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Ann Thorac Surg 2007;84:1036-1038
© 2007 The Society of Thoracic Surgeons

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Case Reports

Successful Conservative Management of Benign Gastro-Bronchial Fistula After Intrathoracic Esophagogastrostomy

^a Department of Medical and Surgical Sciences, Division of General Surgery, I.R.C.C.S. Policlinico San Donato, University of Milan, Milan, Italy
^b Division of Radiology Unit, I.R.C.C.S. Policlinico San Donato, University of Milan, Milan, Italy

Accepted for publication April 13, 2007.

^_* Address correspondence to Prof Bonavina, U.O. Chirurgia Generale, Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan, 20097, Italy (Email: luigi.bonavina{at}unimi.it).

	Abstract

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Benign gastro-bronchial fistula is a rare and devastating complication of esophagectomy with gastric replacement. The most likely cause is a leak from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. The clinical presentation includes cough upon swallowing, fever, and recurrent pneumonia. Early surgical treatment is the standard of care. A unique case of chronic gastro-bronchial fistula is reported in this article. The patient, a 57-year-old woman, was referred from another hospital after 6 months of symptomatic therapy and total enteral nutrition. A self-expanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation.

	Introduction

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The development of a benign fistula between the gastric tube and the tracheobronchial tree represents a rare but catastrophic complication after esophagogastrostomy for esophageal carcinoma. Leakage from an intrathoracic esophagogastrostomy and subsequent development of a mediastinal abscess in the postoperative period can result in a fistula with the trachea or the main bronchus requiring urgent revisional surgery [1]. Other mechanisms leading to gastro-bronchial fistulization are ischemia of the tracheobronchial tree secondary to preoperative radiochemotherapy or to extensive mediastinal node dissection [2], direct surgical injury to the tracheobronchial tree [3], tracheobronchial erosion by the gastric staple line [4, 5], and endoscopic dilatation of an anastomotic stricture [6, 7]. We report a unique case of chronic gastro-bronchial fistula complicating esophagectomy, which was eventually treated by endoesophageal stenting.

A 57-year-old woman with squamous-cell esophageal carcinoma underwent esophagectomy with intrathoracic esophagogastrostomy in another hospital. No preoperative neoadjuvant therapy had been administered. The operation was carried out through a laparotomy and right thoracotomy. The histologic examination of the surgical specimen demonstrated pT1N0M0 squamous-cell carcinoma. The postoperative course was complicated by fever and severe coughing. The patient was allowed to resume oral feeding on postoperative day 8 after a gastrographin swallow study was reported as normal. Despite the persistence of low-grade fever and cough, the patient was discharged home on postoperative day 22 with the diagnosis of bronchopneumonia and the advice to continue oral antibiotic therapy.

One month later the patient was admitted to another hospital in the same town because she was febrile, unable to eat satisfactorily, sleeping upright due to the fear of coughing, and progressively losing weight. She was taking four doses per day of codeine with modest symptomatic improvement. A gastrographin swallow study was performed and showed the presence of a leakage from the intrathoracic esophagogastric anastomosis communicating with the right lung. A chest computed tomographic scan demonstrated the presence of right posterior fluid collection combined with basal pulmonary consolidation (Fig 1). The patient was treated with parenteral nutrition and wide-spectrum antibiotics. She became afebrile, but was still complaining of severe cough upon swallowing and while recumbent. A feeding jejunostomy was performed to prevent continued weight loss, and the patient was discharged home with the recommendation to avoid oral intake.

View larger version (58K): [in this window] [in a new window]   Fig 1. (Left) Gastrographin swallow study showing a leak from the anastomotic site with passage of the contrast medium into the right pulmonary parenchyma. (Right) Axial computed tomographic scan obtained after administration of oral iodine contrast agent. Note the presence of the contrast agent within the transposed gastric tube (wide, white arrow) and in the right main stem bronchus (thin, white arrow) due to the presence of a fistula. The bronchus is surrounded by lung consolidation. Ipsilateral pleural effusion is also evident.

Because the patient refused surgical therapy, a decision was made to proceed with conservative endoscopic treatment of the fistula. An upper gastrointestinal endoscopy was performed under deep sedation. The fistula appeared epithelized and partially obstructed by food debris. After cleansing and brushing the orifice and the proximal fistulous tract, a synthetic glue (Glubran, N-Butil-2-Cyanoacrylate monomer metacrylossysulfolane [GEM S.r.l., Viareggio, LU, Italy]) was injected through a catheter to fill the defect. A metal clip was then applied close to the fistula to serve as a radiologic marker, and a self-expanding plastic stent (Polyflex-stent [Rusch AG, Wiesbaden, Germany]) of 2.5 cm in diameter and 12 cm in length was deployed under radiologic assistance. A gastrographin swallow study was performed the following day and showed the normal transit of the contrast-medium through the stent and no evidence of leaks (Fig 2). The patient resumed oral feeding and was symptom free. The codeine was progressively withdrawn.

View larger version (71K): [in this window] [in a new window]   Fig 2. (Left) Endoscopic view of the gastro-bronchial fistula (arrow). Note the metal clip used for radiologic identification during the deployment of the stent. (Right) Radiologic contrast image of the plastic stent. The arrow shows the metal clip positioned at the site of origin of the gastro-bronchial fistula. Note the correct deployment of the stent with absence of contrast medium between the prosthesis and the esophageal wall.

About 1 month later the patient complained of recurrent cough. A gastrographin swallow study showed distal migration of the stent. The stent was easily removed without complications and was replaced with a covered Ultraflex stent (Boston Scientific, Natick, MA) of 18 mm in diameter and 12 cm in length.

At 1-year follow-up the patient was symptom free, eating regularly, and had regained 5 kg of weight. The computed tomographic scan showed significant reduction of the lung consolidation and the gastrographin swallow study was unremarkable (Fig 3).

View larger version (61K): [in this window] [in a new window]   Fig 3. (Left) Computed tomographic scan performed with oral and intravenous contrast agent administration 1 year after treatment with an Ultraflex stent (Boston Scientific, Natick, MA). Oral contrast agent can be observed only in the neoesophagus; lung consolidation is markedly reduced. (Right) Gastrographin swallow study showing the correct deployment of the stent and complete absence of contrast medium between the prosthesis and the esophageal wall.

	Comment

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Baisi and colleagues [1] reported of a patient who underwent successful surgical repair consisting of suture and intercostal muscle flap on postoperative day 11. Buskens and colleagues [3] reported 6 patients with benign tracheo-neoesophageal fistula that had developed between 18 days and 14 months after esophagectomy. In 4 of these patients the fistula was preceded by leakage from the cervical anastomosis or from the longitudinal suture line of the transposed stomach. All of these patients underwent successful surgical repair, but in 3 of them a colonic extra-anatomical bypass was necessary because the stomach could not be preserved.

Endoscopic management seems to be a reasonable therapeutic option in high-risk patients with gastro-bronchial fistula provided that the transposed stomach is viable and there is no evidence of mediastinitis and sepsis, as was the case described herein. Self-expanding metal and plastic stents have been used as a palliative measure in patients with anastomotic leaks after esophageal surgery [8–10] and in patients with malignant esophago-respiratory fistulas [11]. A potential advantage of the plastic stent is that the complete silicon cover prevents ingrowth of granulation tissue, thus facilitating removal of the device at a later date. However, stent migration has been reported in as many as 37.5% of patients [10], and this is more likely to occur when the device is placed through a nonstenotic esophagogastric anastomosis. Endobronchial stenting is an alternative therapeutic option, but experience with this procedure is still limited [12].

The present case report is unique because our patient presented with a chronic gastro-bronchial fistula 6 months after an esophagectomy. Since the time of the operation she had been unable to eat and drink because of a severe cough and recurrent pneumonia, and she was fed only through a jejunostomy catheter. We believe that this represents the first case of benign gastro-bronchial fistula successfully treated with a covered esophageal metal stent. This endoscopic procedure seems to be safe and may avoid the morbidity of revised surgery in an already compromised patient.

	References

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1. Baisi A, Fumagalli U, Rosati R, Marinoni M, Bonavina L. Successful primary treatment of bronchial fistula complicating esophagogastrectomy Dis Esoph 1994;7:209-211.
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4. Kron I, Johnson A, Morgan R. Gastrotracheal fistula: a late complication after transhiatal esophagectomy Ann Thorac Surg 1989;47:767-768.[Abstract/Free Full Text]
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7. Devbhandari M, Jain R, Galloway S, Ktysiak P. Benign gastro-bronchial fistula—an uncommon complication of esophagectomy: case report BMC Surg 2005;5:16.[Medline]
8. Roy-Choudhury S, Nicholson A, Wedgwood K. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents Am J Roentgenol 2001;176:161-165.[Abstract/Free Full Text]
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