A Large Tracheo-esophageal Fistula Secondary to an Aortic Aneurysm

Abstract

Purpose: Purpose: To present a unique case of tracheo-esophageal fistula (TEF) from a benign cause. Case: 76 yo female presented with a cough, shortness of breath and fever. History included atrial fibrillation, arterial hypertension, COPD and repair of an ascending aortic aneurysm in 2001, complicated by sternal dehiscence. She had previously been admitted 3 times for recurrent pneumonia. She also reported progressive severe dysphagia and coughing with solids and liquids the last few months. Initially, her oxygen saturation was 94% on room air and coarse breath sounds with rhonchi were heard bilaterally. White blood cell count was normal with a left shift; serum chemistries were normal but there was hypocarbia and hypoxia on arterial blood gas. The CT-scan of the chest showed the thoracic aortic aneurysm (7.5x6cm, unchanged), obstruction of the left mainstem bronchus and consolidation of the left lower lung. Radiographic contrast study showed reflux of contrast agent and quick filling of the left bronchial tree. Esophagogastroduodenoscopy (EGD) showed a large TEF at 25cm. The bronchial cartilage had eroded into the esophageal lumen. Her operative risk was high and conservative management was recommended. An endobronchial stent was placed, and she was to undergo subsequent esophageal stenting. However, her left lung volume decreased due to distal migration of the stent and it was removed. Discussion: The combination of dysphagia and recurrent pulmonary infections in the same location in the elderly is suggestive of primary esophageal disease, e.g. achalasia, esophageal cancer or TEF. The diagnostic work-up for dysphagia can start either with EGD or a contrast radiological evaluation. The majority of aspiration pneumonias, however, would be expected to manifest in the right upper lobe. Thus, EGD may be the preferred initial diagnostic test, when TEF is suspected, and it may also be therapeutic. The majority of TEFs are due to underlying malignant disease, most commonly esophageal or lung cancer. Benign TEFs are commonly due to erosion of the endotracheal tube balloon during prolonged intubation, trauma or post-surgical. Chronic compression of the bronchus into the esophagus and subsequent fistula formation from a chronic aneurysm of the ascending aorta is unusual. Surgical repair is the preferred treatment for benign TEFs. Our patient presented prohibitive operative risks and endoluminal therapy was attempted. With the advent of removable silicone stents benign TEFs can be treated nonsurgically.