Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 279-282

Acquired bronchoesophageal fistula: an anesthetic challenge


1 Department of Anesthesia, SKNMC & GH, Pune, Maharashtra, India
2 Department of Anesthesia, Mission Hospital, Durgapur, West Bengal, India
3 Department of Anesthesia, KEM Hospital, Pune, Maharashtra, India

Date of Submission11-Jan-2014
Date of Acceptance02-Mar-2015
Date of Web Publication8-May-2015

Correspondence Address:
Kalyani N Patil
DNB, B12, Mansi Apartments, Behind Suvarnayug Sahakari Bank, Bibwewadi, Pune - 411 037, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.156729

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  Abstract 

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.

Keywords: acquired bronchoesophageal fistula, epidural analgesia, one-lung ventilation


How to cite this article:
Patil KN, Deshpande SD, Bande SB. Acquired bronchoesophageal fistula: an anesthetic challenge. Ain-Shams J Anaesthesiol 2015;8:279-82

How to cite this URL:
Patil KN, Deshpande SD, Bande SB. Acquired bronchoesophageal fistula: an anesthetic challenge. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 May 6];8:279-82. Available from: http://www.asja.eg.net/text.asp?2015/8/2/279/156729

Presented-at Poster Presentation at ISACON in Mumbai on December 2011.



  Introduction Top


Acquired bronchoesophageal fistula is uncommon. Presentation may range from subclinical to severe respiratory distress.

We report a case of a 30-year-old male patient with right bronchoesophageal fistula and right lower lobe bronchiectasis.


  Case history Top


A 30-year-old male patient presented with bouts of cough and choking sensation after swallowing food of 1-year duration. He had history of pulmonary tuberculosis 2 years back, had completed antitubercular therapy, and declared cured.

On examination, he was averagely built and nourished. Respiratory system examination revealed increased tactile vocal fremitus and coarse crepitations over the right axillary and inframammary areas.

The blood investigations were unremarkable.

Chest radiograph revealed enlarged mediastinal nodes.

Computed tomography of the thorax revealed traction diverticulum in thoracic esophagus, with fistula communicating the esophagus and right lower lobe bronchus. The right lower lobe was bronchiectatic ([Figure 1]).
Figure 1: Computed tomography of thorax revealing right lower lobe bronchiectasis.

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Contrast esophagogram demonstrated fistulous communication between the esophagus and right bronchus ([Figure 2]).
Figure 2: Preoperative contrast esophagogram.

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Pulmonary function test revealed mild obstructive pattern, not responding to bronchodilators.

The patient was electively posted for thoracoscopic ligation of the fistula. Preoperative optimization included appropriate antibiotics therapy, acid suppressants, bronchodilators, airway humidification, and chest physiotherapy. Incentive spirometry was taught to the patient so as to facilitate his postoperative recovery.

Anesthesia plan

General anesthesia with lung isolation was given with thoracic epidural.

On the day of surgery, a wide-bore peripheral intravenous access was secured in the operation theater. The patient was premedicated with glycopyrrolate (0.2 mg), ondansetron (4 mg), midazolam (2 mg), and fentanyl (100 mcg) intravenously. Nasogastric tube was inserted. Thoracic epidural catheter was inserted at T6-T7 level, with the patient in the left lateral position. Central venous access was secured in the right subclavian vein. Arterial line was secured in the right radial artery. General anesthesia was induced with thiopentone and vecuronium used as skeletal muscle relaxant. Left-sided double-lumen tube (DLT) no. 35 was inserted and its position and lung isolation were confirmed by auscultation with alternate clamping of tracheal and bronchial lumen of the tube. Anesthesia was maintained with oxygen, nitrous oxide, and isoflurane. The patient was then placed in the left lateral position. Pressure points were secured and tube position was rechecked. A volume of 8 ml 0.25% bupivacaine was given as epidural bolus. Epidural infusion was initiated with 0.25% bupivacaine and rate of infusion was titrated intraoperatively according to the surgical stimulus and patient's hemodynamics. Intraoperative monitoring included SpO 2 , intra-arterial blood pressure (IBP), ECG, EtCO 2 , central venous pressure (CVP), airway pressures and respiratory waveforms, and arterial blood gases (ABGs). Ventilation of both lungs was continued until positioning the patient. Thereafter, the right lung was isolated and the left lung was ventilated through the bronchial lumen of the DLT. All measures to maintain hypoxic pulmonary vasoconstriction were taken. Intermittent suctioning was performed intraoperatively. Intraoperative ABGs revealed satisfactory oxygenation.

Thoracoscopic adhesolysis was attempted, but as the fistula could not be reached, right thoracotomy was performed through posterolateral fifth intercostal space. Right lower lobe bronchus, inferior pulmonary vein, and bronchial artery were ligated and right lower lobectomy was performed. Bronchial stump integrity was checked by applying positive end expiratory pressure (PEEP). Esophageal splaying was sutured.

Intraoperative complications

During fistula ligation, there was sudden increase in peak pressures and decrease in EtCO 2 and desaturation, most likely due to kinking of the tube during airway handling. It was managed by asking the surgeons to temporarily stop the surgical manipulation, and the DLT was withdrawn by about 1 cm.

Postoperative complications

Patient was reversed after return of spontaneous respiratory attempts but he had labored breathing. He was therefore sedated and reparalyzed. DLT was replaced by single-lumen tube. He was shifted to ICU and was ventilated with pressure-controlled ventilation. Patient weaned off over next 24 h with help of ABGs and extubated. Multimodal analgesia including thoracic epidural was given. Contrast esophagogram performed after 5 days showed 'no leak', after which he was discharged ([Figure 3]).
Figure 3: Postoperative contrast esophagogram.

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  Discussion Top
[1],[2]

Etiology

Bronchoesophageal fistula in an adult is rarely encountered in clinical practice. Most commonly they have malignant origin. Benign conditions causing bronchoesophageal fistula are less common and include infections such as tuberculosis, syphilis, histoplasmosis, candidiasis, and actinomycosis [3] . Traumatic factors include prolonged endotracheal intubation and blunt chest injury [4] . Other conditions known to cause fistula include inflammatory conditions such as Crohn's disease, Behcet's disease, broncholithiasis, and corrosive ingestion [3] .

Clinical presentation

Acquired fistulae are frequently misdiagnosed.

Symptoms in nonventilated patient are related to repeated tracheal soiling. They are characterized by bouts of cough after swallowing, often worse with carbonated drinks (Ono's sign) [2] . Sometimes this is evident in certain postures, particularly when the fistula is dependent [5] . Other features that should raise suspicion of fistula are history of trauma, malignancy, or ingestion of caustic substances, complaints of chest pain, hemoptysis, shortness of breath, dysphagia, hoarseness of voice, and pyrexia of unknown origin (PUO) [2] . Delay in diagnosis may be complicated by pneumonia, life-threatening hemoptysis, and respiratory failure [1] .

Acquired fistula in ventilated patient presents as recurrent chest infections and repeated failure to wean from ventilator [2] .

Investigations

Chest radiograph may demonstrate the effects of repeated soiling of the respiratory tract, basal infiltrates, heterogeneous shadows, and bronchiectatic changes.

Conventional barium esophagography is considered to be the most sensitive test for diagnosing bronchoesophageal fistula. Contrast will demonstrate the defect in 70% of lesions [6],[7] . The site, width, length, and direction of the fistula can be identified.

Esophagoscopy will enable the diagnosis of tumors and fistulae. Biopsies can also be taken [2] .

Bronchoscopy allows bronchial lavage, enabling targeted antibiotic therapy and airway clearance, both of which have been shown to improve outcome [6] .

Accurate identification of the site of fistula is central to successful definitive management [2] .

Preoperative management

Principles of preoperative optimization of aeroesophageal fistula are: to minimize further aspiration, prevent and treat pulmonary infection, provide supportive therapy until definitive surgery can be performed, and ensure that the patient is as fit as possible for the surgical procedure [2],[8],[9],[10] . Acid suppression therapy has been shown to reduce acidity and volume of gastric contents, and hence the risk for aspiration.

The site of lesion must be carefully noted as this may dictate the anesthetic approach.

Intraoperative anesthetic management

Important issues to be dealt by the anesthetist are as follows:

  1. Difficulty in oxygenation and/or ventilation depending on the site and size of fistula.
  2. Pulmonary changes due to recurrent aspiration.
  3. Ventilatory management during handling of the airway by surgeons.
  4. One-lung ventilation (OLV).
  5. Prevention of soiling of other lung.
  6. Postoperative analgesia to facilitate early weaning from the ventilator.
Bronchoesophageal fistulae are rare but can present the anesthetist with major difficulties. The site of lesion means that protection of both lungs with standard endotracheal tube is impossible. DLTs have the advantage of OLV, at the same time prevent soiling of the healthy lung, and allow suctioning of the affected lung during surgery. If required, CPAP can also be applied to the lung being operated. Once the fistula is isolated, same tube can be used as standard endotracheal tube and both lungs can be ventilated without the fear of soiling and gastric dilatation. The integrity of bronchial stump is checked by performing leak test. Ventilatory modes should be adopted to avoid unnecessary stress on the surgical repair. Pressure-controlled and high-frequency ventilation have been reported in the literature [2] .

Central venous access with monitoring of the CVP ensures optimal fluid management perioperatively, as thoracic surgeries are associated with major fluid shifts and it is important to avoid overhydration as water-logging of the healthy lung adversely affects the outcome by delaying weaning.

Epidural catheters placed congruent to the surgical site are acknowledged to provide the best analgesia [10] . Epidural analgesic infusion provides stable intraoperative hemodynamics along with excellent postoperative pain relief, which allows early extubation and active involvement of the patient in respiratory physiotherapy.


  Conclusion Top


Optimal ventilatory management with OLV, fluid management guided by CVP, excellent intraoperative and postoperative analgesia with early extubation, and team effort by the anesthetist, surgeon, and intensivist provide the best possible outcome.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Aggarwal D, Mahapatra PR, Malhotra B. Acquired bronchoesophageal fistula. Lung India 2009; 26:24-25.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Contin Educ Anaesth Crit Care Pain 2012; 12:105-108.  Back to cited text no. 2
    
3.
Lim KH, Lim YC, Liam CK, Wong CM. A 52 year old woman with recurrent hemoptysis. Chest 2001; 119:955-957.  Back to cited text no. 3
    
4.
Spalding AR, Burney DP, Richie RE. Acquired benign bronchoesophageal fistulas in the adult. Ann Thorac Surg 1979; 28:378-383.  Back to cited text no. 4
[PUBMED]    
5.
Danino EA, Evans CJ, Thomas JH. Tuberculous bronchoesophageal fistula in a child. Thorax 1995; 10:351-353.  Back to cited text no. 5
    
6.
Couraud L, Ballester ML, Delaisement C. Acquired tracheo-oesophageal fistula and its management. Semin Thorac Cardiovasc Surg 1998; 8:392-399.  Back to cited text no. 6
    
7.
Bartels HE, Stein HJ, Siewart JR. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 1998; 85:403-406.  Back to cited text no. 7
    
8.
Chauhan SS, Long J. Management of tracheo-oesophageal fistula in adults. Curr Treat Options Gastroenterol 2004; 7:31-40.  Back to cited text no. 8
    
9.
Shah CP, Yeolekar ME, Pardiwala FK. Acquired tracheo-oesophageal fistula. J Postgrad Med 1994; 40:83-84.   Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Robins B, Das AK. Anesthetic management of acquired tracheoesophageal fistula: a brief report. Anesth Analg 2001; 93:903-905.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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  Introduction
  Case history
  Conclusion
  Acknowledgements
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   References
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