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ABSTRACT

Tracheoesophageal fistulas are uncommon and present diverse etiologies, among

which is burning of the esophagus due to caustic ingestion. Herein, 9️⃣ we report the case

of a 27-year-old male patient having ingested a caustic substance 14 days prior and

presenting burning 9️⃣ retrosternal pain, weakness, productive cough with purulent sputum

and dyspnea accompanied by hoarseness for the preceding 24 h. Endoscopy of 9️⃣ the upper

digestive tract revealed a tracheoesophageal fistula. Treatment consisted of cervical

exclusion of the esophageal transit, together with gastrostomy. 9️⃣ Subsequently, the

nutrient transit was reconstructed through pharyngocoloplasty. The postoperative

evolution was favorable.

Keywords: Tracheoesophageal fistula/etiology;

Tracheoesophageal fistula/surgery; Esophageal perforation/chemically induced;

9️⃣ Colon/surgery

RESUMO

As fístulas esôfago-traqueais são incomuns e apresentam diversas

etiologias, entre elas, a queimadura química esofágica devida à ingestão cáustica.

Relatamos 9️⃣ o caso de um paciente de 27 anos com história de ingestão cáustica havia

catorze dias, com dor retroesternal brazino jogos 9️⃣ brazino jogos queimação, fraqueza, tosse com escarro

purulento e dispnéia associada à rouquidão no último dia. A endoscopia digestiva alta e

9️⃣ a broncofibroscopia revelaram fístula esôfago-traqueal. O tratamento consistiu no

suporte clínico, drenagem torácica bilateral, exclusão do transito esofágico com

esofagostomia 9️⃣ cervical terminal e gastrostomia. Houve cicatrização espontânea da

fístula esôfago traqueal brazino jogos brazino jogos seis semanas. Posteriormente, realizou-se a

reconstrução do 9️⃣ 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 9️⃣ or corrosive substances remains a cause for

concern in the field of pulmonology due to the severity of the cases. 9️⃣ These substances

are readily available, since they are present in various cleaning products. Therefore,

ingestion (accidental or intentional) of such 9️⃣ 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 9️⃣ the substances most frequently

ingested, caustic soda (sodium hydroxide) being the principal agent.(1-4)Chief among

the acute complications of caustic ingestion 9️⃣ 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

9️⃣ report the case of a patient with TEF caused by caustic ingestion. The patient was

treated for this clinical condition 9️⃣ and later underwent reconstruction of the gastric

transit through pharyngocoloplasty. Since TEFs are uncommon, their surgical management

is still the 9️⃣ source of controversy in the international literature.(6,7) In this

context, we address the peculiarities of TEFs, as well as their 9️⃣ treatment, since they

constitute severe clinical situations presenting high rates of morbidity and

mortality.A 27-year-old male patient, native to and 9️⃣ resident of the city of Conceição

das Alagoas, located in the state of Minas Gerais, sought treatment in the emergency

9️⃣ room 14 days after having ingested a caustic substance. He presented dysphagia for

solid and semi-solid foods, odynophagia, and burning 9️⃣ retrosternal pain for 3 days,

without improvement. He presented undetermined fever during the preceding 24 h,

together with weakness, productive 9️⃣ cough with purulent sputum, and dyspnea accompanied

by hoarseness. The patient described himself as a nonsmoker and nondrinker. He also

9️⃣ stated that he had never undergone surgery.His overall health status was regular,

although he was emaciated. He presented tachypnea, dyspnea, 9️⃣ fever (38.9 °C),

dehydration and intense sialorrhea. Physical examination revealed limited chest

expansion and reduced breath sounds in the left 9️⃣ hemithorax, as well as bilateral

diffuse rhonchi. There were no cardiovascular and abdominal alterations.Laboratory

tests revealed discrete anemia (hemoglobin 11.8 9️⃣ 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 9️⃣ small pneumothorax, left pulmonary consolidation and

mediastinum deviation to the left.We performed upper digestive endoscopy, which

revealed a large fistula 9️⃣ between the esophagus and the left bronchus, although the

device passed without difficulty (Zagar class 3b(8)). The esophageal mucosa was 9️⃣ friable

with intense deposits of fibrin. A nasogastric tube was positioned in the second

portion of the duodenum (Figure 1).The 9️⃣ control chest X ray, after upper digestive

endoscopy, revealed left pneumothorax. Left thoracic drainage was performed with

immediate lung re-expansion. 9️⃣ In the fiberoptic bronchoscopy, we observed an area of

destruction of the distal trachea, carina and left bronchus of approximately 9️⃣ 3 x 1.5 cm

(Figures 2 and 3), as well as exposure of the mediastinal tissue, together with

de-epithelization and 9️⃣ retraction of the epiglottis and right vocal chord.Due to the

poor clinical condition of the patient and the severity of 9️⃣ the lesions found, we chose

to perform terminal cervical esophagostomy and gastrostomy. We used a combination of

broad spectrum antibiotic 9️⃣ therapy, central venous access, correction of the electrolyte

disturbance, respiratory therapy and psychological support.The patient presented

favorable evolution, being discharged 9️⃣ 17 days after admission. Two months after

discharge, he presented to the emergency room with progressive dyspnea for 10 days,

9️⃣ together with intense intercostal wheezing and retractions. The fiberoptic bronchoscopy

revealed supraglottic stenosis (annular neoformation of the fibrotic tissue), and

9️⃣ tracheostomy was indicated. He was monitored as an outpatient, and, six months after

the caustic ingestion, a palatopharyngoplasty was performed, 9️⃣ and the tracheostomy was

deactivated.Eight months after his first admission, the patient was hospitalized (for

better nutritional preparation), and the 9️⃣ reconstruction of the gastric transit was

scheduled. We performed pharyngocoloplasty with retrosternal interposition of the

transverse colon and posterior pharyngocolic 9️⃣ anastomosis. The patient presented

considerable improvement, was discharged on postoperative day 12 and was in outpatient

treatment for 28 months, 9️⃣ presenting favorable clinical evolution.Acquired TEF can have

various etiologies, malignant neoplasms of the esophagus being the most common.(7)

Among the 9️⃣ benign TEFs, ischemia and posterior necrosis of the tracheal and esophageal

membrane, due to the tracheal and gastric tube cuffs 9️⃣ seen in individuals on prolonged

mechanical ventilation, are the most common etiologies.(6,9) Less common etiologies

include foreign bodies, instrumental esophageal 9️⃣ dilation, esophageal diverticulum

perforation, mediastinal abscesses, thoracic trauma (open or closed) and chemical burns

in the esophagus.(6,7,9)In the TEFs resulting 9️⃣ from caustic ingestion, the necrosis

caused by the extent of the chemical burning of the esophagus seems to be the 9️⃣ main

pathophysiological factor.(4) Due to the etiological diversity and the low frequency of

TEFs, there is no consensus in the 9️⃣ 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 9️⃣ benign TEFs and found that the majority of cases were due to

complication of endotracheal intubation. The authors treated all 9️⃣ of the patients

through left cervical incision involving suture of the tracheal and esophageal defect

with interposition of the sternocleidomastoid 9️⃣ muscle flap between the two organs. The

results were positive.Other authors(7) reported their experience in the treatment of 41

patients 9️⃣ with congenital and acquired (benign and malignant) TEFs, in which 11 patients

presented TEFs due to malignant neoplasms, 7 due 9️⃣ to tracheoesophageal trauma, 5 due to

chemical burns, 4 due to congenital disorders and the rest due to other etiologies. 9️⃣ The

proposed surgical treatment was fistulectomy involving the correction (suture) of the

esophageal and tracheal defects (especially in the cases 9️⃣ of posttraumatic TEF cases) or

the creation of an artificial esophagus through the transposition of the jejunal loop

or colon. 9️⃣ The latter was reserved only for cases of extensive esophageal chemical

burning with great inflammation and fibrosis of adjacent tissues. 9️⃣ In the cases of TEF

due to malignant neoplasms, the principal treatment, as a palliative measure, was

gastrostomy.Some authors(4) described 9️⃣ their own surgical technique in the treatment of

TEF due to caustic ingestion. They proposed esophagectomy in which a pulmonary 9️⃣ lobe

patch is used in order to obliterate the lesion of the trachea or bronchus, with

subsequent reconstruction of the 9️⃣ gastric transit through retrosternal interposition of

the ileocolic segment.Regarding the reconstruction of the gastric transit in patients

with esophagus stenosis, 9️⃣ the use of the colon as transposed viscera is well established

in the literature. In more severe caustic stenoses, in 9️⃣ which not only the esophagus but

also the pharynx is affected, the colon is also the organ of choice.(14)The author 9️⃣ of

one study(14) demonstrated that pharyngocoloplasty with posterior pharyngocolic

anastomosis, in the treatment of caustic stenosis of the esophagus and 9️⃣ pharynx,

presents favorable results, low mortality (null index in the sample studied) and

postoperative complications with few overall repercussions (cervical 9️⃣ fistula in 5% of

the cases).We conclude that the appropriate treatment of TEF is fundamental to

obtaining satisfactory results. The 9️⃣ technique employed in the therapeutic management of

our patient proved to be an effective and safe alternative. Although this is 9️⃣ the

description of only one case, we found it important to report it, because the

complications of caustic accidents, especially 9️⃣ TEFs, are uncommon, represent complex,

difficult to treat cases and require protracted treatment, as well as demanding

integrated and multidisciplinary 9️⃣ approaches.1. Corsi PR, Hoyos MBL, Rasslan S, Viana

AT, Gagliardi D. Lesäo aguda esôfago-gástrica causada por agente químico. Rev Assoc 9️⃣ 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 9️⃣ 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, 9️⃣ Jacob L, Servant JM, d'Acremont B,

Roland E, Ghidalia T, Celerier M. Tracheobronchial necrosis after caustic ingestion. J

Thorac Cardiovasc 9️⃣ 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 9️⃣ 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 9️⃣ 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 9️⃣ 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. 9️⃣ 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 9️⃣ Y, Yokoyama T, Arai W, Hyodo M, Nishino H, Sugawara Y, et

al. Tracheoesophageal fistula secondary to chemotherapy for malignant 9️⃣ 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 9️⃣ V, Parimbelli P, Tosato

SM, Narne S. Repair of a recurrent benign Tracheoesophageal fistula with a Gore-Tex

membrane. Ann Thorac 9️⃣ 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

9️⃣ 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. 9️⃣ 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 9️⃣ no tratamento da

estenose caustica do esôfago e da faringe [tese]. São Paulo: Faculdade de Medicina da

Universidade de Sao 9️⃣ Paulo; 1989.*Study carried out at the Universidade Federal do

Triângulo Mineiro (UFTM, Federal University of Triângulo Mineiro) - Uberaba (MG)

9️⃣ Brazil.1. PhD, Full Professor in the Department of Surgical Gastroenterology at the the

Universidade Federal do Triângulo Mineiro (UFTM, Federal 9️⃣ University of Triângulo

Mineiro) - Uberaba (MG) Brazil.2. Adjunct Professor, Chief of the Department of

Thoracic Surgery at the Universidade 9️⃣ Federal do Triângulo Mineiro (UFTM, Federal

University of Triângulo Mineiro) - Uberaba (MG) Brazil.3. Degree in Medicine from the

Universidade 9️⃣ Federal do Triângulo Mineiro (UFTM, Federal University of Triângulo

Mineiro) - Uberaba (MG) Brazil.4. PhD, Adjunct Professor in the Surgical 9️⃣ Techniques and

Experimental Surgery Department at the Universidade Federal do Triângulo Mineiro (UFTM,

Federal University of Triângulo Mineiro) - Uberaba 9️⃣ (MG) Brazil.5. PhD, Adjunct

Professor, Chief of the Department of Surgical Gastroenterology at the Universidade

Federal do Triângulo Mineiro (UFTM, 9️⃣ Federal University of Triângulo Mineiro) - Uberaba

(MG), Brazil.Correspondence to: Marcelo Cunha Fatureto. Departamento de Cirurgia da

UFTM. Av. Getúlio 9️⃣ 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.

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