Eur J Cardiothorac Surg 2003;23:128-130
© 2003 Elsevier Science NL
Esophagobronchial fistula caused by traction esophageal diverticulum
Angel López,
Pedro Rodríguez,
Norberto Santana,
Jorge Freixinet*
Thoracic Surgery Service, Hospital Dr. Negrín, Barranco de la Ballena s/n, 35020 Las Palmas de Gran Canaria, Canary Islands, Spain
Received 14 June 2002;
received in revised form 28 August 2002;
accepted 4 September 2002.
* Corresponding author. Tel.: +34-928-450648; fax: +34-928-450044
e-mail: jfregil{at}gobiernodecanarias.org
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Abstract
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Fistulization is a rare and not often described complication of esophageal diverticula. We present the case of a patient treated surgically in our service who had a history of diverticulum of the third distal of the esophagus, and was diagnosed for irritative post-ingestive cough with associated regurgitation and vomiting of undigested food.
Key Words: Esophageal diverticulum • Complications • Surgical treatment • Esophagobronchial fistula
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1. Introduction
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Esophageal diverticula are evaginations of the mucous projecting from the lumen of the esophagus. Traction diverticulum is an external inflammatory reaction in neighboring mediastinal ganglia that adhere to the esophagus and retract the wall in a way that contracts and scars the tissue, provoking a true diverticulum, meaning that it has as many layers as the esophageal wall itself. This rarely shows any symptoms, and in this case no treatment was deemed necessary. But sometimes, as a result of inflammatory necrosis, a fistula can appear between the diverticulum and the respiratory airways, or even a vascular structure [1]. We present a case of epiphrenic traction diverticulum that fistulized in the bronchial tree. This is a very unusual complication that requires surgical treatment.
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2. Case report
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This case concerns a woman aged 53 years with a personal history of depressive syndrome, varicose veins in lower members, and diverticulum in the lower third of the esophagus. She had been diagnosed 4 years earlier at which time a biopsy was done which was negative for malignancy. She went to her doctor with irritative post-ingestive cough that had been developing over the previous few months, accompanied by regurgitation of undigested food and vomiting. The patient underwent a physical examination without alteration, while an analysis showed only a discrete hyperamylasemia of 293 U/I. Complementary studies included a contrast esophagogram which showed the presence of an epiphrenic diverticulum measuring 1.5x1 cm, and immediately above it another diverticular form measuring 2x1 cm that connected the distal esophagus with segmental bronchial branches of the lower left lobe (Fig. 1a)
. Computerized contrast tomography confirmed this, and also found paraesophageal and mediastinal adenopathies smaller than 2 cm. Fibrobronchoscopy showed no significant lesions in the bronchial tree. An esophageal manometry was done which demonstrated normal motility of the esophagus. An esophagoscopy showed a fistular orifice in the lower portion of the esophagus inside the diverticular zone.
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Fig. 1. (a) Esophagogram showing the diverticula complicated with a fistulous tract between the esophagus and the bronchial tree. (b) Postoperative esophagogram showing no leaks from the esophagus.
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A left thoracotomy was performed. A chronic inflammatory reaction of the mediastinum was found along with three adenopathies of 1.5 cm in diameter. A dissection of the diverticulum and the fistulous tract was carried out. The case was considered a traction diverticulum for which a transection was done using mechanical sutures, placing intercostal muscle between the esophageal and bronchial sutures. Histological diagnosis showed the three esophageal layers in the resectioned diverticulum (Fig. 2)
and non-specific inflammatory adenopathies which confirmed the diagnosis of traction diverticulum. The postoperative evolution was favorable, allowing oral tolerance 48 h after the procedure. A control esophagogram was given at 7 days and no fistulas or esophageal leaks were found (Fig. 1b). The patient was asymptomatic upon her release 9 days after the procedure. Two years later the patient was still asymptomatic and carrying on a normal life.
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3. Discussion
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Benign bronchoesophageal fistulas in adults are infrequent. In the majority of cases they are a consequence of trauma or chronic granulomatous processes such as tuberculosis and histoplasmosis affecting mediastinal structures [1–5]. Traction esophageal diverticula result from an inflammatory contracture outside the esophagus. Bronchoesophageal fistulas associated with traction diverticula are exceptional. The majority of diverticula of the lower third of the esophagus are due to the mechanism of pulsion, associated with esophageal dysmotility [1].
The main symptom of esophagobronchial fistulas is cough associated with swallowing [1,6,7]. This may be accompanied by repeated pulmonary infections and even manifestations of the esophageal diverticulum itself, such as dysphagia, regurgitation, thoracic pain or chronic esophagitis. With regard to diagnosis, an esophagogram with barium is still the technique of choice. Other useful complementary tests are CT of the mediastinum and fibrobronchoscopy. Esophagoscopy also allows for taking biopsies, with the aim of discarding the possibility of associated malignant lesions. In our case intraoperative observation of the retraction of the entire esophageal wall up to the bronchial tree and the presence of inflammatory adenopathies supported the traction mechanism as the pathogenesis of diverticulum. The histology of the resectioned diverticulum which discovered the three esophageal layers demonstrated the traction diverticulum.
The presence of symptoms constitutes the main indication for surgical treatment of esophageal diverticula. In pulsion diverticula, the standard technique is a long esophagomyotomy with diverticulectomy, while in traction diverticula, a local excision of the diverticulum and the adjacent inflammatory mass is done [1,7]. Bronchoesophageal fistulas have been treated with section and mechanical closure, and the interposition of normal neighboring tissue decreases the possibility of a recurrence. It has been described also as a thoracoscopic approach [7].
This case demonstrates that epiphrenic diverticula are not always by pulsion. An esophagobronchial fistula, though rare, could develop and, if so, should be treated surgically.
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References
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Abstract
1. Introduction
