Bronchoesophageal Fistula Research Articles

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE), endorsed by the European Society for Radiotherapy and Oncology (ESTRO), the European Society of Digestive Endoscopy (ESDO), and the European Society for Clinical Nutrition and Metabolism (ESPEN). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations for malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliative treatment of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass (strong recommendation, high quality evidence). 2 For patients with longer life expectancy, ESGE recommends brachytherapy as a valid alternative or in addition to stenting in esophageal cancer patients with malignant dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality of life compared to SEMS placement alone. (Strong recommendation, high quality evidence.) 3 ESGE recommends esophageal SEMS placement as the preferred treatment for sealing malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low quality evidence). 4 ESGE does not recommend the use of concurrent external radiotherapy and esophageal stent treatment. SEMS placement is also not recommended as a bridge to surgery or prior to preoperative chemoradiotherapy. It is associated with a high incidence of adverse events and alternative satisfactory options such as placement of a feeding tube are available. (Strong recommendation, low quality evidence.) Main recommendations for benign disease 1 ESGE recommends against the use of self-expandable stents (SEMSs) as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and costs (strong recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence).

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed.

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application. Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another. All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously. OTSC provided safe and successful closure in a number of settings.

Combined tracheal and esophageal atresia with fatal outcome

Purpose: Congenital tracheal atresia is a rare anomaly (1:50.000). The defect consists of partial or complete absence of the trachea below the larynx. The lower airway often is connected to the gastrointestinal tract via a distal tracheo- or bronchoesophageal fistula.

An Unusual Cause of Dysphagia with Bronchoesophageal Fistula

A 57-year-old man presented with a 4-week history of dysphagia and cough. Physical examination revealed mucocutaneous pallor, and laboratory tests showed a slight anemia (hemoglobin level 12,5 g/dL). An upper gastrointestinal endoscopy reveled an obstructive neoplasm in the midesophagus (Fig. 1); biopsy specimens showed fibrinonecrotic and granulation tissue. Chest computed tomography showed a large peribronchial mass with bronchoesophageal fistula (BEF) (Fig. 2), and bronchoscopy reveled bronchial infiltration and marked caliber reduction of the left main bronchus. The results of examinations of samples from repeat biopsies of esophageal and bronchial lesions were negative for dysplasia or neoplasia. The results of polymerase chain reaction testing for Mycobacterium tuberculosis were positive, so we began administration of tuberculostatics and systemic corticosteroids, assuming lymph node tuberculosis with mediastinal involvement. However, there was a worsening of dyspnea and weight loss, and the results of the Xpert MTB/RIF Assay (Cepheid, Sunnyvale, CA) and Lowenstein–Jensen culture were both negative, leading to the assumption of a false-positive result of the first test. Endoscopic reassessment showed increase esophageal lesion and extensive tracheobronchial destruction, forming a large necrotic cavity in the mediastinum (Fig. 3). Histopathological analysis revealed large lymphocytes with a diffuse growth pattern with negative immunostaining for cytokeratin AE1, cytokeratin AE3, and for cluster of

Management of Tracheo- or Bronchoesophageal Fistula After Ivor-Lewis Esophagectomy.

The development of tracheo- or bronchoesophageal fistula (TBF) after Ivor-Lewis esophagectomy remains to be a rare complication associated with a high mortality rate. In this retrospective study, the charts of patients with TBF after esophagectomy were analyzed in terms of individual patient characteristics, esophagotracheal complications, respiratory function, management, and outcome. Between January 2000 and December 2014, 1204 patients underwent Ivor-Lewis esophagectomy for esophageal cancer; 13 patients (1.1%) developed a TBF. In all 13 patients, a concomitant leakage of the intrathoracic esophagogastrostomy was evident, either prior to diagnosis of TBF (metachronous TBF) or simultaneously (synchronous TBF). TBF was predominantly located in the left main bronchus (n=6, 46.1%) or trachea (n=5, 38.5%). Management of TBF included re-thoracotomy (n=7), interventional endoscopic (n=10) or bronchoscopic therapy (n=4). In the majority of patients (n=8), management consisted of two subsequent treatment modalities. In 3 out of four patients, TBF was successfully treated by endoscopic stenting only. Five patients (38.5%) died following a septic course with multiple organ failure. The development of TBF after Ivor-Lewis esophagectomy is always combined with anastomotic leakage of the esophagogastrostomy. Treatment options primarily depend on the vascularization of the gastric conduit, the severity of the concomitant aspiration pneumonia, and the volume of the air leakage.

Communicating Tubular Esophageal Duplication Combined with Bronchoesophageal Fistula.

Esophageal duplication (ED) is rarely diagnosed in adults and is usually asymptomatic. Especially, ED that is connected to the esophagus through a tubular communication and combined with bronchoesophageal fistula (BEF) is extremely rare and has never been reported in the English literature. This condition is very difficult to diagnose. Although some combinations of several modalities, such as upper gastrointestinal endoscopy, esophagography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, can be used for the diagnosis, the results might be inconclusive. Here, we report on a patient with communicating tubular ED that was incidentally diagnosed on the basis of endoscopy and esophagography during the postoperational evaluation of BEF.

Bronchoesophageal Fistula Stenting Using High-Frequency Jet Ventilation and Underwater Seal Gastrostomy Tube Drainage.

Managing a patient scheduled for bronchoesophageal fistula repair is challenging for the anesthetist. If appropriate ventilation strategy is not employed, serious complications such as hypoxemia, gastric distension, and pulmonary aspiration can occur. We present the case of a 62-year-old man with a bronchoesophageal fistula in the left main stem bronchus requiring the insertion of a Y-shaped tracheobronchial stent through a rigid bronchoscope, under general anesthesia. We successfully managed this intervention and herein report this case to demonstrate the effectiveness of underwater seal gastrostomy tube drainage used in conjunction with high-frequency jet ventilation during bronchoesophageal fistula stenting.

Bronchoesophageal Fistula Repair with Intercostal Muscle Flap Followed by Occlusion of Residual Diverticula with N-butyl Cyanoacrylate (NBCA) Glue: A Case Report

The incidence of bronchoesophageal fistula in presence of benign pathology of tracheal tree or oesophagus is rare. It is encountered in thoracic diseases like tuberculosis, syphilis or histoplasmosis due to erosion by infected lymph node or abscess to adjoining structures. The source of primary pathology has to be eliminated followed by appropriate steps of fistula tract closure is essential for optimal result. We report a 25-year-old patient with left sided bronchoesophageal fistula. He had a past history of pulmonary tuberculosis. A left lower lobectomy followed by repair of oesophageal fistula opening was performed by primary closure and reinforcement with an intercostal muscle flap based on posterior intercostal artery. Postoperative oesophagogram showed short diverticula, which was occluded with n-butyl cyanoacrylate (NBCA) glue under radiological guidance. Feeding was started one week after application of glue without further complication. Reports on intercostals muscle flap repair and intervention of residual oesophageal diverticula with n-butyl cyanoacrylate (NBCA) glue under radiological guidance are scanty.

Bronchoesophageal Fistula in a Female With History of Crohnʼs Disease and Small Cell Lung Cancer

Background: Airway-esophageal fistulas are serious complications of lung or esophageal tumors. They arise either as a result of progression of lung or esophageal malignancies or manifest as a complication of chemoradiation therapy. They can also be a rare complication of Crohn's disease of the esophagus. There is limited literature on bronchoesophageal fistulas in lung cancer patients with Crohn's disease. This is a description of a case involving a middle aged female with history of Crohn's disease diagnosed with small cell lung cancer presenting with dysphagia who was found to have a bronchoesophageal fistula. Case Description: This is a 47 year old female who was diagnosed to have stricturing and fistulizing Crohn's disease 15 years ago, treated in the past with mesalamine (Asacol), prednisone, azathioprine, and infliximab on no current maintenance medications for five years who presents to clinic in December 2014 with dysphagia, nausea and vomiting. Imaging revealed a large mass in the left lower lobe abutting the mediastinum and the carina which was confirmed to be small cell lung cancer by bronchoscopy. She completed 4 cycles of cisplatin and etoposide following which she presented to clinic in May 2015 with fever, tachycardia, and hypotension as well as nausea, vomiting, cough and dysphagia. An upper endoscopy was performed revealing a large esophageal ulcer and bronchoesophageal fistula. She subsequently underwent esophageal stenting with a covered esophageal stent and open gastrostomy tube placement. Discussion: We investigate this case of a bronchoesophageal fistula in a patient with prior history of Crohn's disease and small cell lung cancer. Airway-esophageal fistulas are a known complication of tumor growth or recurrence in lung or esophageal tumors. They can also arise secondary to chemotherapy or radiation. Rarer causes include Crohn's disease, laser therapies, biologics like Bevacizumab and pressure necrosis from esophageal stents. Mean survival is 1-6 weeks. Common causes of death are respiratory infections and malnutrition. Esophageal stenting relieved symptoms in 80% of patients, was more effective (p=0.001) and led to better survival (p=0.07) and better quality of life (p=0.01) in multivariate analyses as compared to bypass or resections. Self expanding metallic stents are preferred over silicone or plastic stents.Figure 1Figure 2Figure 3

Fixing a Rare Complication: Broncho-Esophageal Fistula in Late-Stage Squamous Cell Carcinoma

Case Summary: A 57-year-old male with a past medical history of alcohol and tobacco abuse presented with a cough and unintentional weight loss of 25 pounds. He reported a six-month history of dysphagia, to solids, and has had multiple episodes of aspiration pneumonia (PNA) in that time period. A Chest CT was preformed and demonstrated a left sided subcarinal mass occluding the bronchus and extending 2 cm into the left lower lobe. Bronchoscopy confirmed a nearly complete occlusion of the left lower lobe bronchus by the mass. Biopsy was consistent with non-keratinizing squamous cell carcinoma. Upper GI fluoroscopy showed dilation of the proximal esophagus with an apple-core lesion at the level of the carina. Esophagogastroduodenoscopy (EGD) with biopsy of the esophageal lesion was consistent with squamous cell carcinoma. Endoscopic ultrasound (EUS) confirmed the stage (IV) and helped to define the anatomy. Self-expandable metallic stents (SEMS) were placed in the esophagus and left bronchus, permitting closure of the airway-esophageal fistula (AEF.) The patient underwent chemotherapy and radiation with a good outcome. Discussion: The development of an airway-esophageal fistula (AEF) in advanced esophageal or lung cancers, though rare, is a dangerously debilitating condition. The AEF may also result secondary to patients undergoing radiation or chemotherapy treatment. AEF may lead to poor nutrition, deterioration of the airway, and pulmonary sepsis, threatening patient survival and inevitably diminishing quality of life. Modern advanced interventional endoscopy has enabled the precise placement of esophageal and bronchial stents, while reducing complications in the treatment of AEF. After stent insertion, there is immediate relief of dysphagia symptoms and termination of airway-ablating aspiration. Although plastic or silicone stents have been used in years past, SEMS have become the gold standard as they tend to better seal large defects, experience lower rate of migration, and demonstrate a greater increase in post-operative quality of life. In our patient with non-keratinizing squamous cell carcinoma of the esophagus, SEMS were used to effectively seal off an AEF successfully relieving him of dysphagia symptoms and recurring PNA.Figure 1Figure 2Figure 3

Congenital broncho-esophageal fistula presenting as persistent lung abscess

We describe an 8-year-old male who presented with persistent lung abscess. The boy was subsequently found to be having congenital broncho-esophageal fistula. This condition has been reported rarely worldwide in children. It is probably the first case of congenital broncho-esophageal fistula presenting as persistent lung abscess from India.

The successful management of a Bronchoesophageal fistula after lung transplantation: a case report

We describe an unprecedented, disastrous complication after bilateral lung transplantation (BLT), a bilateral bronchial dehiscence with a right bronchoesophageal fistula leading to life-threatening septic shock. We also report the successful endoscopic management of this complication by double stenting and stress the efficacy of the multidisciplinary approach to this critical case.

Acquired tubercular bronchoesophageal fistula in a hemophiliac child

Acquired bronchoesophageal fistula in children is usually a late diagnosis, due to the rarity of the condition. The diagnosis was further complicated by presence of multiple co-morbid conditions. We would like to emphasize the importance of tackling the co-morbid factors strategically along with the surgical aspects in this case report.

Clinical Application of Fully Covered Self-Expandable Metal Stents in the Treatment of Bronchial Fistula

Background The study was designed to access the feasibility, safety, and efficacy of fully covered self-expandable metal stents in the treatment of bronchial fistula. Methods Clinical data of nine patients (seven males and two females) who were treated with placement of tracheobronchial or bronchial fully covered self-expandable metal stents from August 2005 to November 2011 were analyzed retrospectively. Among these patients, seven were diagnosed with bronchopleural fistula, one with tracheopleural fistula, and one with left main bronchoesophageal fistula. Eight had accompanying thoracic empyema. The fistula orifices ranged from 3.5 mm to 25 mm in diameter. All patients received topical anesthesia. L-shaped stents were placed in six patients and I-shaped stents in three under fluoroscopic guidance. After stent placement, patients with empyema were treated with pleural lavage. Results Stent placement in the tracheobronchial tree was successful in all patients, without procedure-related complications. The operating time was 5 to 16 minutes. A small amount of bubble overflowed from the intrathoracic drainage tube of only one patient. In the other patients, the bubble in the intrathoracic drainage tube disappeared immediately or angiography showed no overflow of contrast agent from the fistula orifice. The effective rate of fistula orifice closure after stent placement was 100%, with 88.9% rated as excellent. One patient coughed the stent out 5 days after placement and hence a new stent was placed. Among the patients with empyema, one died of septicemia arising from empyema on day 8 and another died of brain metastases of lung cancer 6 months after stent insertion with persistent empyema. In the other six patients, empyema resolved after 2 to 5 months (cure rate 75%). Seven patients were followed up for 3 to 36 months. During follow-up, one stent was removed 8 months after implantation due to difficult expectoration, without recurrent empyema. The remaining patients tolerated the stents well. The stents remained stable without migration or empyema recurrence, and they could eat and drink well. Conclusion The use of fully covered self-expandable metal stents is a safe, effective, and fast minimally invasive method to treat bronchial fistula, especially for selected cases with empyema.

Delayed presentation of post tuberculous broncho oesophageal fistula in an adult: Perioperative anaesthetic management.

Sir, A 42-year-old male had a recurrent cough with expectoration for last 6 months more with supine position and aggravated by the intake of food. He was referred for a pre-anaesthetic checkup for left pneumonectomy with repair of broncho oesophageal fistula (BEF). He had a history of parietal lobe abscess, drained twice with residual left-sided hemiplegia and focal seizures and had completed two courses of antituberculous treatment (ATT) 15 years back. The patient could lie down only in left lateral position. His investigations were unremarkable. Pulmonary function testing showed moderate impairment of lung function with moderately reduced vital capacity. X-ray and computerised tomography of the chest showed cystic bronchiectasis in left lower lobe. There were fibrosis and pleural thickening in bilateral lung fields with dilated oesophagus. Communicating tract between the lateral wall of the lower oesophagus and left lower lobe bronchus was seen at D-8 [Figure 1]. Post-inflammatory BEF was suggested in view of surrounding inflammatory changes and mediastinal lymphadenopathy. Barium swallow confirmed the same. Magnetic resonance imaging of the brain revealed post-operative changes with residual ring configuration in right posterior frontal lobe with moderate perilesional oedema. Figure 1 Computed tomography scan chest showing cystic bronchiectasis in left lower lobe and fistulous communication between oesophagus and left lower lobe bronchus The patient was accepted under American Society of Anaesthesiologists grade III. Antibiotics, chest physiotherapy, incentive spirometry, deep breathing exercises and all antiepileptic medications were continued till the morning of surgery. The patient was already on continuous Ryle's tube aspiration. After pre-medication, the thoracic epidural catheter was placed at T6-T7 interspace. Epidural test dose was followed by 3 mg of morphine. Monitoring included continuous electrocardiography, invasive blood pressure, end tidal carbon dioxide, SpO2, temperature, urine output and blood loss. After nasogastric tube aspiration and pre-oxygenation in the left lateral position, injection fentanyl 50 μg and sleep doses of thiopentone were given. As the patient went asleep, he was turned supine, and the cricoid pressure was applied. Injection rocuronium 50 mg was given to felicitate insertion of right sided double lumen tube (DLT) 41F. Intermittent positive pressure ventilation was avoided. Placement of DLT was confirmed clinically and fibreoptically. The left lung was isolated and collapsed immediately to prevent gastric distension and loss of lung volume. The patient was placed in right lateral position. Anaesthesia was maintained with nitrous oxide, oxygen, isoflurane, and rocuronium. Left pneumonectomy with excision of BEF track was done with blood loss of 2.5 L which was adequately replaced. A nasogastric tube was also placed. At closure, 6 ml of 0.125% bupivacaine was given through the epidural catheter. After extubation of trachea, the patient was shifted to intensive care unit for observation and made an uneventful recovery. BEF is rarely reported in the literature.[1] It may be congenital or acquired. Acquired causes include malignancy, trauma, oesophageal diverticulosis, infections such as syphilis, tuberculosis (TB) and actinomycosis. TB is the most common cause of infective BEF. The development of BEF in TB is related to mediastinal lymph node involvement.[2] Infection and subsequent adhesions between tracheobronchial lymph nodes and oesophagus with subsequent development of a traction diverticulum communicating with the respiratory tree are the mechanism for BEF formation. The aim during induction of anaesthesia is to avoid gas flow through the fistula which can cause gastric distension and impaired ventilation.[3] Positive pressure ventilation should be avoided. Spontaneous ventilation should be maintained during induction until gentle ventilation by mask provides an effective gas exchange. Double lumen intubation is required which protects the contralateral lung from contamination and provides the ability to ventilate it without applying positive pressure to the fistula.[3] Keeping the same in mind, rapid sequence induction was planned as insertion of DLT under spontaneous ventilation is difficult. Once placed, the diseased lung was isolated and kept collapsed. A surgical field fire is a known hazard during the surgery for BEF repair.[4] Avoiding the use of electrocautery while the fistula is open, using wet sponges, and decreasing the oxygen concentration in the gases before the division of fistula could reduce this incidence.[4] We instituted one lung ventilation with little loss of gases and a quick repair of the fistula to avoid the same. Post-tuberculous BEF is a rare entity and scarcely reported in the literature. BEF as a complication of TB can present at varied time intervals. There are reports of both immediate as well as a presentation in the chronic healing phase of TB.[1,2] Our patient received two complete courses of ATT 15 years back. BEF developed a decade later during the chronic healing phase of TB. Chronic suppuration not only damaged the left lung but also lead to the development of BEF. To conclude, prompt recognition and meticulous perioperative management lead to the successful outcome of our patient.

Acquired bronchoesophageal fistula: an anesthetic challenge

We report a rare case of acquired esophageal traction diverticulum, associated with tuberculous lymphadenitis leading to benign bronchoesophageal fistula of the right lower lobe bronchus. A 30-year-old male patient was admitted to our hospital with history of pulmonary tuberculosis 2 years back and complaints of cough and choking sensation after swallowing for 1 year. The diagnosis of bronchoesophageal fistula was made by contrast esophagogram and confirmed on computed tomographic scan. He was posted for thoracoscopic ligation of the fistula. Anesthetic management included thoracic epidural and general anesthesia with one-lung ventilation. Preoperative optimization, management of one-lung ventilation, optimum fluid management guided by central venous pressures, excellent analgesia with thoracic epidural, postoperative ICU care, and team efforts were important to make us succeed in this rare case of acquired benign bronchoesophageal fistula.

Fully Covered Self-Expandable Metal Stent in Tracheobronchial Disorders: Clinical Experience

Background: The third-generation fully covered self-expandable metallic stent (SEMS) has been developed to solve the problems of difficult removal and in-stent granuloma formation related to the uncovered or partially covered type. There are few written reports about the performance of this type of stents with early encouraging results. Objectives: To report and analyse our experience with the Silmet® stent in the management of malignant and benign tracheobronchial disorders. Methods: We retrospectively reviewed medical records of patients who underwent fully covered SEMS Silmet placement at the Interventional Pulmonology Unit, La Maddalena Cancer Center, Palermo, Italy, between May 2010 and August 2013. Results: Stents were placed in 52 patients with malignant (n = 49) and benign airway obstruction (n = 2) and broncho-oesophageal fistula (n = 1). SEMSs were inserted into the trachea (n = 19), the main bronchi (n = 21) and the peripheral bronchi (n = 31). Besides 1 procedural dislocation, the deployment was successful in all patients with an immediate significant improvement of symptoms (Barthel Index p < 0.001; Medical Research Council score p < 0.001). A radiographic improvement was detected in 48% of patients. The mean follow-up duration was 119 ± 120 days (range 22-549 days). Complications observed were: migration (7.6%), tumour overgrowth (15%), infections (5.7%), granulation tissue formation (3.8%) and mucus plug (3.8%). Conclusions: The Silmet stent is effective, safe and simple to implant and remove. We suggest its use in cases of tight stenoses, in the treatment of small- to medium-caliber airways or in cases of tortuous airways.

健側アプローチによる成人の先天性食道気管支瘻の一手術例

健側アプローチによる成人の先天性食道気管支瘻の一手術例

Acquired broncho-oesophageal fistula in an adult

Acquired broncho-oesophageal fistula in an adult

Spontaneous bronchoesophageal fistula in an adult – A possible delayed sequela of pulmonary tuberculosis

Spontaneous bronchoesophageal fistula in the adult 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 50year old man, treated for pulmonary tuberculosis 15years 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.