Ann Thorac Surg 1996;62:1850-1852
© 1996 The Society of Thoracic Surgeons
Case Report
Delayed Presentation of a Tracheoesophageal Fistula After Blunt Chest Trauma
Sharon M. Weber, MD,
Michael J. Schurr, MD,
John R. Pellett, MD
Department of Surgery, University of Wisconsin Hospital, Madison, Wisconsin
Accepted for publication June 18, 1996.
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Abstract
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Traumatic tracheoesophageal fistula is an uncommon injury after blunt chest injury. Rapid deceleration against the steering wheel during a high-speed motor vehicle crash is the usual mechanism of injury. Previous reports document few cases of delayed diagnosis and repair of tracheoesophageal fistula. We report a case of delayed diagnosis of tracheoesophageal fistula more than 20 years after the original trauma and describe the subsequent operative repair.
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Introduction
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Traumatic tracheoesophageal fistula (TEF) is an uncommon injury after blunt chest injury; a recent review of the world literature revealed only 59 cases over the past 60 years [1]. Most are diagnosed at the time of presentation; however, delayed diagnosis and repair has been described in 3 patients [2, 3]. We report a case of delayed diagnosis and repair of a TEF more than 20 years after the original blunt chest injury.
A 42-year-old man presented to the University of Wisconsin Hospital with a long history of coughing after swallowing. His symptoms improved when he leaned 45 degrees to the left and swallowed small amounts of fluid. His past medical history was significant for a blunt chest injury with avulsion of the right subclavian artery that had occurred 20 years ago in a motor vehicle crash. A right thoracotomy was performed at the time of the original injury, the subclavian artery was ligated, and the innominate artery was oversewn. Admission esophagoscopy was normal; however, bronchoscopy revealed "bluish discoloration" of the posterior trachea and blood in the tracheobronchial tree.
The patient resumed oral intake on posttrauma day 6, but experienced aspiration after swallowing. The results of an esophagogram were normal. Subsequently, the patient was discharged; however, he continued to complain of aspiration with swallowing that was controlled only by leaning to the left.
The patient had one episode of aspiration with near-asphyxiation 16 years after the original trauma. Due to complaints of heartburn and regurgitation of food and acid into the oropharynx, he was diagnosed with gastroesophageal reflux disease. An upper endoscopy, performed 20 years after the original injury, demonstrated two tracheoesophageal fistulas.
Admission chest radiograph demonstrated a dilated, air-filled esophagus on both the anteroposterior and lateral films (Figs 1, 2
). Bronchoscopy revealed two 0.5-cm posterior fistulas at the midtracheal level (Fig 3). The patient was explored through a right thoracotomy. The fistulas were isolated, and the trachea was closed with interrupted absorbable suture. The esophagus was repaired in two layers with an inner layer of absorbable suture and an outer layer of interrupted silk. An interposition pleural flap was placed between the trachea and the esophagus and secured with interrupted silk sutures. The postoperative course was complicated by a persistent air leak that required reoperation for a ruptured apical bleb. He was discharged 1 month after admission and has done well since his repair.
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Comment
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Traumatic tracheoesophageal fistulas are caused by rapid deceleration against a steering wheel in 75% of patients, crush injuries in 7%, and miscellaneous causes in approximately 20% [1]. A minority of patients will be symptomatic at the time of presentation. These patients have a TEF that forms immediately after injury. In the majority (60%) symptoms will develop 3 to 10 days after the initial blunt trauma [1]. In this setting, there is a posterior tracheal tear that initially seals. The esophagus is also injured at the time of the original injury. The mucosal blood flow is impaired and results in ischemia of the anterior portion of the esophagus. This leads to subsequent fistulization between the esophagus and the trachea. Symptoms developed soon after the initial trauma in our patient; however, the diagnosis was not established until 20 years later.
Coughing after swallowing, Ono's sign, is the classic symptom in TEF. Other common signs include subcutaneous air, pneumothorax or pneumomediastinum, and hemoptysis [1]. The diagnosis is typically established with the use of esophagogram, endoscopy, and bronchoscopy; however, these methods are associated with significant false-negative rates, up to 33% for endoscopy [3] and 12.5% for contrast studies [4]. Computed tomography has been found to be helpful in select cases.
Our patient was diagnosed 20 years after his original trauma. At the time of his original presentation he was asymptomatic and esophagoscopy and bronchoscopy had negative results. Symptoms developed on posttrauma day 6; however, results of an esophagogram were normal. This emphasizes that many of these TEFs are not present immediately after injury. It also points out the difficulty in making this diagnosis using a combination of bronchoscopy, esophagoscopy, and esophagography. One needs to maintain a high index of suspicion and make use of serial diagnostic tests in patients with symptoms of aspiration after deceleration or crush injury.
Three previous cases of delayed repair at 1, 7, and 24 years have been described [2, 3]. One of these patients presented with delayed symptoms 14 months after the initial trauma (3); the others were symptomatic at the time of the original injury [2, 3]. Six cases of conservative management have been described. Four of these resulted in death, attributable to infection in two [4, 5–7]. There have been select cases of spontaneous closure of TEF after failed primary repair. Although fistula closure with conservative therapy is occasionally successful, the overall mortality rate for nonoperative treatment is 67% [1].
Surgical repair through a right thoracotomy is indicated as soon as possible after diagnosis. Primary closure versus esophageal exclusion is dependent on the time to diagnosis and resultant degree of mediastinal contamination. In a series of 127 patients with nontraumatic esophageal perforations, 64% of complications occurred in patients repaired more than 24 hours after presentation [8]. Esophageal and tracheal defects require debridement to viable tissue. The trachea is closed with one layer of absorbable suture, and the esophagus is closed with an inner layer of absorbable suture and an outer layer of interrupted silk suture. To reinforce the repair, a pleural or intercostal muscle interposition flap should be used. The risk of recurrent fistulization or breakdown of the repair is thought to decrease with this technique. The overall mortality in those with primary repair is 8% [1].
Tracheoesophageal fistula is an uncommon injury in blunt chest trauma. However, due to the high mortality with delayed diagnosis, a high degree of suspicion should be maintained. We report a case of delayed repair of a traumatic TEF 20 years after the original trauma with symptoms present since posttrauma day 6.
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Footnotes
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Address reprint requests to Dr Schurr, Department of Surgery, University of Wisconsin Hospital, 600 Highland Ave, Madison, WI 53792 (e-mail: schurr{at}surgery.wisc.edu).
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References
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- Gerzic Z, Raki S, Randjelovic T. Acquired benign esophagorespiratory fistula: report of 16 consecutive cases. Ann Thorac Surg 1990;50:724–7.
- Kelly JP, Webb WR, Moulder PV, et al. Management of airway trauma. II: combined injuries of the trachea and esophagus. Ann Thorac Surg 1987;43:160–3.[Abstract]
- Vinson PP. External trauma as a cause of lesions of the esophagus. Am J Dig Dis 1936;3:456–9.
- Piquet M, Muller M, Marchand M, et al. Fistule oesophagobronchique en rapport avec une violente compression thoracique. Ann Med Leg 1939;19:125–32.
- Hatzitheofilou C, Conlan AA, Katz G, et al. Tracheoesophageal fistula following blunt chest trauma. South Afr J Surg 1983;21:105–8.
- Bladeregroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 1986;42:235–9.[Abstract]
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Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma
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Abstract
Introduction
