Ann Thorac Surg 2004;77:328-329
© 2004 The Society of Thoracic Surgeons
Case report
Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient
Ermanno Scappaticci, MDa,
Francesco Ardissone, MDc,
Sergio Baldi, MDa,
Francesco Coni, MDa,
Flavio Revello, MDa,
Pier Luigi Filosso, MDb,
Enrico Ruffini, MDb*
a Respiratory Diseases, Ospedale San Giovanni Battista, and University of Torino, Torino, Italy
b Thoracic Surgery, Ospedale San Giovanni Battista, and University of Torino, Torino, Italy
c Department of Thoracic Surgery, Ospedale S. Luigi Gonzaga, Orbassano, Italy
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Shiraishi, Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan 602-8566.
e-mail: isao{at}koto.kpu-m.ac.jp
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Abstract
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Management of acquired nonmalignant tracheo-esophageal fistula (TEF) in mechanically ventilated patients is controversial. Surgical correction is often contraindicated because the high operative risk and spontaneous closure is unlikely due to the positive pressure ventilation. We present a case of successful closure of an iatrogenic TEF in a mechanically ventilated patient with bronchoscopic application of fibrin glue. The technique may be proposed in high-risk patients as either an alternative to surgery or as a first-line attempt before surgical correction.
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Introduction
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Management of acquired nonmalignant tracheo-esophageal fistulas (TEF) in ventilated patients is controversial. Surgical closure is often contraindicated because of the associated operative risks, whereas the need for continuous mechanical ventilation in the postoperative period increases the risk of breakdown of the suture. On the other hand, spontaneous closure using conservative treatment is seldom reported in ventilated patients. Some authors recently reported satisfactory results with the use of expandable stents or endoscopic gluing, most in children [1–3]. We present a technique of closure of TEF in a mechanically ventilated adult patient with endoscopic gluing.
A 69-year old human with severe chronic obstructive lung disease presented with subcutaneous emphysema a few hours following endotracheal intubation for a neurologic accident. Bronchoscopy was performed and evidenced a 3-cm-long, 5-cm-wide fissuration, with two edematous mucosal flaps of the membranous portion of the trachea beginning 4 rings from the cricoid cartilage (Fig 1). At the distal end of the fissuration there was a small ( < 0.5 cm) TEF, confirmed by esophagoscopy, which showed a tiny mucosal bruise at 22 cm from the incisor teeth with bubbling of air into the lumen during forced ventilation.
Surgical correction was excluded due to the high operative risk. The anticipated prolonged ventilation led us to consider that a spontaneous closure would be unlikely because of the decubitus of the tube and its cuff on the tracheal lesion. Endoscopic gluing was therefore considered. The endotracheal tube was progressively retracted under bronchoscopic guidance up to the cricoid cartilage; a thin catheter (Bronchial Cytology Brushes Protection Catheter, 1.8 x 80 mm, Meditalia s.a.s., Italy) was advanced through the operative channel and positioned at the proximal end of the lesion. A total dose of 0.5 mL of Tissucol (Tissucol Immuno, Heidelberg, Germany)—slow solidification type—was gently spread on the tracheal fissuration. The original 8-mm endotracheal tube was then replaced with a smaller one (6.5 mm), which was cautiously advanced into the distal trachea with the intent to reduce the tracheal distension. Bronchoscopy after 24 hours showed a near complete approximation of the edges of the lesion with an apparent closure of the TEF. The patient had an uncomplicated recovery and was eventually extubated 10 days after the injury. On that occasion, endoscopic assessment showed complete healing of the trachea (Fig 2)
and esophagus.
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Comment
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In previous reports [4, 5] we have demonstrated that endoscopic gluing is a valid procedure for closure of postresectional bronchopleural fistulas. On the basis of these encouraging results, we applied the technique in the present case of TEF in a ventilated patient in whom surgery was contraindicated and spontaneous closure by conservative treatment was unlikely to occur.
According to our experience, the closure of the fistula by endoscopic gluing occurs very rapidly ( < 24 hours), resulting from both a mechanical occlusion by the solidified glue and the associated reactive tissue reaction. In the present case we employed a fibrin glue, which solidifies more slowly, resulting in a more homogeneous spread over the lesion.
In conclusion, endoscopic gluing successfully closed a small iatrogenic TEF in a mechanically ventilated patient. The technique is safe, repeatable, and does not exclude the use of subsequent surgical correction in case of failure, so that it may be proposed as an alternative to surgery in high-risk patients or as a first-line attempt.
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References
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- Willets I.E., Dudley N.E., Tam P.K.H. Endoscopic treatment of recurrent tracheo-esophageal fistulae: long-term results. Pediatr Surg Int 1998;13(4):256-258.[Medline]
- Hoelzer D.J., Luft J.D. Successful long-term endoscopic closure of a recurrent tracheoesophageal fistula with fibrin glue in a child. Int J Pediatr Otorhinolaryngology 1999;48(3):259-263.[Medline]
- Raijman I. Endoscopic management of esophagorespiratory fistulas: expanding our options with expandable stents. Am J Gastroenterol 1998;93(4):496-499.[Medline]
- Scappaticci E., Ardissone F., Ruffini E., Baldi S., Mancuso M. Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Ann Thorac Surg 1994;57:119-122.[Abstract]
- Scappaticci E., Ardissone F., Ruffini E., Baldi S., Revello F., Coni F. As originally published in 1994: Postoperative bronchopleural fistula: endoscopic closure in 12 patients. Updated in 2000. Ann Thorac Surg 2000;69:1629-1630.[Abstract/Free Full Text]
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Abstract
Introduction
