Congenital esophagobronchial fistula communicated to esophageal diverticulum, report of a case

We encountered a successful repair of congenital esophagobronchial fistula communicated to esophageal diverticulum. A 35 year-old-female has had frequent episodes of pneumonia since her 1st delivery. Barium esophagogram revealed a fistulous tract between the esophageal diverticulum and the right lower lobe bronchus. Bronchogram showed a ectatic dilatation at B6a and B6c. The resection of diverticulum and right lower lobectomy including the removal of fistulous tract were carried out. Histological examination of the resected fistula revealed a smooth connection between squamous epithelium and columnar epithelium. And muscularis mucosa was maintained with no evidence of inflammatory changes. So this case was diagnosed a Braimbridge I type esophagobronchial fistula. In Japan 21 cases of congenital esophagobronchial fistula with diverticulum have been reported. It is assumed that three histological findings as mentioned above is important for the diagnosis of congenital esophagobronchial fistula.     

Congenital and acquired esophagobronchial fistula

We report a case of a patient with repeated intractable pneumonia due to congenital and acquired esophagobronchial fistula that was relieved by surgery. The patient was a 69-year-old female, who had repeatedly developed pneumonic symptoms since December 2000. It was found that she had a fistula from an esophageal diverticulum into the right bronchus and was diagnosed with congenital esophagobronchial fistula (Braimbridge classification type I). The patient was not relieved with conservative treatment and the diverticulum and fistula were subsequently excised. Considering the complications, lobectomy was not performed. In postoperative esophagraphy, a second fistula was found at a different site that was then removed during a second surgery. This fistula operation was formed a posteriori based on the conditions around the fistula. We had difficulty with the diagnosis and treatment. However, the patient had a good outcome With surgical treatment. A review of the relevant literature is also presented.     

Esophagobronchial fistula and bronchiectasis arising from traction diverticulosis

Bronchoesophageal fistulas associated with traction diverticula are exceptional. We presented a case of traction diverticulum that fistulized to the bronchial tree and resulted in segmentary bronchiectasis. We encountered a successful repair of esophagobronchial fistula communicated to esophageal diverticulum. To our knowledge, there is no reported case of traction diverticulosis causing esophagobronchial fistula and bronchiectasis in a similar fashion.     

Esophagobronchial Fistula Closure Using a Novel Endoscopic Over-the-Scope-Clip

We report on a patient who presented with a symptomatic esophagobronchial fistula arising from an esophageal diverticulum with recurrent pulmonary infections despite prophylactic antibiotics. She was not an optimal candidate for esophageal stenting, bronchial stenting, or surgery and had refused a gastrostomy tube placement. We performed a successful endoscopic fistula closure using a novel endoscopic over-the-scope-clip device providing an effective seal of the fistula with durable resolution of symptoms.     

颈椎前路内固定术后中远期食管并发症

 目的 探讨颈椎前路内固定术后中远期食管并发症的发生率及其诊疗策略。方法 对2001年1月至2011年12月2316例行颈椎前路内固定手术患者发生的中远期食管并发症情况进行回顾性分析。食管中远期并发症包括术后2周以上发生的食管穿孔、食管气管瘘、食管皮下瘘、食管憩室、食管胸膜瘘及食管狭窄等。结果 共4例患者发生中远期食管并发症,发生率为0.17%(４/２３1６),其中食管穿孔发生率为0.09%(2例)。病例1为31岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后7年发现食管憩室合并食管穿孔。手术取出内固定,清创后切除憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例2为46岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后3年发现食管憩室。手术取出内固定,切除食管憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例3为58岁女性患者,自体髂骨移植融合加钢板内固定(C6)术后5年出现食管憩室。手术取出内固定,切除食管憩室,胸锁乳突肌肌瓣修补食管。病例4为56岁女性患者,钛网植骨融合加钢板内固定(C6)术后3年出现食管穿孔。手术取出内固定,清创后胸锁乳突肌肌瓣修补食管。4例患者术后食管并发症均获得成功治疗,恢复良好。结论 颈椎前路内固定术后中远期食管并发症的发生率较低,X线片、消化道造影及消化道内镜检查是主要的诊断方法,手术是其主要的治疗手段。     

Secondary esophageal surgery following repair of esophageal atresia with distal tracheoesophageal fistula

During the period 1948 through 1988, 498 patients with esophageal atresia and distal tracheoesophageal fistula were admitted to the Royal Children's Hospital, Melbourne. Fifty patients had a second operative procedure on the esophagus, for anastomotic stricture (30), recurrent fistula (15), both (4), and a postmyotomy diverticulum (1). During the same period, nine patients underwent esophageal replacement and 33 patients a Nissen fundoplication. Improvements in the technique of esophageal anastomosis, and in recent years the use of fundoplication to correct gastroesophageal reflux have led to a marked reduction in the need for secondary surgery to the esophagus after repair of esophageal atresia. Esophageal replacement is rarely required in esophageal atresia and distal tracheoesophageal fistula. One-layer end-to-end esophageal anastomosis using interrupted sutures resulted in the lowest rate of recurrent fistula and anastomotic stricture.     

Congenital esophago-bronchial fistula in the adult--a case report

A very rare case of congenital esophago-bronchial fistula in the adult is reported. Sixty-five years old, female. Complaining cough at drinking water and epigastric pain was diagnosed as esophago-bronchial fistula with esophageal diverticulum by Barium swallow and esophagoscopy. The resection of the fistula and diverticulum and the repair were carried out with smooth postoperative course. No evidence of inflammation along the fistula was demonstrated at surgery and microscopic findings of the resected material revealed the direct communication from the squamous epithelium to the cuboidal epithelium with underlying muscle layer in the wall. These results suggested this case the congenital esophago-bronchial fistula (Braimbridge type I).     

非恶性食管-气管/支气管瘘的外科治疗

目的探讨非恶性食管-气管/支气管瘘的临床特点和处理方法。方法回顾性分析2002年1月至2011年10月北京协和医院收治12例非恶性食管-气管/支气管瘘患者的临床资料,其中男6例,女6例;平均年龄49.8(32～72)岁。食管气管瘘7例,食管支气管瘘1例,食管癌术后胸胃支气管瘘2例,食管憩室支气管瘘2例。右侧开胸入路9例,左侧开胸3例。行食管瘘、气管瘘修补7例;食管瘘、支气管瘘修补1例;胸胃瘘、支气管瘘修补术2例;食管下段、左肺下叶切除,食管胃弓下吻合术1例;左肺下叶切除,食管憩室瘘修补术1例。结果全部患者均顺利恢复,无手术合并症或死亡,7～10 d恢复经口进食。术后3个月～1年内复查纤维支气管镜及上消化道造影,无气管支气管狭窄,无食管狭窄,不必采用支架或扩张治疗。术后随诊3个月～10年,均恢复良好。结论食管-气管/支气管瘘排除恶性病因,明确瘘口位置,术前给予充分营养支持,手术Ⅰ期修补瘘口,可以获得良好的治疗效果。     

Acquired benign esophagorespiratory fistula: report of 16 consecutive cases

Sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20-year period. A delay in diagnosis was usual, and most patients were first seen with a pulmonary infection already developed. Contrast esophageal x-ray studies established the diagnosis in all patients. There were seven esophagotracheal and nine esophagobronchial fistulas. A fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients. A fistula as the consequence of trauma developed in 9 patients, and these fistulas were situated at a higher level of the respiratory tree. All patients underwent surgical treatment; in 12 it was definitive, and in 4 temporary gastrostomy was performed to improve nutrition before definite repair. The definitive repair consisted of eventual diverticulectomy, division of the fistula, and suture of both esophageal and respiratory defects. Two patients required esophageal resection and later reconstruction with colon interposition. One patient died, creating an operative mortality of 8.3% in the definitive-repair group. The remaining 11 patients had a gratifying long-term result. There were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection. Early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided. Early direct repair gives excellent results.     

食管癌食管支气管瘘的外科治疗

目的总结外科治疗食管癌食管支气管瘘的技术特点和经验,探讨安全、有效的治疗方案。方法回顾性总结第四军医大学唐都医院2007年1月至2010年11月收治12例食管癌食管支气管瘘患者的临床资料,男9例,女3例;年龄37～62岁,平均年龄51.24岁。根据不同病情,12例患者分别采取4种手术方式治疗食管支气管瘘(:1)食管部分切除+食管胃隧道式吻合术+肺叶切除术2例;(2)食管部分切除+食管胃器械吻合术+肺叶切除术5例;(3)食管部分切除+结肠代食管术+肺叶切除术4例;(4)食管部分切除+食管胃吻合术+左全肺切除术1例。结果围手术期死亡2例,病死率为16.67%(2/12),其中1例为食管癌侵及左肺下叶支气管,行食管部分切除+食管胃隧道式吻合术+左肺下叶切除术后第4 d死于心力衰竭;另1例为食管癌侵及左肺上叶支气管行食管部分切除+食管胃器械吻合术+左肺上叶切除术后第11 d死于重症感染伴肾功能衰竭。术后并发轻度脓胸4例,总并发症发生率为41.67%(5/12),并发支气管吻合口瘘1例,经抗感染、引流等治疗后愈合出院。随访1个月～3年,死亡1例;其余患者未出现明显并发症,无死亡。结论依据患者的病情,选择个体化手术方式,是临床治疗食管癌食管支气管瘘患者安全有效的治疗方案。     

Esophageal diverticulum in an infant with Down's syndrome and type III esophageal atresia

An 18-month-old infant with Down's syndrome presented with a symptomatic esophageal diverticulum (ED) located at the cervical esophagus. He had been operated on successfully for an esophageal atresia and distal tracheoesophageal fistula in the newborn period. Neither surgical maneuvers nor esophageal trauma could explain the ED, which was resected through a cervical approach.     

Carcinoma within a middle esophageal (parabronchial) diverticulum: A case report and the review of the literature

A case of carcinoma developed in the middle esophageal (parabronchial) diverticulum is reported. In recent literature, 44 cases of carcinoma in esophageal diverticulum were reported. Most of the patients who had carcinoma in a diverticulum have a long-term history of symptom related to diverticula. Prognosis of these patients was poor because the carcinomas were far advanced when they were found. Therefore, the patient with esophageal diverticulum should be checked with esophagogram, esophagoscopy and biopsy, considering the possibility of development of carcinoma. Most of the cases of carcinoma in a diverticulum were treated with diverticulectomy. However, we consider that radical esophagectomy is a better method of treatment.     

Benign acquired bronchoesophageal fistula in an adult

A 45-year-old woman was admitted to our hospital with a diagnosis of bronchoesophageal fistula, after a barium esophagography performed in an annual medical check-up had demonstrated an esophageal diverticulum in the middle of the thoracic esophagus, having a narrow bridge between the right intermediate bronchi. The patient had a history of tuberculosis in her childhood, and chest radiography showed multiple calcified hilar lymph nodes. The fistula was observed on gastroenteroscopy and on bronchofiberscopy. The patient was treated surgically, with ligation and resection of the fistula. The fistulous tract was attached to a calcified hilar lymph node, and both the diverticulum and fistula were concluded to have been caused by the tuberculous lymphadenitis in her childhood. It is very uncommon to have bronchoesophageal fistula, caused by tuberculosis in childhood, diagnosed and treated surgically at more than forty years later.     

Distal congenital esophageal stenosis associated with esophageal atresia

A series of six patients with congenital esophageal stenosis associated with esophageal atresia (EA) and distal tracheoesophageal fistula is presented. Three patients required only repeated dilatations, and have had good results. Two patients required limited resections of the distal esophagus, with excellent results. One patient died following a Heller myotomy. Tracheobronchial rests were present in the distal esophagus in the latter three patients. Diagnosis of congenital distal esophageal stenosis following repair of EA requires a high index of suspicion and a careful review of previous esophagrams. It is important to exclude anastomotic stricture and stenosis associated with gastroesophageal reflux. This requires barium esophagram, esophagoscopy with biopsy, and esophageal pH monitoring. Once a congenital basis for distal esophageal stenosis is suspected, management consists of dilatation by bouginage followed by balloon dilatation. Resection is reserved for persistent stenoses from tracheobronchial rests, which usually do not respond to dilatations.     

<Emphasis Type="Italic">Candida</Emphasis> esophagitis complicated by an esophago-airway fistula: Report of a case

Candida esophagitis rarely involves life-threatening complications, such as necrosis, perforation, or fistula formation between the esophagus and the airway. We herein report a case of Candida esophagitis complicated by esophagobronchial and esophagopulmonary fistulas. The patient in our study was a 70-year-old man with a 3-month history of dysphagia. Based on endoscopy and histological findings, he was diagnosed with a coinfection of Candida spp. and herpes simplex virus. Antifungal and antiviral therapy was administered without success. The esophagopulmonary fistula formation and a lung abscess were identified 7 months later. The patient was deemed intolerable to an esophagectomy due to his poor general condition, thus necessitating a two-stage operation. A cervical esophagostomy and a tube drainage of the thoracic esophagus were followed by an esophageal bypass using the pedicled jejunum via an antethoracic route. Although the lung abscess resolved, the inflammation of the esophagus persisted. A fistula between the esophagus and the left main bronchus eventually formed postoperatively and the patient died due to respiratory failure.     

A case of congenital esophago-bronchial fistula communicated between esophageal diverticulum and left main bronchus in the adult--a review of 47 cases in the Japanese literature]

We experienced a successful repair of congenital esophago-bronchial fistula communicated between esophageal diverticulum and left main bronchus in adult case. The patient was a 60-year-old female. She had much wet cough on taking meals since 10 years ago. At the mass screening, a esophago-bronchial fistula was detected by upper GI series. Barium esophagography revealed a fistula between esophageal diverticulum and left main bronchus. The resection of diverticulum and fistula were undergone. In the operation, there exited no adhesion or inflammation around the fistula, therefore it was easy to isorate from the surrounding tissues. This case was categorized as Brainbridge type I esophago-bronchial fistula communicated to left main bronchus. Forty-six cases of congenital esophago-bronchial fistula with diverticulum were reported in Japan, but no cases which communicated with left main bronchus were reported. Then it is assumed that this is the first case in Japan.     

Successful application of an omental pedicle flap in delayed repair of a perforated esophageal diverticulum: Report of a case

Mediastinitis resulting from a perforated esophageal diverticulum is a potentially fatal complication and the surgical treatment of persistent esophagomediastinal fistula may be difficult. In this report, we describe the successful application of an omental pedicle flap in the delayed repair of a perforated esophageal diverticulum. A 53-year-old man presented with chest and back pain and a diagnosis of perforated esophageal diverticulum was subsequently confirmed. After receiving conservative treatment, he was referred to our department and underwent surgical repair 6 months following the onset of the perforation. Through a right thoracotomy, the mucosal layer of the esophagus around the diverticulum was sutured, and an omental pedicle flap was used to cover the suture line and obliterate the fistulous tract. His postoperative course was uneventful and the suture line healed well. The successful treatment of this patient reinforces our belief that wider application of the omental pedicle flap can be expected in the field of thoracic surgery.     

Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft: report of 44 patients

Results with the use of a diaphragmatic graft in the surgical relief of achalasia are reported for 44 patients. The operative technique involves construction of a pedicle flap of diaphragm the size of the muscular defect on the lower segment of the esophagus and suture of the transplanted diaphragmatic pedicle to the site of the esophageal muscular defect. Immediate operative results were good; there was only one complication, a case of pneumonia that was cured. Patients were followed from 3 months to 19 years. Two patients were lost to follow-up. Excellent results were obtained in 39 patients; 3 patients still had nausea and heartburn, but were better than before operation. This procedure has three advantages: (1) it prevents occurrence of fistula and diverticulum at the site of the esophageal muscular defect; (2) it effectively eliminates formation of restenosis due to scar and reflux esophagitis; and (3) it allows the cardia to recover its normal function and the esophagus to return to normal size at the site of operation.     

Sealing of a tracheoesophageal fistula using a Sengstaken-Blakemore tube for mechanical ventilation during general anesthesia

A 78-yr-old man was admitted to our hospital because of repeated episodes of pneumonia. Both fiberoptic bronchoscopy and esophagoscopy revealed a large tracheoesophageal fistula and protrusion of the metal stent from the esophagus into the trachea. Placement of a Dumon stent was planned for sealing this fistula under general anesthesia. Anesthetic management is difficult because of the care needed to prevent aspiration of esophageal contents and diversion of oxygen through the fistula into the stomach from the trachea when patients are under mechanical ventilation. Our method of sealing a large tracheoesophageal fistula with a Sengstaken-Blakemore tube was performed successfully.     

Diverticulum of the midthoracic esophagus: pathogenesis and surgical treatment

Midthoracic esophageal diverticula represent 15% of all esophageal diverticula. Gastrointestinal endoscopy, barium swallow, esophageal manometry (indispensable for detecting any motor alterations often at the root of the pathogenesis of the diverticulum and for selecting the best surgical option), and 24-h pHmetry are the correct examinations to perform. Simple diverticulectomy performed via thoracoscopy can be sufficient for small diverticula without associated motor alterations. In other cases, it is best to combine diverticulectomy with a longitudinal extramucous myotomy extending at least 3 or 4 cm above and below the neck of the diverticulum or to the entire esophageal body for diffuse esophageal spasm. We report the case of a 67-year-old male patient with a sacciform diverticulum at the mid-third on the anterior wall of the thoracic esophagus. Manometric examination showed peristaltic waves with an amplitude and duration that were above normal at the inferior third of the esophagus. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) were essentially normal. The diagnosis was pulsion-type midthoracic esophageal diverticulum. We performed a diverticulectomy with endoGIA via right thoracoscopy and extramucous myotomy extended from the upper margin of the diverticulum to the esophageal inlet in the hiatus, corresponding to the area showing motor alteration. After 3 months, the patient reported complete remission of symptoms and had gained 4 kg. Radiography of the digestive tube showed a normal transit at the distal esophagus. Manometric follow-up revealed the presence of peristaltic waves with a normal amplitude and duration along the entire esophagus.