Acquired spontaneous bronchoesophageal fistula in an adult

Abstract

Spontaneous bronchoesophageal fistula in adults is a rare clinical entity. Most bronchoesophageal fistulae are due to malignancy, prolonged endotracheal intubation or trauma. Granulomatous infections like tuberculosis, HIV and mediastinitis are rare causes of acquired bronchoesophageal fistula. We report a case of a 50 year old man, treated for pulmonary tuberculosis 15 years ago, who developed a spontaneous bronchoesophageal fistula between the mid-esophagus and right main stem bronchus, having no history of malignancy or trauma. Surgical closure of the fistula was done and post operative recovery was uneventful. In this case, the bronchoesophageal fistula probably developed as a delayed sequela of pulmonary tuberculosis as the patient had no active signs of pulmonary tuberculosis clinically or histopathologically.A 50 year old male chronic smoker was referred to us with history of paroxysms of cough and expectoration following intake of liquids and intermittent fever since 3 months. Patient had pulmonary tuberculosis 15 years ago for which he was treated and became asymptomatic after that. Patient had no history of trauma, prolonged mechanical ventilation or malignancy. On examination patient had tachycardia, mild pallor and bilateral basal crepitations on chest auscultation. Blood counts and erythrocyte sedimentation rate were normal. Chest X-ray was normal except for prominent bronchovascular markings in the right mid-zone. Three successive sputum examinations for acid fast bacilli were negative. A barium swallow showed a fistulous communication between the midesophagus and the right main stem bronchus (Fig. 1). Upper GI endoscopy confirmed the fistulous communication between esophagus and right main stem bronchus 28 cm from incisors. CT scan of the chest showed no evidence of active tuberculosis in the patient other than fibrotic foci and hilar and mediastinal lymphadenopathy. The patient was subsequently explored via a right anterolateral thoracotomy through the fifth intercostal space. The mid-esophagus was dissected, incised longitudinally with a 4 cm incision and communication with right main stem bronchus identified by instilling saline in the open esophagus (Fig. 2). Due to extensive fibrosis and adhesions in the posterior mediastinum, dissection and excision of the fistulous tract were not attempted.

Successful closure of chronic, nonhealing tubercular esophagobronchial fistula with an over‑the‑scope clip

“…[1][2][3] Fistulous communications with respiratory tract are most commonly due to esophageal malignancy, and benign causes of fistula include tuberculosis, trauma, iatrogenic, corrosive ingestion, poison, and inhalation burns. [4,7] The traditional treatment of BEF has been surgery with few reports of successful closure with conservative management including nasogastric/nasojejunal feeding. [4][5][6] With advancement in endoscopic therapy, various endoscopic management options have been used in treatment of fistulae including self-expanding metallic stents (SEMS), mechanical closure with through the scope hemoclips, sealants, endoscopic ligation with banding devices, and the recent development of OTSC.…”

“…[4,7] The traditional treatment of BEF has been surgery with few reports of successful closure with conservative management including nasogastric/nasojejunal feeding. [4][5][6] With advancement in endoscopic therapy, various endoscopic management options have been used in treatment of fistulae including self-expanding metallic stents (SEMS), mechanical closure with through the scope hemoclips, sealants, endoscopic ligation with banding devices, and the recent development of OTSC. [8][9][10][11][12] The OTSC system (Ovesco Endoscopy AG, Tubingen, Germany) is a biocompatible, elastic nitinol endoscopic clip which aims at having better capture of tissue around the leaks/ulcers and therefore has been shown to be effective in management of gastrointestinal perforations, leaks, and bleeding.…”

“…[1][2][3] Bronchoesophageal fistula (BEF)/mediastinoesophageal fistula is a rare but potentially serious complication of esophageal/mediastinal tuberculosis. [4][5][6] Most of the reported cases of BEF/mediastinoesophageal fistula have resolved with antitubercular therapy (ATT) alone. The traditional treatment of BEF has been surgery with few reports of successful closure with conservative management including nasogastric/ nasojejunal feeding.…”

“…The traditional treatment of BEF has been surgery with few reports of successful closure with conservative management including nasogastric/ nasojejunal feeding. [4][5][6] Various endoscopic options such as hemoclips, fully covered metallic stents, and fibrin glue have also been used for refractory BEF. [7][8][9] Here, we present a case of posttubercular BEF successfully closed with OTSC after a failed attempt to close it with multiple hemoclips.…”

Fístula bronquioesofágica asociada a reflujo gastroesofágico

“…La fistula broncoesofágica adquirida en los adultos es una rara entidad clínica, siendo las causas tumorales malignas las más frecuentes, de estas al menos el 77% se deben a un tumor primario esofágico, 16% a una tumoración primaria pulmonar; en cuanto a las causas no tumorales, al menos el 75% se deben como complicación iatrogénica por dispositivos endotraqueales, las restantes son una gama de entidades variadas siendo las causadas por tuberculosis, histoplasmosis, infecciones por VIH, mediastinitis y sífilis una rareza (1,2) , en la literatura actual no se encuentra bibliografía que mencione el reflujo gastroesofágico como causal, sin embargo hay 3 reportes de fistulización traqueoesofagica (3,4,5) .…”