INTRODUCTION:Caustic substance ingestion usually from accidental ingestion or attempted suicide can cause significant and often fatal injuries. Emergency management of caustic agent ingestion is well established, however morbidity and mortality remains high. Tracheo-Esophageal Fistula (TEF) is a potential complication of caustic substance ingestion and can be very difficult to correct. We present a case of TEF successfully managed without surgical closure.
CASE PRESENTATION:A 32 year old female patient ingested Drano® (NaOH) in a suicide attempt. She was admitted to an outside hospital with findings of intestinal perforation and after initial resuscitation, underwent an exploratory laparotomy. A gastrectomy, duodenectomy, pancreatectomy, splenectomy, esophageal diversion with creation of a right cervical side to side esophagocutaneous fistula, tracheostomy, and feeding jejunostomy were necessitated. Five days post-operatively, the patient demonstrated leakage of air via the esophagocutaneous fistula during positive pressure ventilation. A TEF was subsequently confirmed by CT scan of the chest and endoscopy. She was transferred to our hospital for definitive airway management.On arrival, a bedside flexible bronchoscopy was performed. Severe distal membranous tracheal necrosis involving the main carina and extending to the proximal main bronchi with an obvious TEF was discovered. No instrumentation or debridement of the trachea was performed during the initial evaluation; however the existing tracheostomy appliance was exchanged for a Bivona tracheostomy system (Smiths Medical, Rockland, MA) with the tip placed just above the TEF to prevent further pressure on the surrounding tissues. The length of the new tracheostomy tube was adjusted over time as needed under bronchoscopic control. The patient was ventilated with minimal loss of tidal volume using pressure-control ventilation. She was placed on a strict schedule of therapeutic fiberoptic bronchoscopy and airway toilet every six hours, and as needed. This was performed only by a senior surgical resident or attending physician and blind airway manipulation was not allowed. Aggressive management of oral secretions and early enteral nutrition resulted in gradual healing of the trachea and fistula closure. The patient was discharged home from our hospital several months later on home enteral feedings.
DISCUSSIONS:Early surgical repair of TEF following caustic ingestion is hazardous given poor wound healing and the inability of tissues to hold suture ensuring a tension free repair.1 Primary resection and reconstruction is reserved for small defects and may result in tracheal stenosis requiring dilatation. Other authors report successful surgical intervention with the use of simple externalized T-tubes, tracheoplasty or bronchoplasty with a pedicled muscle flap, and tracheal and bronchial sleeve resection.1 Several other technical points must be emphasized. Removal of any foreign body in contact with the fistula is necessary and includes nasogastric tubes, which contribute to pressure necrosis and prevent the esophageal wall from healing. In addition, soilage from saliva and respiratory secretions is a significant contributor towards poor wound healing and ongoing pneumonia. Under this premise, we employed a strict, round-the-clock schedule of flexible therapeutic bronchoscopy to minimize contamination of the upper airway, facilitate the evacuation of pulmonary secretions, and expedite recovery. Blind suctioning carries significant potential for injury to friable tissue and thus was not permitted at any time. Additionally, only well-trained personnel were allowed to perform bronchoscopy, minimizing iatrogenic trauma from inexperience.
CONCLUSION:Caustic ingestion is devastating and often fatal. Prompt diagnosis of TEF and early tracheostomy may halt ongoing iatrogenic injury through blind instrumentation of the airway. We submit that a concerted and organized schedule of frequent, flexible bronchoscopy and airway maintenance allows for adequate healing prior to any further reconstruction of the digestive tract and/or airway.
DISCLOSURE:Timothy Lin, No Financial Disclosure Information; No Product/Research Disclosure Information