Ann Thorac Surg 2007;84:2093-2095. doi:10.1016/j.athoracsur.2007.06.071
© 2007 The Society of Thoracic Surgeons
Case Reports
Endoscopic Management for Broncholithiasis With Bronchoesophageal Fistula
Tetsuhiko Go, MDa,*,
Hiroaki Kobayashi, MDa,
Munehisa Takata, MDa,
Hiroki Shirasaki, MDb,
Shiro Miyayama, MDc
a Department of Thoracic Surgery, Fukiken Saiseikai Hospital, Fukui City, Fukui, Japan
b Department of Pulmonology, Fukiken Saiseikai Hospital, Fukui City, Fukui, Japan
c Department of Radiology, Fukui Saiseikai Hospital, Fukui City, Fukui, Japan
Accepted for publication June 25, 2007.
* Address correspondence to Dr Go, Fukui Saiseikai Hospital, Wadanaka-cho 1-4-6, Fukui city, Fukui, 9188503, Japan (Email: g-tetsu{at}wa3.so-net.ne.jp).
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Abstract
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We report a case of broncholithiasis with bronchoesophageal fistula that was successfully managed endoscopically using endoscopic laser therapy and a covered self-expandable metallic stent.
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Introduction
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Broncholithiasis may present with a diversity of symptoms such as absence of symptoms, severe cough, pneumonia, life-threatening hemoptysis, and bronchoesophageal fistula (BEF). The choice of treatment from observation to surgery is selected depending on the size and location of stones, underlying complications, and patient condition. Endoscopic treatment for complicated broncholithiasis such as BEF is not expected due to the radical nature of the procedure, and surgical approaches are usually selected.
A 75-year-old man was referred to our department for the treatment of broncholithiasis with bronchoesophageal fistula (BEF). He had a long history of silicosis due to his occupation as a construction worker. Before referral, he had been treated for aspiration pneumonia for 2 months due to fever and severe cough on swallowing. On examination for percutaneous endoscopic gastrostomy, the gastroscope revealed esophageal fistula. Broncholithiasis with BEF was finally diagnosed by following computed tomography (Fig 1). A part of subcarinal cavitary calcified lymph nodes eroding into the left main bronchus was the cause of BEF.
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Fig 1. (A) Sagittal computed tomographic scan showing multiple calcified lymph nodes. Subcarinal lymph nodes (broncholith) protrude into the left main bronchus. (B) Fiberoptic bronchoscopy showing a large broncholith in the left main bronchus.
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At the time of transfer, he suffered from methicillin-resistant staphylococcus aureus pneumonia and was in a malnourished state. Intensive nutritional care including hyperalimentation and multi-antibiotic therapy was started. Although he entered a critical condition at one stage with disseminated intravascular coagulation due to methicillin-resistant staphylococcus aureus pneumonia, gradual recovery was achieved. We suggested that he undergo permanent percutaneous endoscopic gastrostomy and abandon hope of oral food intake because of surgical risks. However, the patient refused this option and insisted on eating food again. We decided to perform endoscopic treatment on him. Under general anesthesia, we shattered the stone protruding into the left main bronchus for stent placement using a neodymium:yttrium-aluminum-garnet laser through a flexible bronchoscope with application of high power (50 W) and short pulses (0.2 to 0.5 secs) with 5-second rest intervals. The procedure took approximately 4 hours and required a total of 12,626 J. No complications occurred during and after this procedure. After 1-week, a self-expandable metallic stent (SEMS) was placed in the left main bronchus to prevent migration of residual subcarinal calcified stone into the bronchial lumen (Fig 2). Slight leakage from the esophageal fistula into the bronchial lumen but no flow into the mediastinum was identified on swallowing radio-contrast medium, so the esophageal fistula and lymph node cavity were filled gastro-endoscopically with coils and cyanoacrylate. Oral food intake was gradually reintroduced, and the patient was discharged 2 months after endoscopic laser surgery. Although further SEMS placement in the left main bronchus was required 1 year after initial treatment due to stone migration, at the time of this writing (ie, 2 years after treatment), the patient remains able to eat.
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Fig 2. (A) Bronchoscopic image of the left main bronchus after removal of the stone. (B) Image of fiberoptic bronchoscopy after covered placement of a self-expandable metallic stent in the left main bronchus.
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Comment
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Bronchoesophageal fistula due to broncholithiasis is a rare entity. Reports of the treatment of BEF due to broncholithiasis are limited, and surgery has been required for most cases. Conversely, the perioperative morbidity rate is not always low, and symptoms remain unresolved in some cases [1].
Management of broncholithiasis should be planned depending on circumstances such as the size and location of the broncholith, presence or absence of complications, and mostly importantly, patient condition [2]. Considering the condition of the patient, including malnutrition, performance status, and methicillin-resistant staphylococcus aureus pneumonia, surgery was believed to represent a very demanding approach and a high risk of postoperative morbidity was expected. The endoscopic maneuver was thus selected to grant his request, although indications for endoscopic laser treatment for broncholithiasis such as fragmenting the stones are limited, and the effects are somewhat uncertain [3–5].
Computed tomography was helpful in evaluating relationships to surrounding organs, particularly vascular structures [4]. In our case, a part of subcarinal lymph nodes, which stuck to the pulmonary artery and esophagus, structured a lump and eroded into the left main bronchus.
Regarding the technical aspects, we focused on the following points: fragmentation and vaporization of the stone in piecemeal fashion, rather than resection of the entire stone; frequent suction of smoke during the procedure to prevent post-treatment pneumonia; and care not to cause any burns on surrounding tissue [5]. According to these principles, the laser easily made holes in and broke the stones protruding into the left main bronchus [6]. The most severe hemorrhage and pneumonia related to endoscopic treatment including laser therapy on broncholithiasis may be preventable by avoiding excessive force or traction of stones with forceps, and by frequent suction of vaporized smoke [4, 7].
Indications for SEMS insertion for benign disease should be considered carefully, as the SEMS consists of titanium wire and silicone membrane, and durability is estimated as 1 to 2 years, although efficacy against BEF has been confirmed [8, 9]. The reason why we deployed the SEMS only in the bronchus was that this patient had no stenosis at the esophagus. In the case of no esophageal stenosis, we can not expect effective sealing by the esophageal stent, even if we place the SEMS in the esophagus [10].
Cyanoacrylate and coils were also useful to fill the inner space of the calcified lymph node cavity. This was effective in preventing food and liquid leakage from the esophagus into the fistula space in our case. This is also used for other types of fistulas [11]. However, we have to be cautious about the possibility of pulmonary artery erosion due to cyanoacrylate. Because of the shell formation by the calcified lymph nodes, the cavity wall and no inflammation in the mediastinum, we believed that we could avoid pulmonary artery erosion.
In conclusion, our experience suggests that laser therapy and SEMS placement could represent useful treatment options for broncholithiasis with BEF, even for palliative effect, particularly in patients displaying poor medical condition.
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References
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- Ford MAP, Mueller PS, Morgenthaler TI. Bronchoesophageal fistula due to broncholithiasis: a case series Respir Med 2005;99:830-835.[Medline]
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- Aust MR, Prakash UBS, McDougall JC, et al. Bronchoscopic broncholithotripsy J Bronchol 1994;1:37-41.
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- Miks VM, Kvale PA, Riddle JM, et al. Broncholith removal using the YAG laser Chest 1986;90:295-297.[Medline]
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- Wu WC, Katon RM, Saxon RR, et al. Silicon-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature Gastrointest Endosc 1994;40:22-33.[Medline]
- Li YD, Li MH, Han XW, et al. Gastrotracheal and gastrobronchial fistulas: management with covered expandable metallic stents J Vasc Radiol 2006;17:1649-1656.
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- Goldman SY, Greben CR, Setton A, et al. Bronchobiliary fistula successfully treated with n-butyl cyanoacrylate via a bronchial approach J Vasc Interv Radiol 2007;18:151-155.[Medline]
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Abstract
Introduction
