnosis. Only surgical treatment without delay prevents pulmonary complications and even lethal consequences.
References
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