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Tracheoesophageal Fistula Following Post-Intubation Esophageal Perforation
Signs and Symptoms of Chest Diseases SESSION TITLE: Student/Resident Case Report Poster - Signs and Symptoms of Chest Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Tracheoesophageal Fistula Following Post-Intubation Esophageal Perforation Mohammad Karimzada BS* Jessica Keeley MD; and Dennis Kim MD UCLA David Geffen School of Medicine, Los Angeles, CA
SIGNS AND SYMPTOMS OF CHEST DISEASES
INTRODUCTION: The formation of tracheoesophageal fistula (TEF) following intubation is an infrequent complication that typically occurs in the setting of prolonged intubation rather than secondary to esophageal perforation.1 There are no reports of fistulization after post-intubation esophageal perforation. CASE PRESENTATION: A 50 year old woman presented with dysphagia for two months as well as chest pain, chills, and productive cough for three days prior to admission. She was afebrile with stable vital signs and physical exam was unremarkable except for healed tracheostomy and healed bilateral neck incisions. Five months prior to admission she had undergone a colonoscopy during which she was intubated. Post-procedure she developed mediastinitis and a retropharyngeal abscess. Cervical exploration revealed an esophageal perforation. This was stented endoscopically. The patient passed a video swallow test and was discharged. In the three months between discharge and readmission, the patient was hospitalized twice for respiratory infections. At the time of presentation, CT chest demonstrated viscous fluid within the stent. Upper endoscopy demonstrated a 3 cm TEF 20 cm from the incisors with a stent that had migrated distally. Bronchoscopy demonstrated a 1.5 cm void at the posterior trachea 6 cm above the carina. After four esophageal stent revisions complicated by stent migration and improper fit, adequate seal of the fistula was achieved with Strattice mesh and fully covered esophageal stent along with a tracheal stent. DISCUSSION: This case represents a rare instance of esophageal perforation secondary to intubation with subsequent TEF formation. TEF in adults is generally encountered with malignancy, foreign body ingestion, caustic injury, trauma, or iatrogenic causes such as complications of tracheostomy cuffs.2 Dysphagia after stenting can be caused by bolus obstruction or stent migration, and this patient had evidence to support both theories given viscous fluid in the stent on CT as well as migration on endoscopy.3 Her recurrent respiratory infections and productive cough correlate with pulmonary contamination due to an aberrant communication with the esophagus. CONCLUSIONS: Dysphagia after stenting of benign esophageal lesions such as a stricture, leak, perforation, or fistula would more likely indicate stent migration, which is the most common complication, or perhaps bolus obstruction.3 However, recurrent respiratory infections and productive cough in a patient stented for esophageal pathology should raise suspicion for tracheoesophageal fistula. Reference #1: Paraschiv M. Tracheoesophageal fistula - a complication of prolonged tracheal intubation. Journal of Medicine and Life. 2014;7(4):516-521. Reference #2: Acquired tracheo-oesophageal fistula in adults. Diddee R and Shaw I. Continuing Education in Anaesthesia, Critical Care & Pain. 2006;6(3):105-108. Reference #3: Hindy P, Hong J, Lam-tsai Y, Gress F. A comprehensive review of esophageal stents. Gastroenterol Hepatol. 2012;8(8):526-34. DISCLOSURE: The following authors have nothing to disclose: Mohammad Karimzada, Jessica Keeley, Dennis Kim No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1371
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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150#4S CHEST OCTOBER 2016
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Tracheoesophageal Fistula Following Post-Intubation Esophageal Perforation Mohammad Karimzada BS* Jessica Keeley MD; and Dennis Kim MD UCLA David Geffen School of Medicine, Los Angeles, CA
SIGNS AND SYMPTOMS OF CHEST DISEASES
INTRODUCTION: The formation of tracheoesophageal fistula (TEF) following intubation is an infrequent complication that typically occurs in the setting of prolonged intubation rather than secondary to esophageal perforation.1 There are no reports of fistulization after post-intubation esophageal perforation. CASE PRESENTATION: A 50 year old woman presented with dysphagia for two months as well as chest pain, chills, and productive cough for three days prior to admission. She was afebrile with stable vital signs and physical exam was unremarkable except for healed tracheostomy and healed bilateral neck incisions. Five months prior to admission she had undergone a colonoscopy during which she was intubated. Post-procedure she developed mediastinitis and a retropharyngeal abscess. Cervical exploration revealed an esophageal perforation. This was stented endoscopically. The patient passed a video swallow test and was discharged. In the three months between discharge and readmission, the patient was hospitalized twice for respiratory infections. At the time of presentation, CT chest demonstrated viscous fluid within the stent. Upper endoscopy demonstrated a 3 cm TEF 20 cm from the incisors with a stent that had migrated distally. Bronchoscopy demonstrated a 1.5 cm void at the posterior trachea 6 cm above the carina. After four esophageal stent revisions complicated by stent migration and improper fit, adequate seal of the fistula was achieved with Strattice mesh and fully covered esophageal stent along with a tracheal stent. DISCUSSION: This case represents a rare instance of esophageal perforation secondary to intubation with subsequent TEF formation. TEF in adults is generally encountered with malignancy, foreign body ingestion, caustic injury, trauma, or iatrogenic causes such as complications of tracheostomy cuffs.2 Dysphagia after stenting can be caused by bolus obstruction or stent migration, and this patient had evidence to support both theories given viscous fluid in the stent on CT as well as migration on endoscopy.3 Her recurrent respiratory infections and productive cough correlate with pulmonary contamination due to an aberrant communication with the esophagus. CONCLUSIONS: Dysphagia after stenting of benign esophageal lesions such as a stricture, leak, perforation, or fistula would more likely indicate stent migration, which is the most common complication, or perhaps bolus obstruction.3 However, recurrent respiratory infections and productive cough in a patient stented for esophageal pathology should raise suspicion for tracheoesophageal fistula. Reference #1: Paraschiv M. Tracheoesophageal fistula - a complication of prolonged tracheal intubation. Journal of Medicine and Life. 2014;7(4):516-521. Reference #2: Acquired tracheo-oesophageal fistula in adults. Diddee R and Shaw I. Continuing Education in Anaesthesia, Critical Care & Pain. 2006;6(3):105-108. Reference #3: Hindy P, Hong J, Lam-tsai Y, Gress F. A comprehensive review of esophageal stents. Gastroenterol Hepatol. 2012;8(8):526-34. DISCLOSURE: The following authors have nothing to disclose: Mohammad Karimzada, Jessica Keeley, Dennis Kim No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1371
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1258A
[
150#4S CHEST OCTOBER 2016
]