1866 “I am Choking:” An Unusual Late Complication of a Gunshot Injury

Abstract

INTRODUCTION: Benign tracheo-esophageal fistulas (TEF) in adults are an uncommon entity. We present the case of a patient who presented with dysphagia, was diagnosed with a benign TEF, and was successfully managed with endoscopic clipping with complete resolution. CASE DESCRIPTION/METHODS: A 64-year-old male veteran was referred to gastroenterology clinic for evaluation of dysphagia, specifically coughing and choking when eating. Previous history included stable pulmonary nodules, PET-avid mediastinal lymphadenopathy of unclear etiology, and GERD. Patient reported a gunshot wound to the throat over 30 years prior to presentation, which had required a left posterior thoracotomy. Barium esophagram showed a 6 mm diverticulum of the proximal esophagus, with extravasation of contrast into the trachea. EGD was performed, which identified a diverticulum with a small fistula at 20 cm from the incisors. The remainder of the esophagus appeared to be unremarkable, with no evidence of masses. Three hemoclips were deployed, with successful closure of the defect. Repeat barium esophagram 6 weeks post-procedure noted no contrast in the trachea, with the patient reporting improvement of symptoms. Repeat EGD 6 months post-procedure showed no evidence of diverticulum, fistula, nor clips. DISCUSSION: Nonmalignant TEF in adults are uncommon entities. Most acquired benign TEF are secondary to endotracheal cuff injury from prolonged mechanical intubation, but may be due to trauma, prior surgeries, foreign bodies, and mediastinal infections. Classical treatments for acquired TEF include surgical approaches with single or multistage procedures. Endoscopic therapies are increasingly studied with high technical and clinical success rates. While management of TEF is often performed with esophageal stents, tracheal stents, or a combination of both, literature review shows that patients may be successfully managed with endoscopic clips, or stents with a combination of sutures and cautery. For patients with persistent dysphagia and unexplained pulmonary findings, a high index of suspicion must be maintained for a benign TEF, and endoscopic interventions may be critical for clinical resolution. References Silon, Bryan, et al. “Endoscopic management of esophago-respiratory fistulas: a multicenter retrospective study of techniques and outcomes.” Digestive diseases and sciences 62.2 (2017): 424-431. Santosham, Rajan. “Management of acquired benign tracheoesophageal fistulae.” Thoracic surgery clinics 28.3 (2018): 385-392.