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ABSTRACT

Tracheoesophageal fistulas are uncommon and present diverse etiologies, among

which is burning of the esophagus due to caustic ingestion. Herein, 👄 we report the case

of a 27-year-old male patient having ingested a caustic substance 14 days prior and

presenting burning 👄 retrosternal pain, weakness, productive cough with purulent sputum

and dyspnea accompanied by hoarseness for the preceding 24 h. Endoscopy of 👄 the upper

digestive tract revealed a tracheoesophageal fistula. Treatment consisted of cervical

exclusion of the esophageal transit, together with gastrostomy. 👄 Subsequently, the

nutrient transit was reconstructed through pharyngocoloplasty. The postoperative

evolution was favorable.

Keywords: Tracheoesophageal fistula/etiology;

Tracheoesophageal fistula/surgery; Esophageal perforation/chemically induced;

👄 Colon/surgery

RESUMO

As fístulas esôfago-traqueais são incomuns e apresentam diversas

etiologias, entre elas, a queimadura química esofágica devida à ingestão cáustica.

Relatamos 👄 o caso de um paciente de 27 anos com história de ingestão cáustica havia

catorze dias, com dor retroesternal em 👄 brazino777 casino baixar queimação, fraqueza, tosse com escarro

purulento e dispnéia associada à rouquidão no último dia. A endoscopia digestiva alta e

👄 a broncofibroscopia revelaram fístula esôfago-traqueal. O tratamento consistiu no

suporte clínico, drenagem torácica bilateral, exclusão do transito esofágico com

esofagostomia 👄 cervical terminal e gastrostomia. Houve cicatrização espontânea da

fístula esôfago traqueal em brazino777 casino baixar seis semanas. Posteriormente, realizou-se a

reconstrução do 👄 trânsito alimentar através de faringocoloplastia. A evolução

pós-operatória foi satisfatória.

Palavras-chave: Fístula traqueoesofágica/etiologia;

Fístula traqueoesofágica/cirurgia;Perfuração esofágica/induzido quimicamente;

Cólon/cirurgia.

The ingestion of caustic 👄 or corrosive substances remains a cause for

concern in the field of pulmonology due to the severity of the cases. 👄 These substances

are readily available, since they are present in various cleaning products. Therefore,

ingestion (accidental or intentional) of such 👄 substances occurs frequently.(1-3)In

children, accidental ingestion prevails, whereas voluntary ingestion (with suicidal

intent) is more common in adults.(1,2) Alkalis are 👄 the substances most frequently

ingested, caustic soda (sodium hydroxide) being the principal agent.(1-4)Chief among

the acute complications of caustic ingestion 👄 are gastric hemorrhage, esophageal

perforation, gastrocolic fistula, esophageal-aortic fistula, and tracheoesophageal

fistula (TEF).(1,2) The principal late complication is esophageal stenosis.(1-3,5)We

👄 report the case of a patient with TEF caused by caustic ingestion. The patient was

treated for this clinical condition 👄 and later underwent reconstruction of the gastric

transit through pharyngocoloplasty. Since TEFs are uncommon, their surgical management

is still the 👄 source of controversy in the international literature.(6,7) In this

context, we address the peculiarities of TEFs, as well as their 👄 treatment, since they

constitute severe clinical situations presenting high rates of morbidity and

mortality.A 27-year-old male patient, native to and 👄 resident of the city of Conceição

das Alagoas, located in the state of Minas Gerais, sought treatment in the emergency

👄 room 14 days after having ingested a caustic substance. He presented dysphagia for

solid and semi-solid foods, odynophagia, and burning 👄 retrosternal pain for 3 days,

without improvement. He presented undetermined fever during the preceding 24 h,

together with weakness, productive 👄 cough with purulent sputum, and dyspnea accompanied

by hoarseness. The patient described himself as a nonsmoker and nondrinker. He also

👄 stated that he had never undergone surgery.His overall health status was regular,

although he was emaciated. He presented tachypnea, dyspnea, 👄 fever (38.9 °C),

dehydration and intense sialorrhea. Physical examination revealed limited chest

expansion and reduced breath sounds in the left 👄 hemithorax, as well as bilateral

diffuse rhonchi. There were no cardiovascular and abdominal alterations.Laboratory

tests revealed discrete anemia (hemoglobin 11.8 👄 g/dl), leukocytosis (18,500

leukocytes/mm3, with 8% rods), discrete electrolyte disturbance and hypoalbuminemia

(2.2 g/dl). A chest X ray showed a 👄 small pneumothorax, left pulmonary consolidation and

mediastinum deviation to the left.We performed upper digestive endoscopy, which

revealed a large fistula 👄 between the esophagus and the left bronchus, although the

device passed without difficulty (Zagar class 3b(8)). The esophageal mucosa was 👄 friable

with intense deposits of fibrin. A nasogastric tube was positioned in the second

portion of the duodenum (Figure 1).The 👄 control chest X ray, after upper digestive

endoscopy, revealed left pneumothorax. Left thoracic drainage was performed with

immediate lung re-expansion. 👄 In the fiberoptic bronchoscopy, we observed an area of

destruction of the distal trachea, carina and left bronchus of approximately 👄 3 x 1.5 cm

(Figures 2 and 3), as well as exposure of the mediastinal tissue, together with

de-epithelization and 👄 retraction of the epiglottis and right vocal chord.Due to the

poor clinical condition of the patient and the severity of 👄 the lesions found, we chose

to perform terminal cervical esophagostomy and gastrostomy. We used a combination of

broad spectrum antibiotic 👄 therapy, central venous access, correction of the electrolyte

disturbance, respiratory therapy and psychological support.The patient presented

favorable evolution, being discharged 👄 17 days after admission. Two months after

discharge, he presented to the emergency room with progressive dyspnea for 10 days,

👄 together with intense intercostal wheezing and retractions. The fiberoptic bronchoscopy

revealed supraglottic stenosis (annular neoformation of the fibrotic tissue), and

👄 tracheostomy was indicated. He was monitored as an outpatient, and, six months after

the caustic ingestion, a palatopharyngoplasty was performed, 👄 and the tracheostomy was

deactivated.Eight months after his first admission, the patient was hospitalized (for

better nutritional preparation), and the 👄 reconstruction of the gastric transit was

scheduled. We performed pharyngocoloplasty with retrosternal interposition of the

transverse colon and posterior pharyngocolic 👄 anastomosis. The patient presented

considerable improvement, was discharged on postoperative day 12 and was in outpatient

treatment for 28 months, 👄 presenting favorable clinical evolution.Acquired TEF can have

various etiologies, malignant neoplasms of the esophagus being the most common.(7)

Among the 👄 benign TEFs, ischemia and posterior necrosis of the tracheal and esophageal

membrane, due to the tracheal and gastric tube cuffs 👄 seen in individuals on prolonged

mechanical ventilation, are the most common etiologies.(6,9) Less common etiologies

include foreign bodies, instrumental esophageal 👄 dilation, esophageal diverticulum

perforation, mediastinal abscesses, thoracic trauma (open or closed) and chemical burns

in the esophagus.(6,7,9)In the TEFs resulting 👄 from caustic ingestion, the necrosis

caused by the extent of the chemical burning of the esophagus seems to be the 👄 main

pathophysiological factor.(4) Due to the etiological diversity and the low frequency of

TEFs, there is no consensus in the 👄 literature regarding the ideal treatment of this

clinical condition and the proposed treatments are various.(6,7,9-11)Some authors(6)

studied 31 patients with 👄 benign TEFs and found that the majority of cases were due to

complication of endotracheal intubation. The authors treated all 👄 of the patients

through left cervical incision involving suture of the tracheal and esophageal defect

with interposition of the sternocleidomastoid 👄 muscle flap between the two organs. The

results were positive.Other authors(7) reported their experience in the treatment of 41

patients 👄 with congenital and acquired (benign and malignant) TEFs, in which 11 patients

presented TEFs due to malignant neoplasms, 7 due 👄 to tracheoesophageal trauma, 5 due to

chemical burns, 4 due to congenital disorders and the rest due to other etiologies. 👄 The

proposed surgical treatment was fistulectomy involving the correction (suture) of the

esophageal and tracheal defects (especially in the cases 👄 of posttraumatic TEF cases) or

the creation of an artificial esophagus through the transposition of the jejunal loop

or colon. 👄 The latter was reserved only for cases of extensive esophageal chemical

burning with great inflammation and fibrosis of adjacent tissues. 👄 In the cases of TEF

due to malignant neoplasms, the principal treatment, as a palliative measure, was

gastrostomy.Some authors(4) described 👄 their own surgical technique in the treatment of

TEF due to caustic ingestion. They proposed esophagectomy in which a pulmonary 👄 lobe

patch is used in order to obliterate the lesion of the trachea or bronchus, with

subsequent reconstruction of the 👄 gastric transit through retrosternal interposition of

the ileocolic segment.Regarding the reconstruction of the gastric transit in patients

with esophagus stenosis, 👄 the use of the colon as transposed viscera is well established

in the literature. In more severe caustic stenoses, in 👄 which not only the esophagus but

also the pharynx is affected, the colon is also the organ of choice.(14)The author 👄 of

one study(14) demonstrated that pharyngocoloplasty with posterior pharyngocolic

anastomosis, in the treatment of caustic stenosis of the esophagus and 👄 pharynx,

presents favorable results, low mortality (null index in the sample studied) and

postoperative complications with few overall repercussions (cervical 👄 fistula in 5% of

the cases).We conclude that the appropriate treatment of TEF is fundamental to

obtaining satisfactory results. The 👄 technique employed in the therapeutic management of

our patient proved to be an effective and safe alternative. Although this is 👄 the

description of only one case, we found it important to report it, because the

complications of caustic accidents, especially 👄 TEFs, are uncommon, represent complex,

difficult to treat cases and require protracted treatment, as well as demanding

integrated and multidisciplinary 👄 approaches.1. Corsi PR, Hoyos MBL, Rasslan S, Viana

AT, Gagliardi D. Lesäo aguda esôfago-gástrica causada por agente químico. Rev Assoc 👄 Med

Brás. 2000;46(2):98-105.2. Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J

Clin Gastroenterol 2003;37(2):119-24.3. Andreollo NA, Lopes LR, Tercioti 👄 Júnior V,

Brandalise NA, Leonardi LS. Esôfago de Barret associado à estenose cáustica do esôfago.

Arq Gastroenterol. 2003;40(3):148-51.4. Sarfati E, 👄 Jacob L, Servant JM, d'Acremont B,

Roland E, Ghidalia T, Celerier M. Tracheobronchial necrosis after caustic ingestion. J

Thorac Cardiovasc 👄 Surg. 1992;103(3):412-3.5. Mamede RC, Mello Filho FV. Ingestion of

caustic substances and its complications. São Paulo Med J. 2001;119(1):10-5.6. Baisi 👄 A,

Bonavina L, Narne S, Peracchia A. Benign tracheoesophageal fistula: results of surgical

therapy. Dis Esophagus. 1999;12(3):209-11.7. Gudovsky LM, Koroleva 👄 NS, Biryukov YB,

Chernousov AF, Perelman MI. Tracheoesophageal fistulas. Ann Thorac Surg.

1993;55(4):868-75.8. Zagar ZA, Kochjar R, Mehta S, Mehta 👄 SK. The role of endoscopy in

the management of corrosive ingestion and modified endoscopic classification of burns.

Gastrointest Endosc. 1991;37(2):165-9.9. 👄 Gerzic Z, Rakic S, Randjelovic T. Acquired

benign esophagorespiratory fistula: report of 16 consecutive cases. Ann Thorac Surg.

1990;50(5):724-7.10. Hosoya 👄 Y, Yokoyama T, Arai W, Hyodo M, Nishino H, Sugawara Y, et

al. Tracheoesophageal fistula secondary to chemotherapy for malignant 👄 B-cell lymphoma

of the thyroid: successful surgical treatment with jejunal interposition and mesenteric

patch. Dis Esophagus. 2004;17(3):266-9.11. Bardini R, Radicchi 👄 V, Parimbelli P, Tosato

SM, Narne S. Repair of a recurrent benign Tracheoesophageal fistula with a Gore-Tex

membrane. Ann Thorac 👄 Surg. 2003;76(1):304-6.12. Ergün O, Celik A, Mutaf O. Two-stage

coloesophagoplasty in children with caustic burns of the esophagus: hemodynamic basis

👄 of delayed cervical anastomosis--theory and fact. J Pediatr Surg. 2004;39(4):545-8.13.

Miranda MP, Genzini T, Ribeiro MA, Crescentini F, Faria JCM. 👄 Emprego de anastomose

vascular microcirúrgica para incremento do fluxo sanguíneo na esofagocoloplastia. An

Paul Med Cir. 2000;127(1):142-6.14. Cecconello I. Faringocoloplastia 👄 no tratamento da

estenose caustica do esôfago e da faringe [tese]. São Paulo: Faculdade de Medicina da

Universidade de Sao 👄 Paulo; 1989.*Study carried out at the Universidade Federal do

Triângulo Mineiro (UFTM, Federal University of Triângulo Mineiro) - Uberaba (MG)

👄 Brazil.1. PhD, Full Professor in the Department of Surgical Gastroenterology at the the

Universidade Federal do Triângulo Mineiro (UFTM, Federal 👄 University of Triângulo

Mineiro) - Uberaba (MG) Brazil.2. Adjunct Professor, Chief of the Department of

Thoracic Surgery at the Universidade 👄 Federal do Triângulo Mineiro (UFTM, Federal

University of Triângulo Mineiro) - Uberaba (MG) Brazil.3. Degree in Medicine from the

Universidade 👄 Federal do Triângulo Mineiro (UFTM, Federal University of Triângulo

Mineiro) - Uberaba (MG) Brazil.4. PhD, Adjunct Professor in the Surgical 👄 Techniques and

Experimental Surgery Department at the Universidade Federal do Triângulo Mineiro (UFTM,

Federal University of Triângulo Mineiro) - Uberaba 👄 (MG) Brazil.5. PhD, Adjunct

Professor, Chief of the Department of Surgical Gastroenterology at the Universidade

Federal do Triângulo Mineiro (UFTM, 👄 Federal University of Triângulo Mineiro) - Uberaba

(MG), Brazil.Correspondence to: Marcelo Cunha Fatureto. Departamento de Cirurgia da

UFTM. Av. Getúlio 👄 Guaritá, s/n, CEP 38025-440, Uberaba, MG, Brazil. Phone 55 34

3332-2155. E-mail: cremauftm@mednet/mfat@terraSubmitted: 16/12/05. Accepted, after

review: 13/3/06.

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