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Management of gastro-bronchial fistula complicating a subtotal esophagectomy: a case report.

Martin-Smith JD, Larkin JO, O'Connell F, Ravi N, Reynolds JV - BMC Surg (2009)

Bottom Line: On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis.He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support.A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistula This is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Surgery, St James's Hospital and Trinity College Dublin, Dublin, Ireland. jmartins@tcd.ie

ABSTRACT

Background: The development of a fistula between the tracheobronchial tree and the gastric conduit post esophagectomy is a rare and often fatal complication.

Case presentation: A 68 year old man underwent radical esophagectomy for esophageal adenocarcinoma. On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis. A fiberoptic bronchoscopy was performed which demonstrated a gastro-bronchial fistula in the posterior aspect of the left main bronchus. He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support. A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistula

Conclusions: This is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy. Our experience would suggest that in very carefully selected cases where bronchopulmonary contamination from the fistula is minimal or absent, there is no associated inflammation of the tracheobronchial tree and the patient is stable from a respiratory point of view without evidence of sepsis, there may be a role for a trial of conservative management.

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Bronchoscopic appearance (day 16 post-op) of a fistulous opening in the posterior aspect of the left main bronchus, communicating with esophagogastric anastomosis.
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Figure 1: Bronchoscopic appearance (day 16 post-op) of a fistulous opening in the posterior aspect of the left main bronchus, communicating with esophagogastric anastomosis.

Mentions: On day four postoperatively he had a neutrophil leucocytosis of 15 × 109/L and evidence of left basal consolidation. This persisted despite antibiotics, and a CT of thorax demonstrated no other abnormalities. He was managed on the ward, and his FiO2 varied from 0.4 to 0.6. Aspiration pneumonia was considered possible, and his nasogastric tube was left in situ. His neck wound was dry with no signs of inflammation or leakage. On day 14 the nasogastric drainage bag dramatically filled with air, and this persisted throughout the day and succeeding days, but without deterioration in respiratory function or evidence of progressive sepsis. A fiberoptic bronchoscopy was performed on day 16 which demonstrated bubbling at a gastro-bronchial fistula in the posterior aspect of the left main bronchus (Fig. 1). An endoscopy revealed a healthy gastric tube but a tiny area of granulation tissue in the anterior portion of the anastomosis, the assumed site of fistula communication. A CT scan of the thorax demonstrated air in the mediastinum and the gastric conduit (Fig. 2)


Management of gastro-bronchial fistula complicating a subtotal esophagectomy: a case report.

Martin-Smith JD, Larkin JO, O'Connell F, Ravi N, Reynolds JV - BMC Surg (2009)

Bronchoscopic appearance (day 16 post-op) of a fistulous opening in the posterior aspect of the left main bronchus, communicating with esophagogastric anastomosis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2803445&req=5

Figure 1: Bronchoscopic appearance (day 16 post-op) of a fistulous opening in the posterior aspect of the left main bronchus, communicating with esophagogastric anastomosis.
Mentions: On day four postoperatively he had a neutrophil leucocytosis of 15 × 109/L and evidence of left basal consolidation. This persisted despite antibiotics, and a CT of thorax demonstrated no other abnormalities. He was managed on the ward, and his FiO2 varied from 0.4 to 0.6. Aspiration pneumonia was considered possible, and his nasogastric tube was left in situ. His neck wound was dry with no signs of inflammation or leakage. On day 14 the nasogastric drainage bag dramatically filled with air, and this persisted throughout the day and succeeding days, but without deterioration in respiratory function or evidence of progressive sepsis. A fiberoptic bronchoscopy was performed on day 16 which demonstrated bubbling at a gastro-bronchial fistula in the posterior aspect of the left main bronchus (Fig. 1). An endoscopy revealed a healthy gastric tube but a tiny area of granulation tissue in the anterior portion of the anastomosis, the assumed site of fistula communication. A CT scan of the thorax demonstrated air in the mediastinum and the gastric conduit (Fig. 2)

Bottom Line: On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis.He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support.A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistula This is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Surgery, St James's Hospital and Trinity College Dublin, Dublin, Ireland. jmartins@tcd.ie

ABSTRACT

Background: The development of a fistula between the tracheobronchial tree and the gastric conduit post esophagectomy is a rare and often fatal complication.

Case presentation: A 68 year old man underwent radical esophagectomy for esophageal adenocarcinoma. On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis. A fiberoptic bronchoscopy was performed which demonstrated a gastro-bronchial fistula in the posterior aspect of the left main bronchus. He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support. A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistula

Conclusions: This is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy. Our experience would suggest that in very carefully selected cases where bronchopulmonary contamination from the fistula is minimal or absent, there is no associated inflammation of the tracheobronchial tree and the patient is stable from a respiratory point of view without evidence of sepsis, there may be a role for a trial of conservative management.

Show MeSH
Related in: MedlinePlus