ABSTRACT
Tracheoesophageal fistulas are uncommon and present diverse etiologies, among
which is burning of the esophagus due to caustic ingestion. Herein, 🌞 we report the case
of a 27-year-old male patient having ingested a caustic substance 14 days prior and
presenting burning 🌞 retrosternal pain, weakness, productive cough with purulent sputum
and dyspnea accompanied by hoarseness for the preceding 24 h. Endoscopy of 🌞 the upper
digestive tract revealed a tracheoesophageal fistula. Treatment consisted of cervical
exclusion of the esophageal transit, together with gastrostomy. 🌞 Subsequently, the
nutrient transit was reconstructed through pharyngocoloplasty. The postoperative
evolution was favorable.
Keywords: Tracheoesophageal fistula/etiology;
Tracheoesophageal fistula/surgery; Esophageal perforation/chemically induced;
🌞 Colon/surgery
RESUMO
As fístulas esôfago-traqueais são incomuns e apresentam diversas
etiologias, entre elas, a queimadura química esofágica devida à ingestão cáustica.
Relatamos 🌞 o caso de um paciente de 27 anos com história de ingestão cáustica havia
catorze dias, com dor retroesternal em 🌞 betfair big brother brasil queimação, fraqueza, tosse com escarro
purulento e dispnéia associada à rouquidão no último dia. A endoscopia digestiva alta e
🌞 a broncofibroscopia revelaram fístula esôfago-traqueal. O tratamento consistiu no
suporte clínico, drenagem torácica bilateral, exclusão do transito esofágico com
esofagostomia 🌞 cervical terminal e gastrostomia. Houve cicatrização espontânea da
fístula esôfago traqueal em betfair big brother brasil seis semanas. Posteriormente, realizou-se a
reconstrução do 🌞 trânsito alimentar através de faringocoloplastia. A evolução
pós-operatória foi satisfatória.
Palavras-chave: Fístula traqueoesofágica/etiologia;
Fístula traqueoesofágica/cirurgia;Perfuração esofágica/induzido quimicamente;
Cólon/cirurgia.
The ingestion of caustic 🌞 or corrosive substances remains a cause for
concern in the field of pulmonology due to the severity of the cases. 🌞 These substances
are readily available, since they are present in various cleaning products. Therefore,
ingestion (accidental or intentional) of such 🌞 substances occurs frequently.(1-3)In
children, accidental ingestion prevails, whereas voluntary ingestion (with suicidal
intent) is more common in adults.(1,2) Alkalis are 🌞 the substances most frequently
ingested, caustic soda (sodium hydroxide) being the principal agent.(1-4)Chief among
the acute complications of caustic ingestion 🌞 are gastric hemorrhage, esophageal
perforation, gastrocolic fistula, esophageal-aortic fistula, and tracheoesophageal
fistula (TEF).(1,2) The principal late complication is esophageal stenosis.(1-3,5)We
🌞 report the case of a patient with TEF caused by caustic ingestion. The patient was
treated for this clinical condition 🌞 and later underwent reconstruction of the gastric
transit through pharyngocoloplasty. Since TEFs are uncommon, their surgical management
is still the 🌞 source of controversy in the international literature.(6,7) In this
context, we address the peculiarities of TEFs, as well as their 🌞 treatment, since they
constitute severe clinical situations presenting high rates of morbidity and
mortality.A 27-year-old male patient, native to and 🌞 resident of the city of Conceição
das Alagoas, located in the state of Minas Gerais, sought treatment in the emergency
🌞 room 14 days after having ingested a caustic substance. He presented dysphagia for
solid and semi-solid foods, odynophagia, and burning 🌞 retrosternal pain for 3 days,
without improvement. He presented undetermined fever during the preceding 24 h,
together with weakness, productive 🌞 cough with purulent sputum, and dyspnea accompanied
by hoarseness. The patient described himself as a nonsmoker and nondrinker. He also
🌞 stated that he had never undergone surgery.His overall health status was regular,
although he was emaciated. He presented tachypnea, dyspnea, 🌞 fever (38.9 °C),
dehydration and intense sialorrhea. Physical examination revealed limited chest
expansion and reduced breath sounds in the left 🌞 hemithorax, as well as bilateral
diffuse rhonchi. There were no cardiovascular and abdominal alterations.Laboratory
tests revealed discrete anemia (hemoglobin 11.8 🌞 g/dl), leukocytosis (18,500
leukocytes/mm3, with 8% rods), discrete electrolyte disturbance and hypoalbuminemia
(2.2 g/dl). A chest X ray showed a 🌞 small pneumothorax, left pulmonary consolidation and
mediastinum deviation to the left.We performed upper digestive endoscopy, which
revealed a large fistula 🌞 between the esophagus and the left bronchus, although the
device passed without difficulty (Zagar class 3b(8)). The esophageal mucosa was 🌞 friable
with intense deposits of fibrin. A nasogastric tube was positioned in the second
portion of the duodenum (Figure 1).The 🌞 control chest X ray, after upper digestive
endoscopy, revealed left pneumothorax. Left thoracic drainage was performed with
immediate lung re-expansion. 🌞 In the fiberoptic bronchoscopy, we observed an area of
destruction of the distal trachea, carina and left bronchus of approximately 🌞 3 x 1.5 cm
(Figures 2 and 3), as well as exposure of the mediastinal tissue, together with
de-epithelization and 🌞 retraction of the epiglottis and right vocal chord.Due to the
poor clinical condition of the patient and the severity of 🌞 the lesions found, we chose
to perform terminal cervical esophagostomy and gastrostomy. We used a combination of
broad spectrum antibiotic 🌞 therapy, central venous access, correction of the electrolyte
disturbance, respiratory therapy and psychological support.The patient presented
favorable evolution, being discharged 🌞 17 days after admission. Two months after
discharge, he presented to the emergency room with progressive dyspnea for 10 days,
🌞 together with intense intercostal wheezing and retractions. The fiberoptic bronchoscopy
revealed supraglottic stenosis (annular neoformation of the fibrotic tissue), and
🌞 tracheostomy was indicated. He was monitored as an outpatient, and, six months after
the caustic ingestion, a palatopharyngoplasty was performed, 🌞 and the tracheostomy was
deactivated.Eight months after his first admission, the patient was hospitalized (for
better nutritional preparation), and the 🌞 reconstruction of the gastric transit was
scheduled. We performed pharyngocoloplasty with retrosternal interposition of the
transverse colon and posterior pharyngocolic 🌞 anastomosis. The patient presented
considerable improvement, was discharged on postoperative day 12 and was in outpatient
treatment for 28 months, 🌞 presenting favorable clinical evolution.Acquired TEF can have
various etiologies, malignant neoplasms of the esophagus being the most common.(7)
Among the 🌞 benign TEFs, ischemia and posterior necrosis of the tracheal and esophageal
membrane, due to the tracheal and gastric tube cuffs 🌞 seen in individuals on prolonged
mechanical ventilation, are the most common etiologies.(6,9) Less common etiologies
include foreign bodies, instrumental esophageal 🌞 dilation, esophageal diverticulum
perforation, mediastinal abscesses, thoracic trauma (open or closed) and chemical burns
in the esophagus.(6,7,9)In the TEFs resulting 🌞 from caustic ingestion, the necrosis
caused by the extent of the chemical burning of the esophagus seems to be the 🌞 main
pathophysiological factor.(4) Due to the etiological diversity and the low frequency of
TEFs, there is no consensus in the 🌞 literature regarding the ideal treatment of this
clinical condition and the proposed treatments are various.(6,7,9-11)Some authors(6)
studied 31 patients with 🌞 benign TEFs and found that the majority of cases were due to
complication of endotracheal intubation. The authors treated all 🌞 of the patients
through left cervical incision involving suture of the tracheal and esophageal defect
with interposition of the sternocleidomastoid 🌞 muscle flap between the two organs. The
results were positive.Other authors(7) reported their experience in the treatment of 41
patients 🌞 with congenital and acquired (benign and malignant) TEFs, in which 11 patients
presented TEFs due to malignant neoplasms, 7 due 🌞 to tracheoesophageal trauma, 5 due to
chemical burns, 4 due to congenital disorders and the rest due to other etiologies. 🌞 The
proposed surgical treatment was fistulectomy involving the correction (suture) of the
esophageal and tracheal defects (especially in the cases 🌞 of posttraumatic TEF cases) or
the creation of an artificial esophagus through the transposition of the jejunal loop
or colon. 🌞 The latter was reserved only for cases of extensive esophageal chemical
burning with great inflammation and fibrosis of adjacent tissues. 🌞 In the cases of TEF
due to malignant neoplasms, the principal treatment, as a palliative measure, was
gastrostomy.Some authors(4) described 🌞 their own surgical technique in the treatment of
TEF due to caustic ingestion. They proposed esophagectomy in which a pulmonary 🌞 lobe
patch is used in order to obliterate the lesion of the trachea or bronchus, with
subsequent reconstruction of the 🌞 gastric transit through retrosternal interposition of
the ileocolic segment.Regarding the reconstruction of the gastric transit in patients
with esophagus stenosis, 🌞 the use of the colon as transposed viscera is well established
in the literature. In more severe caustic stenoses, in 🌞 which not only the esophagus but
also the pharynx is affected, the colon is also the organ of choice.(14)The author 🌞 of
one study(14) demonstrated that pharyngocoloplasty with posterior pharyngocolic
anastomosis, in the treatment of caustic stenosis of the esophagus and 🌞 pharynx,
presents favorable results, low mortality (null index in the sample studied) and
postoperative complications with few overall repercussions (cervical 🌞 fistula in 5% of
the cases).We conclude that the appropriate treatment of TEF is fundamental to
obtaining satisfactory results. The 🌞 technique employed in the therapeutic management of
our patient proved to be an effective and safe alternative. Although this is 🌞 the
description of only one case, we found it important to report it, because the
complications of caustic accidents, especially 🌞 TEFs, are uncommon, represent complex,
difficult to treat cases and require protracted treatment, as well as demanding
integrated and multidisciplinary 🌞 approaches.1. Corsi PR, Hoyos MBL, Rasslan S, Viana
AT, Gagliardi D. Lesäo aguda esôfago-gástrica causada por agente químico. Rev Assoc 🌞 Med
Brás. 2000;46(2):98-105.2. Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J
Clin Gastroenterol 2003;37(2):119-24.3. Andreollo NA, Lopes LR, Tercioti 🌞 Júnior V,
Brandalise NA, Leonardi LS. Esôfago de Barret associado à estenose cáustica do esôfago.
Arq Gastroenterol. 2003;40(3):148-51.4. Sarfati E, 🌞 Jacob L, Servant JM, d'Acremont B,
Roland E, Ghidalia T, Celerier M. Tracheobronchial necrosis after caustic ingestion. J
Thorac Cardiovasc 🌞 Surg. 1992;103(3):412-3.5. Mamede RC, Mello Filho FV. Ingestion of
caustic substances and its complications. São Paulo Med J. 2001;119(1):10-5.6. Baisi 🌞 A,
Bonavina L, Narne S, Peracchia A. Benign tracheoesophageal fistula: results of surgical
therapy. Dis Esophagus. 1999;12(3):209-11.7. Gudovsky LM, Koroleva 🌞 NS, Biryukov YB,
Chernousov AF, Perelman MI. Tracheoesophageal fistulas. Ann Thorac Surg.
1993;55(4):868-75.8. Zagar ZA, Kochjar R, Mehta S, Mehta 🌞 SK. The role of endoscopy in
the management of corrosive ingestion and modified endoscopic classification of burns.
Gastrointest Endosc. 1991;37(2):165-9.9. 🌞 Gerzic Z, Rakic S, Randjelovic T. Acquired
benign esophagorespiratory fistula: report of 16 consecutive cases. Ann Thorac Surg.
1990;50(5):724-7.10. Hosoya 🌞 Y, Yokoyama T, Arai W, Hyodo M, Nishino H, Sugawara Y, et
al. Tracheoesophageal fistula secondary to chemotherapy for malignant 🌞 B-cell lymphoma
of the thyroid: successful surgical treatment with jejunal interposition and mesenteric
patch. Dis Esophagus. 2004;17(3):266-9.11. Bardini R, Radicchi 🌞 V, Parimbelli P, Tosato
SM, Narne S. Repair of a recurrent benign Tracheoesophageal fistula with a Gore-Tex
membrane. Ann Thorac 🌞 Surg. 2003;76(1):304-6.12. Ergün O, Celik A, Mutaf O. Two-stage
coloesophagoplasty in children with caustic burns of the esophagus: hemodynamic basis
🌞 of delayed cervical anastomosis--theory and fact. J Pediatr Surg. 2004;39(4):545-8.13.
Miranda MP, Genzini T, Ribeiro MA, Crescentini F, Faria JCM. 🌞 Emprego de anastomose
vascular microcirúrgica para incremento do fluxo sanguíneo na esofagocoloplastia. An
Paul Med Cir. 2000;127(1):142-6.14. Cecconello I. Faringocoloplastia 🌞 no tratamento da
estenose caustica do esôfago e da faringe [tese]. São Paulo: Faculdade de Medicina da
Universidade de Sao 🌞 Paulo; 1989.*Study carried out at the Universidade Federal do
Triângulo Mineiro (UFTM, Federal University of Triângulo Mineiro) - Uberaba (MG)
🌞 Brazil.1. PhD, Full Professor in the Department of Surgical Gastroenterology at the the
Universidade Federal do Triângulo Mineiro (UFTM, Federal 🌞 University of Triângulo
Mineiro) - Uberaba (MG) Brazil.2. Adjunct Professor, Chief of the Department of
Thoracic Surgery at the Universidade 🌞 Federal do Triângulo Mineiro (UFTM, Federal
University of Triângulo Mineiro) - Uberaba (MG) Brazil.3. Degree in Medicine from the
Universidade 🌞 Federal do Triângulo Mineiro (UFTM, Federal University of Triângulo
Mineiro) - Uberaba (MG) Brazil.4. PhD, Adjunct Professor in the Surgical 🌞 Techniques and
Experimental Surgery Department at the Universidade Federal do Triângulo Mineiro (UFTM,
Federal University of Triângulo Mineiro) - Uberaba 🌞 (MG) Brazil.5. PhD, Adjunct
Professor, Chief of the Department of Surgical Gastroenterology at the Universidade
Federal do Triângulo Mineiro (UFTM, 🌞 Federal University of Triângulo Mineiro) - Uberaba
(MG), Brazil.Correspondence to: Marcelo Cunha Fatureto. Departamento de Cirurgia da
UFTM. Av. Getúlio 🌞 Guaritá, s/n, CEP 38025-440, Uberaba, MG, Brazil. Phone 55 34
3332-2155. E-mail: cremauftm@mednet/mfat@terraSubmitted: 16/12/05. Accepted, after
review: 13/3/06.
