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Ann Thorac Surg 1996;62:1030-1032
© 1996 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Helsinki University Central Hospital, Helsinki, and Department of Surgery, Tampere University Central Hospital, Tampere, anta-Hame Central Hospital HameenlinnaFinland
Accepted for publication May 22, 1996.
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Abstract |
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Methods. We present 3 patients with tuberculous fistulas of the esophagus. Two of our 3 patients were treated successfully with the combination of operation and antituberculous chemotherapy. Fistulas were resected and closed directly. Suture lines were secured with pedicled pleural flaps.
Results. Both patients who underwent operation recovered without complications. One patient died without definitive diagnosis and treatment.
Conclusions. Treatment of tuberculous fistulas consists of operation and antituberculous chemotherapy, although antituberculous medication alone has been suggested to be effective if the diagnosis is early. However, operation is usually necessary to establish the correct diagnosis. Therefore, we believe that if the cause of the esophageal fistula cannot be verified, thoracotomy should be performed. If the fistula is left untreated the consequences are usually fatal.u: structured abstract OK?
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Introduction |
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In the early half of this century, Mycobacterium infections were quite common and surgeons were aware of this disease. The resolution of antituberculous chemotherapy resulted in progressive reductions in the incidence of pulmonary tuberculosis, which in part has led to insensitivity of the surgical community to this diagnosis [4].
We present 3 patients with tuberculous fistulas of the esophagus, which demonstrate the importance of suspicion and proper sampling at the time of examination [5, 6].
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Patients |
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Esophagoscopy showed an ulcerative orifice of a fistula 25 cm from the incisor teeth, and suspicion of an esophagotracheal fistula was raised. Esophagography with water-soluble contrast agent was performed, but no fistula was detected. Bronchoscopy was normal. Computed tomographic examination of the chest revealed a tumorlike mass at the level of tracheal bifurcation, but no fistula was visualized.
A right thoracotomy was performed and two esophagomediastinal fistulas were detected. The trachea and bronchi were intact, but a large lymph node showing granulomatous inflammation adjacent to the esophagus was removed. Enlarged lymph nodes in the area were removed, both fistulas were resected, and the esophagus was closed with sutures in two layers. The suture lines were secured with tissue glue (Tisseel)u: manufacturer and location of Tisseel and covered with pedicled pleural flaps. The medication (isoniazid, 300 mg; rifampin, 450 mg; and pyrazinamide, 1.5 mg u: mg OK?once dailyu: OK?) for tuberculosis was started postoperatively as the diagnosis was obvious based on frozen specimen and staining. Later the diagnosis was also verified by cultures.
The recovery was uneventful and the patient was discharged from the hospital on the seventh postoperative day. Medication was continued for 6 months. Esophagoscopy was performed 7 months after the operation. The esophagus was completely healed and he is now symptomless.
Patient 2
A 76-year-old white man was treated by his family doctor due to fever and bronchitis continuing for 2 months. He had cough related to meals for several weeks but no fever. His chest roentgenogram was normal and he was prescribed penicillin by a family doctor. The symptoms, however, persisted and he was referred to Tampere University Central Hospital.
Esophagoscopy and bronchoscopy were normal, but barium study demonstrated a fistula to the mediastinum. Biopsy specimens taken from the esophagus did not show any malignancy or specific infection. No staining or cultures for Mycobacterium infection were performed. The human immunodeficiency virus test was not performed. He had paranoid schizophrenia for years and was very reluctant to accept any form of therapy or medication. Therefore, a Wilson-Cook esophageal endoprosthesis was applied by endoscopy and he was discharged from the hospital.
Six months after this procedure he was readmitted because of cough, headache, backache, fever, and enlarged lymph nodes of the neck. In admission urinary retention causing hydronephrosis was observed. Laboratory examination showed elevated C-reactive protein level (80 mg/L), elevated creatinine level (568 µmol/L), and digitalis intoxication. A computed tomographic scan of the chest revealed a destructive process in the 11th thoracic vertebra causing a compression of the spinal cord resulting in urinary retention. Computed tomographic scan also showed enlarged mediastinal lymph nodes, but no fistula was detected. He refused any kind of therapy and died 3 weeks after admission. Autopsy revealed a tuberculous esophagomediastinal fistula, spondylitis, and pericarditis. The diagnosis was verified with staining and cultures.
Patient 3
A 31-year-old black man originally from Somalia, currently a permanent resident of Finland for 4 years, was admitted to Helsinki University Central Hospital. He presented with cough after drinking and slightly enlarged lymph nodes of the neck. He had cough after drinking for 3 years, but no pulmonary infection or fever.
Chest roentgenogram showed increased density behind the heart; otherwise, it was completely normal. Esophagoscopy revealed a fistulous opening 32 cm from the incisor teeth, and the fistula between the esophagus and the right main bronchus was verified also by the use of water-soluble contrast agent (Fig 1
). Bronchoscopy was normal, but computed tomographic scan showed a pathologic mass just below the carina and also the course of the fistula was partially visualized. The human immunodeficiency virus test was negative.
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The patient recovered without complications, and medication (isoniazid, 300 mg; rifampin, 450 mg; and pyrazinamide, 2 g once dailyu: OK?) was continued 6 months postoperatively. Six months after the operation esophagoscopy showed a completely healed esophagus and he has been symptomless thereafter.
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Comment |
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Dysphagia and chest pain are the most common symptoms caused by esophageal tuberculosis. Unfortunately, they are typical symptoms in almost all esophageal disorders and no specific features can be given in this respect. Hematemesis also has been reported as a sign of esophageal tuberculosis, but our patients did not have any bleeding [7]. Cough is usually related after ingestion of liquids, especially in cases of esophagorespiratory fistulas. However, our patients with esophagomediastinal fistulas had a history of cough related to meals, but they did not have any pulmonary infections. It is important that associated diseases and racial factors also are taken into account, as lymphous involvement is more common in the nonwhite population [8]. Patients in immunocompromised states, such as acquired immunodeficiency syndrome, are susceptible to Mycobacterium infections [5, 6].
Roentgenographic findings in esophageal tuberculosis are unspecific. Plain chest roentgenogram may show mediastinal lymphadenopathy, but otherwise it is usually normal, except in pulmonary tuberculosis. Esophagography performed either with barium or water-soluble agents shows fistula in most cases. In our series esophagography was positive in 2 patients. Williford and associates [9] and Im and colleagues [10] reported the computed tomographic scan to be the most complete method of examining the mediastinal region. Mediastinal lymphadenopathy and even the fistulous tracts may be diagnosed with the aid of computed tomography. Computed tomographic scan of the mediastinum was performed in 2 of our patients at the time of initial diagnosis. The fistula was visualized in 1 patient, but only partially. Our experience is that the combination of different diagnostic methods gives the best result. However, most important is the suspicion of the possibility of tuberculosis. Mediastinal lymphadenopathy without pulmonary changes is uncommon and extremely rare as a cause of dysphagia [1]. In these cases all biopsies, cultures, and stainings should be performed.
It is generally accepted that surgical treatment is necessary for esophagorespiratory fistulas. Esophageal endoprosthesis applied with endoscopy in combination with antituberculosis chemotherapy can be considered if the patient refuses operation or is unfit for thoracotomy. In addition to appropriate chemotherapy, tuberculous fistulas usually require surgical treatment. However, fistulas of tuberculous origin have been successfully treated by medical management alone [11–14]. Medical management alone can only be tried if the disease is diagnosed early and if the fistula is short, narrow, and without abscess. We believe, based on our limited experience, however, that surgical closure of the fistulous tract to airways is safer and a more rapid recovery is achieved than by medical management alone. On the other hand, operation is often required to obtain the diagnosis. Delay in the initiation of antituberculous chemotherapy or continuation of it without response may result in fatal complications, such as erosion of the aorta [2], and enhance the transmission of tuberculosis [15]. Therefore, most researchers still recommend an early surgical approach to confirm the cause of the fistula. At the same time the fistula can be closed directly.
Right thoracotomy is the best exposure of esophageal fistulas. A fistula should be excised and openings can be closed directly. The closure should be secured either with myoplasty [16] or by pedicled pleural flap as suggested by Grillo and Wilkins [17]. On the basis of our previous experience we have used additional tissue glue to reinforce the closure before normal healing has occurred [18, 19]. Tracheal or esophageal resection is rarely necessary. Antituberculous medication should be started without any delay and continued for 6 months. In our 2 patients treated with the combination of operation and chemotherapy, recovery was uneventful, and in both the esophagus was completely healed.
In conclusion, as there are no specific signs or symptoms in this disease, it is important that all stainings and cultures are taken if the cause of a fistula is confirmed to be benign. Whether or not patients are treated medically or surgically depends on the extent of the disease, the presence of a fistula, and an assessment of the risks of operative treatment. Only early and accurate diagnosis enables definitive treatment and prevents fatal complications of this condition.
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This article has been cited by other articles:
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  H. A. Gaissert, C. L. Roper, G. A. Patterson, and H. C. Grillo Infectious necrotizing esophagitis: outcome after medical and surgical intervention Ann. Thorac. Surg., February 1, 2003; 75(2): 342 - 347. [Abstract] [Full Text] [PDF]
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 L. Kotsis, M. Poczi, and K. Orban Management of oesophageal carcinoma with associated lung tuberculosis Eur. Respir. J., April 1, 2002; 19(4): 784 - 785. [Full Text] [PDF]
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