INTRODUCTION: Acquired tracheo-oesophageal fistula is an unusual but potentially life-threatening complication of traumatic endotracheal intubation. We describe a patient who had this uncommon complication at the level of the carina.
CASE PRESENTATION: A 57-year-old gentleman with a history of acute myeloid leukaemia (AML) type M3 developed pneumonia whilst undergoing chemotherapy. This was complicated by pancytopaenia, disseminated intravascular coagulation and severe sepsis necessitating admission to the Intensive Care Unit for 6 weeks with prolonged and recurrent intubations. Following his recovery, the patient described recurring symptoms of choking after food intake and coughing after drinking for the next 20 years. These symptoms were associated with intermittent haemoptysis and episodes of “chest infections”. The patient required several admissions for these “chest infections” and was thought to be developing bronchiectasis. Oesophagogastroduodenoscopy (OGD) showed 2 oesophageal diverticula at 27 cm from the incisors in the mid-oesophagus. A barium swallow subsequently demonstrated a communication between the mid thoracic oesophagus with the left main bronchus. A computed tomographic study of the thorax then demonstrated a tracheo-oesophageal fistula measuring 8 mm in diameter at the carina with moderate bronchiectasis of the entire lower lobe of the left lung. The patient was offered surgical repair but he declined. He re-presented 1 month later with haemoptysis and left lung collapse. A flexible bronchoscopy revealed a 1 cm fistulous opening on the left aspect of the membranous portion of the carina into the oesophagus. There was a clot occluding the left main bronchus that was removed. An OGD showed a 1 cm fistula opening at the anterolateral aspect of the mid-oesophagus. Biopsy of the edges of the fistula demonstrated no evidence of malignancy. He underwent right thoracotomy and division of the tracheo-oesophageal fistula. The oesophageal defect was closed primarily and the tracheal defect was closed with a dura mater patch (Dura Guardβ) with concomitant insertion of gastrostomy and jejunostomy tubes. His post-operative recovery was uneventful and the jejunostomy tube was removed when the patient tolerated oral diet. He was discharged home well on the 15th post-operative day.
DISCUSSIONS: High endotracheal tube cuff pressure and subsequent reduced perfusion and ischaemic damage of the trachea have been implicated as contributory factors in the development of tracheo-oesophageal fistulae after prolonged mechanical ventilation. In addition, complications such as sepsis and poor general condition of patients are also thought to play a role in the development of this potentially lethal complication. The commonest site for the development of tracheo-oesophageal fistulae is usually at the level of the cuff of the endotracheal tube in the proximal trachea. There has been no previous case reports published of tracheo-oesophageal fistulae occurring at the level of the carina. In our patient's case it was most likely caused by trauma from the tip of the endotracheal tube. Our patient also developed bronchiectasis in the left lower lobe secondary to chronic aspiration (20 years!) from the tracheo-oesophageal fistula. This is because the fistula was located on the left side of the posterior carina.
CONCLUSION: We present the first reported case of an acquired carinal tracheo-oesophageal fistula. The main aim of treatment in tracheo-oesophageal fistulae is protection of the airway from gross contamination from the oesophagus. Spontaneous closure is unusual and surgical repair should be attempted in all patients. The patient's original condition and contamination of the tracheo-bronchial tree make the timing of surgical repair a challenge.
DISCLOSURE: Atasha Asmat, None.