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Ann Thorac Surg 2006;82:2278-2280
© 2006 The Society of Thoracic Surgeons

Case Reports

Erosion of an Esophageal Endoprosthesis Into the Trachea

Sabrina Rampado, MDb, Giorgio Battaglia, MDa, Giovanni Zaninotto, MD, FACSb, Alberto Ruol, MD, FACSa, Giuseppe Portale, MDa, Ermanno Ancona, MD, FACSa,*

b Department of Medical and Surgical Sciences, Clinica Chirurgica III, University of Padova Medical School, Padova, Italy
a Istituto Oncologico Veneto (IOV), University of Padova Medical School, Padova, Italy

Accepted for publication April 18, 2006.

* Address correspondence to Dr Ancona, Istituto Oncologico Veneto (IOV), Department of Medical and Surgical Sciences, Clinica Chirurgica III, University of Padova Medical School, Padova, 35128 Italy. (Email: ermanno.ancona{at}unipd.it).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Acquired benign non-neoplastic tracheoesophageal fistulas are unusual, demanding clinical entities. Surgical technique and final outcome depends on fistula size. A one-stage procedure with esophageal resection is preferred when the fistula is located in the upper third of the trachea and is less than 1 cm long.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
We report the case of a 40-year-old woman with a long tracheoesophageal fistula developing after endoesophageal prosthesis placement for a post-actinic stenosis. The fistula was too large for a one-stage procedure. We decided to leave a de-functionalized esophagus in place with a bipolar exclusion. Later, after the patient had completely recovered from recurrent pneumonia, the nutritional tract was restored with a retrosternal esophagogastroplasty. Scarring of the esophageal wall led to a complete closure of the fistula. Fifty months after the closure of the fistula, a follow-up computed tomographic scan of the chest revealed an esophagocele. The patient underwent a right thoracotomy with resection of the residual esophagus.

Acquired benign tracheoesophageal fistulas are unusual and demanding clinical entities, especially when they are large and located in the distal trachea. They are mostly iatrogenic lesions caused by orotracheal intubation [1, 2], and less frequently by erosion of the esophageal prosthesis.

Both surgical technique and final outcome depend on the size of the fistula. The one-stage procedure by Mathesin and colleagues [2] in 1991, consisting of tracheal resection with primary anastomosis and closure of the esophagus in two layers, is still the preferred method for treating an acquired benign tracheoesophageal fistula located in the upper third of the trachea and less than 1 cm long.

When the fistula is longer and located in the middle-lower third of the trachea, thoracotomic primary surgical repair is associated with a high mortality rate (75%; 3 of 4 patients in Mathesin and colleagues’ [2] experience). To reduce this risk, we preferred to leave the esophagus in place, using a bipolar exclusion, and restore the nutritional tract only after respiratory infections were completely resolved.

We report the case of a patient with a low tracheoesophageal fistula caused by erosion of an esophageal prosthesis, which was inserted for palliation of post-actinic stenosis proving unamenable to endoscopic dilations.

A 40-year-old woman was diagnosed with scleronodular Hodgkin’s lymphoma (stage 3B) in 1995 and given chemoradiotherapy, apparently achieving a complete response. In 1996, the disease relapsed and she was treated with further chemotherapy and stem cell transplantation with complete remission. In May 1998, she had dysphagia develop for post-actinic esophageal stenosis. A few months and several endoscopic dilations later, a prosthesis (esophageal Z-stent) was placed, which unfortunately migrated into the stomach. In January 1999, a second prosthesis (Endocoil [Instent Inc, Eden Prairie, MN], uncovered) caused the patient significant chest pain. It was consequently removed and another prosthesis (Ultraflex [Boston Scientific Inc, Natick, MA], uncovered) was placed. The patient received several endoscopic dilations to relieve dysphagia due to granulation tissue in the esophageal lumen. In March 2000, due to a persistent cough, she had a chest computed tomographic scan that ruled out any recurrence of disease and diagnosed a tracheoesophageal fistula.

The patient (1.55 m tall; 37 kg; body mass index, 15.4) came to our attention in July 2001, suffering from cough, recurrent pneumonia, and significant weight loss (5 kg in 6 months) with a gastrostomy.

Bronchoscopy (Fig 1) showed a marked substance loss in the pars membranacea of the lower third of the trachea, extending 4 cm proximally from the carina. The erosion of the esophageal prosthesis was also clearly evident on the posterior wall of the trachea, with the tracheal lumen slightly reduced due to protrusion of the prosthesis.


Figure 1
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  		Fig 1. Bronchoscopy of a major loss of substance extending from the carina 4 cm upward.

 
Endoscopy revealed granulation tissue infiltrating through the uncovered prosthesis. In August 2001, after an attempt to remove the prosthesis endoscopically had failed, the patient underwent surgery. The first step consisted in removing the prosthesis adherent to the esophageal wall, by a longitudinal esophagotomy through a right thoracotomy. Bipolar exclusion of the esophagus through a left cervical esophagostomy completed the first step. The distal esophagus was drained with a Silastic (Rusch, Kernan, Germany) tube through the abdomen. The stomach, closed at the cardia, was drained on a Petzer (Porges, Cedex, France) tube. A feeding jejunostomy was added.

With time, bronchoscopies documented a gradual reduction in size, and finally the complete closure of the fistula. In November 2001, a pouch containing fibrotic tissue was found at the site of the fistula. In April 2002, the patient had completely recovered and had gained 6 kg in 9 months. The gastrointestinal tract was reconstructed through a retrosternal cervical esophagogastroplasty.

Twelve months after the reconstruction (Fig 2), bronchoscopy revealed a completely re-epithelialized area at the site of the fistula. Fifty months after the closure of the fistula, a follow-up computed tomographic scan of the chest revealed an esophagocele. The patient underwent a right thoracotomy with resection of the residual esophagus.


Figure 2
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  		Fig 2. Bronchoscopy (12 months after reconstruction) completely reepithelialized area at the site of the fistula, just above the tracheal bifurcation.

 
An approval for reporting this case was obtained by the Ethics Committee of the University of Padova Medical School.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Primary repair of large tracheoesophageal fistulas located in the middle or distal third of the trachea is challenging.

In 1991, Mathesin and colleagues [2] described 38 patients with a tracheoesophageal fistula who underwent primary surgical repair. Four of those with a fistula located in the lower third of the trachea had surgical repair through a thoracotomy, and their mortality rate was 75% (3 of 4 patients).

In our patient, the fistula was large (4 cm) and was located at the carina. It was caused by the erosion of a prosthesis placed in a previously irradiated esophagus.

Spontaneous closure (an extremely rare event [3–5]) and primary repair (unfeasible in a radio-treated esophagus) were both excluded in this case. The esophagus subsequently underwent a complete cicatrization process, which eventually closed the fistula.

In two previous cases of fistula after dilation for esophageal stenosis due to caustic injury, we isolated the fibrotic esophagus and left it "in situ," obtaining a spontaneous repair of the fistula, which shows that this may be an effective and relatively safe therapeutic option [6].

In this case, the patient’s poor conditions due to malnutrition and recurrent pneumonia ab ingestis, made us prefer a two-step approach (ie, bipolar exclusion first, then reconstruction of the alimentary tract with a retrosternal cervical esophagogastroplasty). The patient completely recovered from her respiratory, phonatory, and swallowing functions.

Esophageal reconstruction with the transposition of the stomach or colon to the neck is a codified operation with acceptable morbidity and mortality rates [7].

In conclusion, the bipolar exclusion of the esophagus and cicatrization of the esophageal wall, leading to the closure of the tracheal fistula, enabled a two-step reconstruction of the gastrointestinal tract, avoiding the high mortality rate of single-stage surgery. A strict follow-up with chest computed tomography is mandatory because of the risks of degeneration of the residual esophagus and the development of esophagocele, as in the case of our patient.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Dartevelle F, Macchiarini P. Management of acquired tracheoesophageal fistula Chest Surg Clin N Am 1996;6:819-836.[Medline]
  2. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired non malignant tracheoesophageal fistula Ann Thorac Surg 1991;52:759-765.[Abstract]
  3. Dartevelle P, Khalife J, Levasseur P, Rojas-Miranda A, Chapelier A, Le Brigand H, Merlier M. Esophagotracheal fistulas after respiratory intensive care Chirurgie 1985;111:84-92.[Medline]
  4. LeBrigand H, Roy B. Fistules tracheo-oesophagiennes après tracheotomies: a propos de 4 observations Chirurgie 1966;92:405-416.
  5. Marzelle J, Dartevelle P, Khalife J, Rojas-Miranda A, Chapelier A, Levasseur P. Surgical management of acquired postintubation tracheo-esophageal fistulas Eur J Cardiothorac Surg 1989;3:499-502.[Abstract]
  6. Ancona E, Zaninotto G, Rossi M, Bardini R. Traitement des fistules oesophagotracheo-bronchiques consècutives à l’ingestion de caustique: nouvelle tecnique d’exclusion de l’oesophage associée à l’oesophago-colo-plastie rètrosternaleA propos de deux cas. Ann Chirurgie 1984;38:23-25.
  7. Kolh P, Honore P, Degauque C, Gielen J, Gerard P, Jacquet N. Early stage results after oesophageal resection for malignancy–colon interposition vs. gastric pull-up Eur J Cardiothorac Surg 2000;18:293-300.[Abstract/Free Full Text]




This Article
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