CURRENT REVIEW
Esophagopleural Fistula Following Pulmonary Resection Gulshan K. Sethi, M.D., and Timothy Takaro, M.D.
ABSTRACT The development of esophagopleural found to be resistant to the antimycobacterial fisfula following pulmonary resection is an uncom- drugs he had formerly taken, and he was treated mon but serious complication. The fistula may ap- with pyrazinamide, ethambutal, and viomycin. pear either soon after operation, due to direct trauma The cavitary lesion did not respond to this to the esophagus or to its blood supply during exten- therapy, and in October, 1965, resection of the sive dissection, or later, in association with the de- left upper lobe and the superior segment of the velopment of a bronchopleural fistula and empyema lower lobe was performed. The remaining lower following the pulmonary resection. Treatment of lobe was inadequate to fill the pleural space, and these fistulas is usually complicated, and the recovery in order to avoid a large residual air space, a period is prolonged. Control of infection, Marlex tent was constructed. In spite of this prehyperalimentation, obliteration of the empyema caution, a large space remained, for which a space, and closure of the fistula with a muscle or five-rib thoracoplasty was performed six pleural flap are recommended methods of manage- months later. Nevertheless, an empyema was ment. The pathogenesis, treatment, results, and pre- diagnosed two months afterward. The infected vention of this complication are discussed. Marlex mesh was removed, and a modified
Schede thoracoplasty was performed for a susThe occurrence of esophagopleural fistula fol- pected bronchopleural fistula. Two weeks later, lowing pulmonary resection is an uncommon ingested food particles were seen in the drainage but serious complication. Before 1960 these fis- from the chest, and both a bronchopleural and tulas were usually found following pneumonec- an esophagopleural fistula were thought to be tomy for tuberculosis or suppurative disease of present. An esophagogram confirmed the diagthe lung. They were rarely reported following nosis of a small esophagopleural fistula (Fig 1). pulmonary resections for cancer. Since the last Because the Schede procedure provided collective review, by one of us, of this complica- adequate drainage, no immediate additional tion [13], we have encountered 3 more patients procedure was deemed appropriate. Three who developed esophagopleural fistula follow- months later, further attempts to collapse this ing pulmonary resection and 28 additional cases anterior-lying apical space were recommended have been reported in the literature [l,3-8, 10- to the patient, but he declined and left the hospi121. The purpose of this paper is to report our 3 tal against advice. Nine months after the Schede patients, review the literature, and discuss the thoracoplasty, in the face of a nonhealing fistula pathogenesis, treatment, and prevention of this and high apical space behind the clavicle that complication. had not been collapsed by two previous thoracoplasty procedures, clavicle resection and Case Reports feeding gastrostomy were carried out. These Patient 28 procedures resulted in healing of the esophagopleural fistula and ultimately of the bronchoA 48-year-old black man had had pulmonary pleural fistula as well. The patient died of unretuberculosis in 1957 that was treated with streptomycin, isoniazid, and para-aminosalicylic lated causes five years later. C O MME N T . In retrospect, the use of Marlex acid. In March, 1965, there was reactivation of bilateral apical tuberculosis with development mesh following resection for tuberculosis was of a cavitary lesion in the left upper lobe. He was probably ill advised and led to the development of an unrecognized apical empyema, which in From the Division of Thoracic and Cardiovascular Surgery, turn was inappropriately managed by thoracoVeterans Administration Hospital, Asheville, NC. plasty. The empyema probably ruptured into Address reprint requests to Dr. Sethi, Veterans Administration Hospital, Asheville, NC 28805. the esophagus following this procedure and 74 0003-497517810025-0115$01.50 @ 1978 by The Society of Thoracic Surgeons
77 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
until the infection could be brought under control. In retrospect, a more aggressive approach to control the infection and repair the esophageal fistula might have altered the outcome. Incidence Esophagopleural fistulas probably occur more frequently than the few reports in the literature would indicate. Takaro and associates [13] encountered 4 esophagopleural fistulas among 934 resections for pulmonary tuberculosis prior to 1961, and Evans [71 reported a similar incidence of 0.5'/0 among 1,389 patients who underwent pneumonectomy for carcinoma of the lung. Etiology and Time of Appearance (Onset) Since the last collective review on this problem, 28 more cases of esophagopleural fistula have been reported in the literature. The time of appearance of the fistula varied from one day to 96 months, suggesting differing etiologies. Most frequently, fistulas occurred within six weeks following operation (Table 1). When a fistula appears soon after operation (within two weeks), it is probably due to direct trauma to the esophagus, which may occur during extensive dissection of the mediastinal lymph nodes adjacent to the esophagus. Radical dissection with stripping of these lymph nodes may not only traumatize the esophagus, it may also jeopardize the blood supply. Dumont and DeGraef [3] pointed out that the blood supply to the esophagus is segmental and that the part of the esophagus lying below the carina has an especially poor blood supply. In this region the blood supply is also shared by other mediastinal structures. For these reasons, the pericarinal region is the most common site of fistula formation. Data concerning the site of fistula formation are available for only 18 of the 31 recent patients. In none of these patients did the fistula occur proximal to the level of the bronchial stump: in 3 it was at the level of the stump, and in the remaining 15 patients it occurred below the stump. Occasionally, during a difficult pulmonary resection, the esophagus may be tented up and inadvertently injured or an unsuspected traction diverticulum of the esophagus may be entered. Previously, necrosis of the esophagus
by a hard drainage tube has also been suggested as a cause of esophageal fistulas. Possible causes of late development of esophagopleural fistula following pulmonary resection include rupture of a paraesophageal abscess into the esophagus, direct inflammatory involvement of the esophageal wall, rupture into the pleural cavity or extrapleural space of a suppurative or caseating lymph node that has previously established communication with the esophageal lumen, and rupture of a traction diverticulum. Perforation into the esophagus of a bronchopleural fistula or an intrapleural empyema of long duration occurred in almost half of these patients. Seven of 8 patients reported by Evans [7] developed a bronchopleural fistula prior to an esophagopleural fistula. Sometimes the exact cause of the fistula is not known (Table 2). The primary pulmonary disease for which resection was performed included carcinoma (19 patients), tuberculosis (10 patients), mesothelioma (1 patient), and suppurative disease of the lung (1 patient). Pneumonectomy was performed in 29 patients and lobectomy in only 2. It is interesting to note that in both patients in whom an esophagopleural fistula developed following lobectomy, the pulmonary resection had been performed for tuberculous infection of the lung. Most fistulas occurred on the right side (26 of 31). This can be explained by the anatomical location of the esophagus. On the right side the esophagus is intimately associated with the mediastinal pleura and thus is more vulnerable to injury during radical pneumonectomy. On the left it is separated from the mediastinal pleura by the aorta through much of its course. Seventeen of the 26 patients in whom fistulas developed on the right side underwent pulmonary resection for carcinoma of the lung. Three of 5 patients in whom fistulas developed on the left side had tuberculosis, and the remaining 2 had cancer of the lung. Diagnosis There are almost no classic signs and symptoms to indicate the development of an esophagopleural fistula. When this complication occurs in the early postoperative period, the clinical pic-
78 The Annals of Thoracic Surgery Vol 25 No 1 January 1978
Table 1 . Review of 31 Patients Undergoing Operative Procedures" for Esophagopleural Fistula
Primary Disease
Side of Resection
Time of Postop Appearance of Fistula
1. 66
CA
R
2 days
2. 45
CA
R
26 mo
3. 57
CA
R
1 mo
TB
R
34 mo
5. 38 TB 6. 32 TB 7. Unknown TI3
R R L
Patient No. and Age (yr)
Management
Result
Direct closure, muscle flap, reverse gastric tube failed, colon interpositionh Direct closure failed, pleural flap'' Direct closure failed, pleural flapb
Fistula healed
Benjamin et a1 [l]
Fistula healed Fistula healed
Dumont and DeGraef [3]
4. 32
Fistula healed
48 mo 44 mo 96 mo
Thoracoplasty failed, direct closureb Thoracoplasty Antibiotic irrigation Antibiotic irrigation
Fistula healed Fistula healed Fistula healed
Efthimiadis et a1 [4] 8. 65
CA
R
2% yr
Muscle flap
Fistula healed
Engelman et a1 [5] 9. 55
CA
R
5 days
Muscle flap and thoracoplasty
Fistula healed
Mesothelioma TB CA CA CA
R
3 mo
Data unavailable
Data unavailable
R R R R
5 days 3 days 11 days 1 day
Data Data Data Data
Data Data Data Data
CA CA CA
R R R
6 wk 7 mo 2 wk
Died 3 days postop Died 54 days postop Fistula healed
CA CA CA CA CA
R R R R R
6 wk 7 mo 22 mo 11 mo 2 mo
Gastrostomy Gastrostomy Direct closure and thoracoplasty Nasogastric tube Nasogastric tube Direct closure Direct closure Nasogastric tube
Grosse [8] 23. 57
TI3
R
5 days
Antibiotic irrigation
Fistula healed
Richardson et a1 1101 24. 61
TB
R
3 wk
Died postop
Infection
R
1 Y'
Direct closure failed, colon bypass 'I Muscle flap and thoracoplasty
Eriksen [6] 10. 61 11. 28 12. 66 13. 67 14. 58
Evans [7] 15. 54 16. 53 17. 48
18. 19. 20. 21. 22.
63 57 74 52 60
25. 51
unavailable unavailable unavailable unavailable
unavailable unavailable unavailable unavailable
Died 17 days postop Died 3 days postop Fistula healed Fistula healed Died 3 days postop
Fistula healed
79 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
Table 1. (Continued)
Patient No. and Age (yr) 26. 62
dos Santos et a1 [ll] 27. 35
Primary Disease
Side of Resection
Time of Postop Appearance of Fistula Management
TI3
L
2 Y'
Direct closure and
Fistula healed
TB
R
6 wk
Esophagogastroplasty
Fistula healed
TB CA CA
L R L
6 mo 1 day 3 wk
Thoracoplasty None
Gastrostomy
Fistula healed Died 1 day postop Died 2 wk postop
CA
L
18 mo
Mousseau-Barbin tube
Died 12 days postop
thoracoplasty failed, muscle flapb
Sethi and Takaro (this report) 28. 48 29. 53 30. 62 Symes et a1 [12] 31. 62
Result
'Patients 23 and 30 underwent lobectomy. All others had pneumonectomy. bThe last procedure performed when more than one operation was necessary to treat the fistula. It was successful in all but Patient 24. CA = carcinoma; TB = tuberculosis. ture may be confused with that of a bronchopleural fistula or an acute empyema. The finding of food particles or gastric contents in the pleural drainage is one of the earliest signs, and is pathognomonic of the development of an esophagopleural fistula. This can be verified by observation in the pleural drainage of previously ingested methylene blue. An esophagogram should confirm the diagnosis. The presence of desquamated or epidermoid squamous cells in the empyema fluid is also reported to be diagnostic of esophagopleural fistula [61. In the chronic state, low-grade fever, severe weight loss, and even emaciation may occur. In
this group, recurrence of tumor in the bronchial stump or chronic empyema is usually suspected. A bronchoscopy may be helpful in excluding the possibility of tumor recurrence in the bronchial stump, and esophagoscopy may confirm the diagnosis of esophageal fistula. Esophagoscopy may also determine whether the fistula site is involved by the neoplastic process [41.
Treatment and Results The survival of patients with esophagopleural fistulas is probably related to the time of appearance of the fistula, etiology, and type of surgical management. Of the 31 patients covered in this review, the mode of treatment and duration of Table 2 . Probable Cause of Esophagopleural survival are available for only 26. Seven patients Fistula in 32 Patients who had only conservative therapy (gastrostomy, jejunostomy, or insertion of a nasogastric Cause No. of Patients or intraluminal esophageal tube) died between two days and two months. Usually these pa8 Bronchopleural fistula tients were so sick that no immediate repair of Empyema 9 the fistula was contemplated. In 15 patients Operative injury 6 (definite or probable) some operative procedure was carried out, such Recurrent carcinoma 1 as closure of the fistula either directly or using a Data unavailable 7 pedicled muscle or pleural flap, obliteration of
80 The Annals of Thoracic Surgery Vol 25 No 1 January 1978
fistula are recommended methods of management. Direct closure of acute and subacute fistulas, and conservative operations on the chest wall, such as a modified Schede thoracoplasty for chronic fistulas, may be palliative rather than curative. They are often considerably safer, however, than extensive esophageal reconstructive procedures using stomach, jejunum, or colon in these debilitated patients. A more conservative approach, such as gastrostomy, jejunostomy, or insertion of a nasogastric or intraluminal esophageal tube, is almost always doomed to failure. Of 7 patients who were treated with one of these modalities, all died within two months [7,12]. In contrast, 14 of 15 patients who were managed more aggresComment sively by a variety of surgical procedures (Table 3) survived. It is possible, however, that the The two most common causes of development of an esophagopleural fistula following pulmonary lesser procedures were performed in debilitated resection are operative injury to the esophagus patients with advanced disease in whom a more and infection. When a fistula is discovered extensive surgical procedure was judged inapshortly after operation, it has probably resulted propriate. Because of the presence of infection and from recognized or unrecognized surgical trauma to the esophagus. Infection may lead to marked inflammatory reaction, direct closure of the formation of an esophageal fistula as early as an esophagopleural fistula may be technically two weeks or as late as nine years following very difficult; in fact, it failed in 5 of 8 patients in pneumonectomy. The presence of ingested food whom it was attempted. The esophageal suture particles or gastric contents in the pleural drain- line should be reinforced with either a pleural or age is pathognomonic of esophagopleural fis- a pedicled chest wall or intercostal muscle flap tula, and esophagography with barium or Gas- [l, 5, 10, 111. With an 86% success rate, this trografin should confirm the diagnosis and proved to be the most effective procedure. If the esophageal perforation is repaired early, before locate the precise site of the fistula. Treatment of these fistulas is usually complica- long-standing changes of inflammation and inted, and the recovery period is prolonged. Con- fection develop in the space left after trol of infection, hyperalimentation, obliteration pneumonectomy, the addition of thoracoplasty of empyema spaces, and possibly repair of the may not be necessary [lo]. Benjamin and as-
the empyema space, or esophageal reconstruction by a bypass procedure. Fourteen of these patients survived, and 1 died postoperatively following a substernal right colon bypass procedure (see Table 1). Multiple procedures were often necessary to accomplish closure of the fistula. Usually, but not always, early attempts to close the fistula by direct suture failed. Three patients were treated by daily instillation of antibiotic solution into the empyema space; all survived. In 2 of these 3 patients the fistulas had occurred late (44 and 90 months) following pneumonectomy for tuberculosis. In 1 patient, diffuse gangrenous esophagitis and esophageal rupture were discovered at autopsy.
Table 3 . Surgical Procedures Used to Repair Esophagopleural Fistula Operation
No. Attempted
No. Successful
Direct closure" Thoracoplasty" Pedicled muscle or pleural flap" Reconstructive procedure"
8 7 7 4
3 5 6 2
Percent
Successful
37.5 71.4 86.0 50.0
aPerformed in combination with thoracoplasty in 2 instances, with 1 success. bPerformed in combination with other procedures-direct closure (2) or muscle flap (2)-in 4 instances, with 3 successes. 'Performed in conjunction with thoracoplasty in 2 instances, both successful. 1 patient two attempts were made; the second succeeded.
81 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
sociates [l] recommended drainage of the empyema followed by direct closure of the fistula reinforced by a pleural flap. After the fistula healed, the empyema cavity was closed by the Clagett procedure [2]. The late occurrence of esophagopleural fistula following pneumonectomy for carcinoma of the lung is ominous and suggests recurrence of the tumor. These patients may be well palliated by insertion of an intraluminal esophageal tube which may control dysphagia satisfactorily and seal off the fistula as well [121. The best form of management for this serious complication is prevention. In anticipated difficult pulmonary resections, it is advisable to obtain a preoperative esophagogram to detect unusual deflections or unsuspected diverticula of the esophagus. During operation, a nasogastric tube may be utilized in much the way general surgeons use urethral catheters in difficult pelvic resections. If the esophageal injury is recognized during operation, a primary repair in two layers should be performed. Prompt and vigorous obliteration of all postoperatively infected spaces may help prevent the late development of esophagopleural fistula. References 1. Benjamin I, Olsen AM, Ellis FH Jr: Esophagopleural fistula. Ann Thorac Surg 7:139, 1969 2. Clagett OT, Geraci JE: A procedure for the rnan-
agement of postpneumonectomy empyerna. J Thorac Cardiovasc Surg 45:141, 1963 3. Dumont A, DeGraef J: La fistule oesophagopleurale, complication tardive d e la pneurnonectomie. Lyon Chir 57:481, 1961 4. Efthimiadis M, Xanthakis D, Primikyrios N, et al: Late esophagopleural fistula after pneumonectomy for bronchial carcinoma. Chest 65:579,1974 5. Engelman RM, Spencer FC, Berg P: Postpneumonectomy esophageal fistula: successful one-stage repair. J Thorac Cardiovasc Surg 59:871, 1970 6. Eriksen KR: Oesophagopleural fistula diagnosed by microscopic examination of pleural fluid. Acta Chir Scand 128:771, 1964 7. Evans JP: Post-pneumonectomy oesophageal fistula. Thorax 27:674, 1972 8. Grosse W: Postoperative Osophagusfistel als seltene Komplikation nach Lungenresektion. Tuber 124:372, 1965 9. Lambert A: Partial claviculectomy as an adjunct to surgical collapse of the chest wall. J Thorac Surg 15:266, 1946 10. Richardson JD, Campbell D, Trinkle JK: Esophagopleural fistula after pneumonectomy. Chest 69:795, 1976 11. dos Santos MI, Netto SM, Marcal 0: Fistula esofagopleural traumatica post-pneumectomia, analise d e un caso tratado por esofagogastroplastia retrosternal. Rev Paul Med 65:263, 1964 12. Symes JM, Page AJF, Flavell G: Esophagopleural fistula: a late complication after pneumonectomy. J Thorac Cardiovasc Surg 63:783, 1972 13. Takaro T, Walkup HE, Okano T: Esophagopleural fistula as a complication of thoracic surgery. J Thorac Cardiovasc Surg 40:179, 1960
Esophagopleural Fistula Following Pulmonary Resection Gulshan K. Sethi, M.D., and Timothy Takaro, M.D.
ABSTRACT The development of esophagopleural found to be resistant to the antimycobacterial fisfula following pulmonary resection is an uncom- drugs he had formerly taken, and he was treated mon but serious complication. The fistula may ap- with pyrazinamide, ethambutal, and viomycin. pear either soon after operation, due to direct trauma The cavitary lesion did not respond to this to the esophagus or to its blood supply during exten- therapy, and in October, 1965, resection of the sive dissection, or later, in association with the de- left upper lobe and the superior segment of the velopment of a bronchopleural fistula and empyema lower lobe was performed. The remaining lower following the pulmonary resection. Treatment of lobe was inadequate to fill the pleural space, and these fistulas is usually complicated, and the recovery in order to avoid a large residual air space, a period is prolonged. Control of infection, Marlex tent was constructed. In spite of this prehyperalimentation, obliteration of the empyema caution, a large space remained, for which a space, and closure of the fistula with a muscle or five-rib thoracoplasty was performed six pleural flap are recommended methods of manage- months later. Nevertheless, an empyema was ment. The pathogenesis, treatment, results, and pre- diagnosed two months afterward. The infected vention of this complication are discussed. Marlex mesh was removed, and a modified
Schede thoracoplasty was performed for a susThe occurrence of esophagopleural fistula fol- pected bronchopleural fistula. Two weeks later, lowing pulmonary resection is an uncommon ingested food particles were seen in the drainage but serious complication. Before 1960 these fis- from the chest, and both a bronchopleural and tulas were usually found following pneumonec- an esophagopleural fistula were thought to be tomy for tuberculosis or suppurative disease of present. An esophagogram confirmed the diagthe lung. They were rarely reported following nosis of a small esophagopleural fistula (Fig 1). pulmonary resections for cancer. Since the last Because the Schede procedure provided collective review, by one of us, of this complica- adequate drainage, no immediate additional tion [13], we have encountered 3 more patients procedure was deemed appropriate. Three who developed esophagopleural fistula follow- months later, further attempts to collapse this ing pulmonary resection and 28 additional cases anterior-lying apical space were recommended have been reported in the literature [l,3-8, 10- to the patient, but he declined and left the hospi121. The purpose of this paper is to report our 3 tal against advice. Nine months after the Schede patients, review the literature, and discuss the thoracoplasty, in the face of a nonhealing fistula pathogenesis, treatment, and prevention of this and high apical space behind the clavicle that complication. had not been collapsed by two previous thoracoplasty procedures, clavicle resection and Case Reports feeding gastrostomy were carried out. These Patient 28 procedures resulted in healing of the esophagopleural fistula and ultimately of the bronchoA 48-year-old black man had had pulmonary pleural fistula as well. The patient died of unretuberculosis in 1957 that was treated with streptomycin, isoniazid, and para-aminosalicylic lated causes five years later. C O MME N T . In retrospect, the use of Marlex acid. In March, 1965, there was reactivation of bilateral apical tuberculosis with development mesh following resection for tuberculosis was of a cavitary lesion in the left upper lobe. He was probably ill advised and led to the development of an unrecognized apical empyema, which in From the Division of Thoracic and Cardiovascular Surgery, turn was inappropriately managed by thoracoVeterans Administration Hospital, Asheville, NC. plasty. The empyema probably ruptured into Address reprint requests to Dr. Sethi, Veterans Administration Hospital, Asheville, NC 28805. the esophagus following this procedure and 74 0003-497517810025-0115$01.50 @ 1978 by The Society of Thoracic Surgeons
77 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
until the infection could be brought under control. In retrospect, a more aggressive approach to control the infection and repair the esophageal fistula might have altered the outcome. Incidence Esophagopleural fistulas probably occur more frequently than the few reports in the literature would indicate. Takaro and associates [13] encountered 4 esophagopleural fistulas among 934 resections for pulmonary tuberculosis prior to 1961, and Evans [71 reported a similar incidence of 0.5'/0 among 1,389 patients who underwent pneumonectomy for carcinoma of the lung. Etiology and Time of Appearance (Onset) Since the last collective review on this problem, 28 more cases of esophagopleural fistula have been reported in the literature. The time of appearance of the fistula varied from one day to 96 months, suggesting differing etiologies. Most frequently, fistulas occurred within six weeks following operation (Table 1). When a fistula appears soon after operation (within two weeks), it is probably due to direct trauma to the esophagus, which may occur during extensive dissection of the mediastinal lymph nodes adjacent to the esophagus. Radical dissection with stripping of these lymph nodes may not only traumatize the esophagus, it may also jeopardize the blood supply. Dumont and DeGraef [3] pointed out that the blood supply to the esophagus is segmental and that the part of the esophagus lying below the carina has an especially poor blood supply. In this region the blood supply is also shared by other mediastinal structures. For these reasons, the pericarinal region is the most common site of fistula formation. Data concerning the site of fistula formation are available for only 18 of the 31 recent patients. In none of these patients did the fistula occur proximal to the level of the bronchial stump: in 3 it was at the level of the stump, and in the remaining 15 patients it occurred below the stump. Occasionally, during a difficult pulmonary resection, the esophagus may be tented up and inadvertently injured or an unsuspected traction diverticulum of the esophagus may be entered. Previously, necrosis of the esophagus
by a hard drainage tube has also been suggested as a cause of esophageal fistulas. Possible causes of late development of esophagopleural fistula following pulmonary resection include rupture of a paraesophageal abscess into the esophagus, direct inflammatory involvement of the esophageal wall, rupture into the pleural cavity or extrapleural space of a suppurative or caseating lymph node that has previously established communication with the esophageal lumen, and rupture of a traction diverticulum. Perforation into the esophagus of a bronchopleural fistula or an intrapleural empyema of long duration occurred in almost half of these patients. Seven of 8 patients reported by Evans [7] developed a bronchopleural fistula prior to an esophagopleural fistula. Sometimes the exact cause of the fistula is not known (Table 2). The primary pulmonary disease for which resection was performed included carcinoma (19 patients), tuberculosis (10 patients), mesothelioma (1 patient), and suppurative disease of the lung (1 patient). Pneumonectomy was performed in 29 patients and lobectomy in only 2. It is interesting to note that in both patients in whom an esophagopleural fistula developed following lobectomy, the pulmonary resection had been performed for tuberculous infection of the lung. Most fistulas occurred on the right side (26 of 31). This can be explained by the anatomical location of the esophagus. On the right side the esophagus is intimately associated with the mediastinal pleura and thus is more vulnerable to injury during radical pneumonectomy. On the left it is separated from the mediastinal pleura by the aorta through much of its course. Seventeen of the 26 patients in whom fistulas developed on the right side underwent pulmonary resection for carcinoma of the lung. Three of 5 patients in whom fistulas developed on the left side had tuberculosis, and the remaining 2 had cancer of the lung. Diagnosis There are almost no classic signs and symptoms to indicate the development of an esophagopleural fistula. When this complication occurs in the early postoperative period, the clinical pic-
78 The Annals of Thoracic Surgery Vol 25 No 1 January 1978
Table 1 . Review of 31 Patients Undergoing Operative Procedures" for Esophagopleural Fistula
Primary Disease
Side of Resection
Time of Postop Appearance of Fistula
1. 66
CA
R
2 days
2. 45
CA
R
26 mo
3. 57
CA
R
1 mo
TB
R
34 mo
5. 38 TB 6. 32 TB 7. Unknown TI3
R R L
Patient No. and Age (yr)
Management
Result
Direct closure, muscle flap, reverse gastric tube failed, colon interpositionh Direct closure failed, pleural flap'' Direct closure failed, pleural flapb
Fistula healed
Benjamin et a1 [l]
Fistula healed Fistula healed
Dumont and DeGraef [3]
4. 32
Fistula healed
48 mo 44 mo 96 mo
Thoracoplasty failed, direct closureb Thoracoplasty Antibiotic irrigation Antibiotic irrigation
Fistula healed Fistula healed Fistula healed
Efthimiadis et a1 [4] 8. 65
CA
R
2% yr
Muscle flap
Fistula healed
Engelman et a1 [5] 9. 55
CA
R
5 days
Muscle flap and thoracoplasty
Fistula healed
Mesothelioma TB CA CA CA
R
3 mo
Data unavailable
Data unavailable
R R R R
5 days 3 days 11 days 1 day
Data Data Data Data
Data Data Data Data
CA CA CA
R R R
6 wk 7 mo 2 wk
Died 3 days postop Died 54 days postop Fistula healed
CA CA CA CA CA
R R R R R
6 wk 7 mo 22 mo 11 mo 2 mo
Gastrostomy Gastrostomy Direct closure and thoracoplasty Nasogastric tube Nasogastric tube Direct closure Direct closure Nasogastric tube
Grosse [8] 23. 57
TI3
R
5 days
Antibiotic irrigation
Fistula healed
Richardson et a1 1101 24. 61
TB
R
3 wk
Died postop
Infection
R
1 Y'
Direct closure failed, colon bypass 'I Muscle flap and thoracoplasty
Eriksen [6] 10. 61 11. 28 12. 66 13. 67 14. 58
Evans [7] 15. 54 16. 53 17. 48
18. 19. 20. 21. 22.
63 57 74 52 60
25. 51
unavailable unavailable unavailable unavailable
unavailable unavailable unavailable unavailable
Died 17 days postop Died 3 days postop Fistula healed Fistula healed Died 3 days postop
Fistula healed
79 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
Table 1. (Continued)
Patient No. and Age (yr) 26. 62
dos Santos et a1 [ll] 27. 35
Primary Disease
Side of Resection
Time of Postop Appearance of Fistula Management
TI3
L
2 Y'
Direct closure and
Fistula healed
TB
R
6 wk
Esophagogastroplasty
Fistula healed
TB CA CA
L R L
6 mo 1 day 3 wk
Thoracoplasty None
Gastrostomy
Fistula healed Died 1 day postop Died 2 wk postop
CA
L
18 mo
Mousseau-Barbin tube
Died 12 days postop
thoracoplasty failed, muscle flapb
Sethi and Takaro (this report) 28. 48 29. 53 30. 62 Symes et a1 [12] 31. 62
Result
'Patients 23 and 30 underwent lobectomy. All others had pneumonectomy. bThe last procedure performed when more than one operation was necessary to treat the fistula. It was successful in all but Patient 24. CA = carcinoma; TB = tuberculosis. ture may be confused with that of a bronchopleural fistula or an acute empyema. The finding of food particles or gastric contents in the pleural drainage is one of the earliest signs, and is pathognomonic of the development of an esophagopleural fistula. This can be verified by observation in the pleural drainage of previously ingested methylene blue. An esophagogram should confirm the diagnosis. The presence of desquamated or epidermoid squamous cells in the empyema fluid is also reported to be diagnostic of esophagopleural fistula [61. In the chronic state, low-grade fever, severe weight loss, and even emaciation may occur. In
this group, recurrence of tumor in the bronchial stump or chronic empyema is usually suspected. A bronchoscopy may be helpful in excluding the possibility of tumor recurrence in the bronchial stump, and esophagoscopy may confirm the diagnosis of esophageal fistula. Esophagoscopy may also determine whether the fistula site is involved by the neoplastic process [41.
Treatment and Results The survival of patients with esophagopleural fistulas is probably related to the time of appearance of the fistula, etiology, and type of surgical management. Of the 31 patients covered in this review, the mode of treatment and duration of Table 2 . Probable Cause of Esophagopleural survival are available for only 26. Seven patients Fistula in 32 Patients who had only conservative therapy (gastrostomy, jejunostomy, or insertion of a nasogastric Cause No. of Patients or intraluminal esophageal tube) died between two days and two months. Usually these pa8 Bronchopleural fistula tients were so sick that no immediate repair of Empyema 9 the fistula was contemplated. In 15 patients Operative injury 6 (definite or probable) some operative procedure was carried out, such Recurrent carcinoma 1 as closure of the fistula either directly or using a Data unavailable 7 pedicled muscle or pleural flap, obliteration of
80 The Annals of Thoracic Surgery Vol 25 No 1 January 1978
fistula are recommended methods of management. Direct closure of acute and subacute fistulas, and conservative operations on the chest wall, such as a modified Schede thoracoplasty for chronic fistulas, may be palliative rather than curative. They are often considerably safer, however, than extensive esophageal reconstructive procedures using stomach, jejunum, or colon in these debilitated patients. A more conservative approach, such as gastrostomy, jejunostomy, or insertion of a nasogastric or intraluminal esophageal tube, is almost always doomed to failure. Of 7 patients who were treated with one of these modalities, all died within two months [7,12]. In contrast, 14 of 15 patients who were managed more aggresComment sively by a variety of surgical procedures (Table 3) survived. It is possible, however, that the The two most common causes of development of an esophagopleural fistula following pulmonary lesser procedures were performed in debilitated resection are operative injury to the esophagus patients with advanced disease in whom a more and infection. When a fistula is discovered extensive surgical procedure was judged inapshortly after operation, it has probably resulted propriate. Because of the presence of infection and from recognized or unrecognized surgical trauma to the esophagus. Infection may lead to marked inflammatory reaction, direct closure of the formation of an esophageal fistula as early as an esophagopleural fistula may be technically two weeks or as late as nine years following very difficult; in fact, it failed in 5 of 8 patients in pneumonectomy. The presence of ingested food whom it was attempted. The esophageal suture particles or gastric contents in the pleural drain- line should be reinforced with either a pleural or age is pathognomonic of esophagopleural fis- a pedicled chest wall or intercostal muscle flap tula, and esophagography with barium or Gas- [l, 5, 10, 111. With an 86% success rate, this trografin should confirm the diagnosis and proved to be the most effective procedure. If the esophageal perforation is repaired early, before locate the precise site of the fistula. Treatment of these fistulas is usually complica- long-standing changes of inflammation and inted, and the recovery period is prolonged. Con- fection develop in the space left after trol of infection, hyperalimentation, obliteration pneumonectomy, the addition of thoracoplasty of empyema spaces, and possibly repair of the may not be necessary [lo]. Benjamin and as-
the empyema space, or esophageal reconstruction by a bypass procedure. Fourteen of these patients survived, and 1 died postoperatively following a substernal right colon bypass procedure (see Table 1). Multiple procedures were often necessary to accomplish closure of the fistula. Usually, but not always, early attempts to close the fistula by direct suture failed. Three patients were treated by daily instillation of antibiotic solution into the empyema space; all survived. In 2 of these 3 patients the fistulas had occurred late (44 and 90 months) following pneumonectomy for tuberculosis. In 1 patient, diffuse gangrenous esophagitis and esophageal rupture were discovered at autopsy.
Table 3 . Surgical Procedures Used to Repair Esophagopleural Fistula Operation
No. Attempted
No. Successful
Direct closure" Thoracoplasty" Pedicled muscle or pleural flap" Reconstructive procedure"
8 7 7 4
3 5 6 2
Percent
Successful
37.5 71.4 86.0 50.0
aPerformed in combination with thoracoplasty in 2 instances, with 1 success. bPerformed in combination with other procedures-direct closure (2) or muscle flap (2)-in 4 instances, with 3 successes. 'Performed in conjunction with thoracoplasty in 2 instances, both successful. 1 patient two attempts were made; the second succeeded.
81 Current Review: Sethi and Takaro: Esophagopleural Fistula after Pulmonary Resection
sociates [l] recommended drainage of the empyema followed by direct closure of the fistula reinforced by a pleural flap. After the fistula healed, the empyema cavity was closed by the Clagett procedure [2]. The late occurrence of esophagopleural fistula following pneumonectomy for carcinoma of the lung is ominous and suggests recurrence of the tumor. These patients may be well palliated by insertion of an intraluminal esophageal tube which may control dysphagia satisfactorily and seal off the fistula as well [121. The best form of management for this serious complication is prevention. In anticipated difficult pulmonary resections, it is advisable to obtain a preoperative esophagogram to detect unusual deflections or unsuspected diverticula of the esophagus. During operation, a nasogastric tube may be utilized in much the way general surgeons use urethral catheters in difficult pelvic resections. If the esophageal injury is recognized during operation, a primary repair in two layers should be performed. Prompt and vigorous obliteration of all postoperatively infected spaces may help prevent the late development of esophagopleural fistula. References 1. Benjamin I, Olsen AM, Ellis FH Jr: Esophagopleural fistula. Ann Thorac Surg 7:139, 1969 2. Clagett OT, Geraci JE: A procedure for the rnan-
agement of postpneumonectomy empyerna. J Thorac Cardiovasc Surg 45:141, 1963 3. Dumont A, DeGraef J: La fistule oesophagopleurale, complication tardive d e la pneurnonectomie. Lyon Chir 57:481, 1961 4. Efthimiadis M, Xanthakis D, Primikyrios N, et al: Late esophagopleural fistula after pneumonectomy for bronchial carcinoma. Chest 65:579,1974 5. Engelman RM, Spencer FC, Berg P: Postpneumonectomy esophageal fistula: successful one-stage repair. J Thorac Cardiovasc Surg 59:871, 1970 6. Eriksen KR: Oesophagopleural fistula diagnosed by microscopic examination of pleural fluid. Acta Chir Scand 128:771, 1964 7. Evans JP: Post-pneumonectomy oesophageal fistula. Thorax 27:674, 1972 8. Grosse W: Postoperative Osophagusfistel als seltene Komplikation nach Lungenresektion. Tuber 124:372, 1965 9. Lambert A: Partial claviculectomy as an adjunct to surgical collapse of the chest wall. J Thorac Surg 15:266, 1946 10. Richardson JD, Campbell D, Trinkle JK: Esophagopleural fistula after pneumonectomy. Chest 69:795, 1976 11. dos Santos MI, Netto SM, Marcal 0: Fistula esofagopleural traumatica post-pneumectomia, analise d e un caso tratado por esofagogastroplastia retrosternal. Rev Paul Med 65:263, 1964 12. Symes JM, Page AJF, Flavell G: Esophagopleural fistula: a late complication after pneumonectomy. J Thorac Cardiovasc Surg 63:783, 1972 13. Takaro T, Walkup HE, Okano T: Esophagopleural fistula as a complication of thoracic surgery. J Thorac Cardiovasc Surg 40:179, 1960
