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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,?? 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 f�stulas es�fago-traqueais s�o incomuns e apresentam diversas
etiologias, entre elas, a queimadura qu�mica esof�gica devida � ingest�o c�ustica.
Relatamos?? o caso de um paciente de 27 anos com hist�ria de ingest�o c�ustica havia
catorze dias, com dor retroesternal em?? link f12 bet queima��o, fraqueza, tosse com escarro
purulento e dispn�ia associada � rouquid�o no �ltimo dia. A endoscopia digestiva alta e
?? a broncofibroscopia revelaram f�stula es�fago-traqueal. O tratamento consistiu no
suporte cl�nico, drenagem tor�cica bilateral, exclus�o do transito esof�gico com
esofagostomia?? cervical terminal e gastrostomia. Houve cicatriza��o espont�nea da
f�stula es�fago traqueal em link f12 bet seis semanas. Posteriormente, realizou-se a
reconstru��o do?? tr�nsito alimentar atrav�s de faringocoloplastia. A evolu��o
p�s-operat�ria foi satisfat�ria.
Palavras-chave: F�stula traqueoesof�gica/etiologia;
F�stula traqueoesof�gica/cirurgia;Perfura��o esof�gica/induzido quimicamente;
C�lon/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 Concei��o
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. Les�o aguda es�fago-g�strica causada por agente qu�mico. Rev Assoc?? Med
Br�s. 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?? J�nior V,
Brandalise NA, Leonardi LS. Es�fago de Barret associado � estenose c�ustica do es�fago.
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. S�o 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. Erg�n 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 microcir�rgica para incremento do fluxo sangu�neo na esofagocoloplastia. An
Paul Med Cir. 2000;127(1):142-6.14. Cecconello I. Faringocoloplastia?? no tratamento da
estenose caustica do es�fago e da faringe [tese]. S�o Paulo: Faculdade de Medicina da
Universidade de Sao?? Paulo; 1989.*Study carried out at the Universidade Federal do
Tri�ngulo Mineiro (UFTM, Federal University of Tri�ngulo Mineiro) - Uberaba (MG)
?? Brazil.1. PhD, Full Professor in the Department of Surgical Gastroenterology at the the
Universidade Federal do Tri�ngulo Mineiro (UFTM, Federal?? University of Tri�ngulo
Mineiro) - Uberaba (MG) Brazil.2. Adjunct Professor, Chief of the Department of
Thoracic Surgery at the Universidade?? Federal do Tri�ngulo Mineiro (UFTM, Federal
University of Tri�ngulo Mineiro) - Uberaba (MG) Brazil.3. Degree in Medicine from the
Universidade?? Federal do Tri�ngulo Mineiro (UFTM, Federal University of Tri�ngulo
Mineiro) - Uberaba (MG) Brazil.4. PhD, Adjunct Professor in the Surgical?? Techniques and
Experimental Surgery Department at the Universidade Federal do Tri�ngulo Mineiro (UFTM,
Federal University of Tri�ngulo Mineiro) - Uberaba?? (MG) Brazil.5. PhD, Adjunct
Professor, Chief of the Department of Surgical Gastroenterology at the Universidade
Federal do Tri�ngulo Mineiro (UFTM,?? Federal University of Tri�ngulo Mineiro) - Uberaba
(MG), Brazil.Correspondence to: Marcelo Cunha Fatureto. Departamento de Cirurgia da
UFTM. Av. Get�lio?? Guarit�, 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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