Bronchoesophageal fistula can result from trauma or infection or rare additional causes.1,28-30 Blunt chest trauma has produced a BEF, although the cervical or supracarinal trachea is more likely to be a locus of posttraumatic esophagorespiratory fistula than a bronchus. Instrumentation (such as variceal sclerosis), chemical burns (lye ingestion), and foreign bodies have all been implicated. Infectious agents associated with fistula include tuberculosis, histoplasmosis (Figure 12-12), actinomycosis, and syphilis. Often, these are associated with inflammatory lymph nodes or broncholithiasis. Nontuberculous empyema, suppurative esophagitis, and infected bronchogenic cysts are other etiologies. Fistula has also been associated with traction diverticula related to lymph nodes. Fistulae have occurred due to necrotizing vasculitis and silicotic nodules.1,28-30
Clinical presentation, diagnosis, and treatment are much the same as described for congenital BEF. Results of surgical treatment are very satisfactory (Figure 12-13).28-30 Since more inflammation may be encountered, and more dissection may be necessary to remove involved lymph nodes than in uninflamed congenital fistulae, I favor interposition of an intercostal muscle flap in these cases. The flap is raised at the time of initial thoracotomy. An associated esophageal diverticulum is resected and the esophagus repaired in two layers. Concomitant pulmonary resection is dictated by irretrievable lung damage from chronic infection.
In our series of 9 patients collected over 41 years, 4 followed thoracic surgery, 3 were due to histoplasmosis, and 1 each were due to silicosis, foreign body, lye ingestion, bronchogenic cyst, and esophageal diverticulum, respectively.30 One BEF was congenital. The patient with lye ingestion succumbed. There were no recurrences after successful surgical closures, performed as described above. During this same period of time, 215 patients were recorded with BEF due to bronchogenic or esophageal malignancy.
figure 12-12 Bronchoesophageal fistula due to histoplasmosis. (Courtesy of Dr. Delos M. Cosgrove III.)
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