Asian Cardiovasc Thorac Ann 2002;10:349-350
© 2002 Asia Publishing EXchange Pte Ltd
Acquired Tracheoesophageal Fistula Following Blunt Trauma to the Chest
Bambarawane LA Karunaratne, FRCS,
Panini A Gooneratne, FRCS,
Savitri Wijesekara, FRCA,
Gamini Goonetilleke, FRCS
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Cardiothoracic Surgery Unit Sri Jayawardenepura General Hospital Nugegoda, Sri Lanka
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For reprint information contact: Bambarawane LA Karunaratne, FRCS Tel: 44 29 2074 4620 Fax: 44 29 2074 5439 email: blakaru{at}hotmail.com SHO Cardiothoracic Surgery, Cardiothoracic Surgery Unit, Ward C5, University Hospital of Wales, Heath Park Cardiff CF 14 4 XW, UK.
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ABSTRACT
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Tracheoesophageal fistula following blunt chest trauma is rare. Typically the patient is a young male with an elastic chest wall who is involved in a motor vehicle accident. In this case the victim was a motorcyclist who collided with a stationary lorry. He underwent surgery 4 weeks after the injury made an uncomplicated recovery.
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INTRODUCTION
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Although the incidence and severity of blunt chest trauma from vehicular accidents have increased, tracheoesophageal fistula (TEF) following such injury is rare. Its diagnosis needs anticipation of its occurrence, and surgical repair is required.
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CASE REPORT
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A 27-year-old male motorcyclist who collided with a stationary lorry was admitted to the accident and emergency unit. Bruising over the right clavicle was seen, and a chest radiograph revealed a fracture in the right clavicle. No mediastinal widening, emphysema, or pneumothorax was noted. He was discharged the next day in the absence of symptoms or signs other than the occasional dry cough. On day 4, the cough became productive with copious amounts of sputum, which was blood stained at times. On day 9, he was admitted with fever, weight loss, dysphagia, and coughing on ingestion. The chest radiograph showed bilateral fluffy shadows in the lungs suggestive of bronchopneumonia, and intravenous broad-spectrum antibiotics were administered. Dysphagia and the likelihood of aspiration pneumonia suggested underlying esophageal pathology. Flexible upper gastrointestinal endoscopy revealed a passage between the esophagus and the trachea just above the carina, confirming a diagnosis of TEF (Figure 1A 
). The patient was nursed in a semirecumbent position and fed via a nasogastric tube. Respiratory tract infection was brought under control with antibiotics and chest physiotherapy.
The patient underwent surgery 27 days after the accident. Anesthesia was administered through a left-sided double-lumen endotracheal tube. Through a right posterolateral thoracotomy at the 4th intercostal space, the azygos vein was divided and the mediastinal pleura incised to expose the fistula. The fistula was isolated and divided. A rent 3.5 cm in length was seen in the membranous portion of the distal trachea. The esophagus at this level showed a rent 2.5 cm long. Care was taken to avoid damage to the blood supply of the trachea. The esophagus was repaired with single-layered interrupted 4/0 polypropylene sutures (Figure 1B 
). The tracheal lesion was repaired with a pedicled pleural flap sutured with 5/0 polypropylene as direct suturing would cause tension and narrowing. An airtight closure was obtained. The chest was closed after insertion of a drain into the pleural cavity. A draining gastrostomy and a feeding jejunostomy were created. The patient was extubated at the end of the operation.
Jejunostomy feeding was started the next day. A gastrograffin study done 10 days postoperatively showed healing of the esophagus with no leakage of contrast material. Oral feeding was started. The patient was discharged 14 days after surgery.
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DISCUSSION
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Considered a rarity, the exact incidence of TEF after blunt trauma is unknown.1 The most common cause is motor vehicle accidents, with the driver being thrown against the steering wheel in most instances. The mechanism most frequently proposed is that the trachea and esophagus are compressed between the sternum and the vertebrae at the moment of impact, resulting in immediate laceration of the membranous trachea, which seals off, and contusion of the anterior esophageal wall. The esophageal muscles split, causing interference to the mucosal blood supply and leading eventually to necrosis. In 3 to 5 days, a fistula is formed, most commonly at or just above the carina.1,2
Most patients become symptomatic within 10 days of injury. In a few, the onset is immediate. Coughing and choking after ingestion is considered a classic sign of TEF. Hemoptysis, increased tracheal secretions, copious production of sputum, dysphagia, hoarseness, and odynophagia are other symptoms. Subcutaneous air, pneumothorax, and pneumomediastinum are commonly found. Concomitant injuries include rib fractures, which are the most common, fracture of the sternum and/or clavicle, and aortic transection.3
Diagnosis of TEF may be confirmed by esophagography. The location and extent of the fistula can be determined by esophagoscopy and bronchoscopy. The limitations of these evaluations have to be considered. False negatives can occur. Detection of the odor of anesthetic gas mixture ejected through the fistula during esophagoscopy, detection of a positive pressure air leak from a nasogastric tube, and computed tomography are other diagnostic methods.1,2,4
Surgical repair should be carried out as soon as possible after diagnosis. Nonoperative management carries a high mortality of 80%, while operative mortality was only 9.3%.1 Stopping oral feeding and insertion of a large-bore nasogastric tube and another in the proximal esophagus to remove secretions are recommended.1 Hyperalimentation, feeding gastrostomy, and draining gastrostomy with a feeding jejunostomy have also been advocated for the preoperative to the early postoperative period.2,4–6
A right posterolateral thoracotomy through the 4th intercostal space with division of the azygos vein provides access to all levels of the esophagus and trachea. The esophageal perforation can be closed with single- or double-layered absorbable or nonabsorbable sutures. The tracheal lesion is closed with interrupted nonabsorbable or absorbable sutures. Interposition of pedicled pleural, pericardial, or intercostal muscle helps to prevent recurrence. The flap may be used as a patch in either the trachea or esophagus if insufficient tissue is available for direct closure. Leaving a small amount of esophageal mucosa when separating the fistula facilitates closure of the tracheal lesion and minimizes tracheal narrowing and late stricture formation.2,3
A high level of suspicion of TEF when treating victims of blunt chest trauma and prompt recognition and surgical intervention are essential for successful management.
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REFERENCES
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- Hilgenberg AD, Grillo HC. Acquired nonmalignant tracheoesophageal fistula. J Thorac Cardiovasc Surg
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J. M. O'Riordan, N. Hickey, O. Ilinski, P. Keeling, and T. N. Walsh
Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma
J. Thorac. Cardiovasc. Surg.,
December 1, 2006;
132(6):
1495 - 1496.
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