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Wu W, Li S, Song X, Wang X, Wang Y, Cai C, Wang J, Li Y, Ma W. Case Report: Differential lung ventilation with jet ventilation via a bronchial blocker for a patient with a large thoracogastric airway fistula after esophagectomy. Front Surg 2022; 9:959527. [DOI: 10.3389/fsurg.2022.959527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/26/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundA thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication of esophagectomy for esophageal and cardia carcinomas. Isolation of the fistula and pulmonary separation is necessary during the surgical repair of a tracheal fistula. However, currently, the reported airway management techniques are not suitable for patients with a large TGAF. This case study presents an alternative technique for performing differential lung ventilation in a patient with a thoracogastric airway fistula.Case presentationA 70-year-old man was diagnosed with a thoracogastric airway fistula situated above the carina after esophagectomy, and a thoracoscope-assisted repair of the fistula and pectoralis major myocutaneous flap transplantation were scheduled. The patient could not tolerate one-lung ventilation and the complex intubating operation due to aspiration pneumonia and the size (3.5 cm × 1.7 cm) of the fistula. We, therefore, performed differential lung ventilation in which an extended 6.5#single-lumen endotracheal tube was inserted into the left main bronchus and a 9Fr bronchial blocker was placed in the right main bronchus by using the video-flexible intubation scope. The right lung was selectively inflated with jet ventilation, while positive pressure ventilation was maintained through the left endotracheal tube. The value of SPO2 remained above 95% throughout the operation.ConclusionFor patients with a large thoracogastric airway fistula, differential lung ventilation of a combination of positive pressure ventilation and jet ventilation is useful. Inserting an extended single-lumen endotracheal tube into the left main bronchus and a bronchial blocker into the right main bronchus could be another way of providing differential ventilation for patients with a large thoracogastric airway fistula.
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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Hwang SM, Kim MJ, Kim S, Kim S. Accidental esophageal intubation via a large type C congenital tracheoesophageal fistula: A case report. World J Clin Cases 2022; 10:11198-11203. [PMID: 36338240 PMCID: PMC9631146 DOI: 10.12998/wjcc.v10.i30.11198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/30/2022] [Accepted: 09/19/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tracheoesophageal fistula (TEF) is a congenital anomaly characterized by interruptions in esophageal continuity with or without fistulous communication to the trachea. Anesthetic management during TEF repair is challenging because of the difficulty of perioperative airway management. It is important to determine the appropriate position of the endotracheal tube (ETT) for proper ventilation and to prevent excessive gastric dilatation. Therefore, the tip of the ETT should be placed immediately below the fistula and above the carina.
CASE SUMMARY A full-term, one-day-old, 2.4 kg, 50 cm male neonate was diagnosed with TEF type C. During induction, an ETT was inserted using video laryngoscope and advanced deeply to ensure that the tip passed over the fistula, according to known strategies. The passage of the ETT through the vocal cords was confirmed via video laryngoscope. However, after inflating the ETT cuff, breath sounds were not heard on bilateral lung auscultation. Instead, gastric sounds were heard. Considering that a large fistula (approximately 6.60 mm × 4.54 mm) located 10.2 mm above the carina was confirmed on preoperative tracheal computed tomography, the possibility of unintentional esophageal intubation was highly suspected. Therefore, we decided to uncuff and withdraw the ETT carefully for repositioning, while monitoring auscultation and end-tidal CO2 simultaneously. At a certain point (9.5 cm from the lip), clear breath sounds and proper end-tidal CO2 readings were suddenly achieved, and adequate ventilation was possible.
CONCLUSION Preanesthetic anatomical evaluation with imaging studies in TEF is necessary to minimize complications related to airway management.
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Affiliation(s)
- Seong Min Hwang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Myeong Jin Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Sora Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Saeyoung Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
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Balkisson M, Kusel B, Torborg AM. A retrospective review of the perioperative management of patients with congenital oesophageal atresia and tracheo-oesophageal fistula at a South African third level hospital. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.3.2685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- M Balkisson
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - B Kusel
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - AM Torborg
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
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Sheng B, Zhong L, Du B. Novel use of balloon-tipped bronchial blockers to occlude neonatal tracheoesophageal fistula: a case series. BMC Pediatr 2022; 22:60. [PMID: 35078431 PMCID: PMC8788077 DOI: 10.1186/s12887-022-03131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Management of the airway and ventilation in neonates with a tracheoesophageal fistula (TEF) remains a significant challenge. The routine method of intubation involves placement of the tracheal tube tip beyond the fistula opening followed by isolation of the fistula from ventilation using the inflated cuff. When the fistula opening is close to the carina or below the level of the carina, the traditional technique is not suitable for adequate ventilation. Moreover, this method fails to prevent gastric insufflation.
Case presentation
We herein report a series of 10 newborns with TEFs (1,090–3,080 g) who underwent bronchoscopic insertion of a 5-Fr balloon-tipped bronchial blocker (BTBB) for temporary occlusion of the fistula. In seven newborns, placement of the BTBB was easily and quickly achieved with no incorrect placements. In addition, we successfully utilized the inner hollow cavity of the BTBB for gastric decompression in six neonates with severe gastric distension. However, three failed placements occurred in premature infants (<2,000 g) because the narrow cricoid cavity was too small to accommodate a 2.8-mm fiberoptic bronchoscope and a BTBB. The procedure was well tolerated by all infants, and no significant adverse events occurred.
Conclusions
Our findings illustrate that BTBBs can provide durable blockage of the fistula opening and should be considered as a treatment modality for infants with large carinal TEFs. Moreover, BTBB placement is neither arduous nor time-consuming. The hollow center, small round balloon, and 30-degree angled tip of the BTBB make this device feasible for clinical application, especially for neonates with severe gastrointestinal distension.
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Ritz LA, Widenmann-Grolig A, Jechalke S, Bergmann S, von Schweinitz D, Lurz E, Hubertus J. Outcome of Patients With Esophageal Atresia and Very Low Birth Weight (≤ 1,500 g). Front Pediatr 2020; 8:587285. [PMID: 33282800 PMCID: PMC7705242 DOI: 10.3389/fped.2020.587285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: Primary repair of esophageal atresia (EA) in infants with very low birth weight (VLBW) and extremely low birth weight (ELBW) has been widely performed in pediatric surgery. However, several studies have shown that complication rates in infants with VLBW are high. We hypothesize preterm children benefit from a shorter, less-traumatizing operation in the first days of life, as staged repair implies. Methods: Patients with EA and VLBW were retrieved from the database of a large national patient organization KEKS e.V. Structured questionnaires were sent to all the patients' families; the responses were pseudonymized and sent to our institution. Results: Forty-eight questionnaires from patients were analyzed. The mean birth weight was 1,223 g (720-1,500 g). Primary repair was performed in 25 patients (52%). Anastomotic insufficiency (AI) was reported in 9 patients (19%), recurrent fistula (RF) in 8 (17%), and anastomotic stenosis in 24 patients (50%). Although AI was almost twice as common after primary repair than after staged repair (24 vs. 13%; p = 0.5), the difference was not statistically significant. RF was more frequent after primary repair (28 vs. 4%; p = 0.04), gastroesophageal reflux was more frequent in the group after staged repair (78 vs. 52%; p = 0.04), and both correlations were statistically significant. Intracranial hemorrhage (ICH) was reported in 11 patients (23%) and was observed in 7 of them (64%, p = 0.4) after primary repair. ICH was reported in 60% of patients with ELBW and 75% of patients when ELBW was paired with primary repair. Conclusion: This study demonstrates the complication rate in patients with VLBW is higher than the average of that in patients with EA. The study indicates that a staged approach may be an option in this specific patient group, as less RF and AI are seen after staged repair. ICH rate in patients with ELBW seemed to be especially lower after staged repair. Interestingly, gastroesophageal reflux was statistically significantly higher in the group after staged repair, and postoperative ventilation time was longer. It is therefore necessary to individually consider which surgical approach is appropriate for this special patient group.
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Affiliation(s)
- Laura Antonia Ritz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Anke Widenmann-Grolig
- KEKS e.V., National German Patient Organization for Diseases of the Esophagus, Stuttgart, Germany
| | - Stefan Jechalke
- KEKS e.V., National German Patient Organization for Diseases of the Esophagus, Stuttgart, Germany
| | - Sandra Bergmann
- Department of Pediatric Surgery, Speech and Language Therapy, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Eberhard Lurz
- Department of Pediatric Gastroenterology, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jochen Hubertus
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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Okumuş M, Zübarioğlu AU, Atalan R. Treatment of two newborns with esophageal atresia and distal tracheoesophageal fistula complicated by gastric perforation: choosing the simple way. Acta Chir Belg 2020; 120:282-285. [PMID: 30714508 DOI: 10.1080/00015458.2018.1564491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Gastric distention and perforation are possible results in a preterm newborn with esophageal atresia and distal tracheoesophageal fistula, especially when there is a need for mechanical ventilatory support. The results of the reported cases treated with emergency thoracotomy and fistula ligation after gastrostomy are not very satisfactory. Sometimes simple temporary solutions can be useful for stabilization and allow safety for required surgical treatment for later.Patient and methods: Two preterm newborns with esophageal atresia and distal tracheoesophageal fistula complicated by gastric perforation were reported.Results: Both of the patients were initially treated with a simple peritoneal drainage and, then the definitive operations were performed without any problem in stabilized patients.Conclusion: Performing fistula ligation or occlusion as an initial treatment in patients with impaired cardiac and respiratory functions may worsen the status of the patient. In such cases, it could be better to perform simple interventions first to facilitate subsequent treatments.
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Affiliation(s)
- Mustafa Okumuş
- Department of Pediatric Surgery, Yeni Yüzyıl University, Faculty of Medicine Gaziosmanpaşa and Bahat Hospital, Gaziomanpaşa, Turkey
| | - Adil Umut Zübarioğlu
- Department of Pediatrics Division of Neonatology, Yeni Yüzyıl University, Faculty of Medicine, Gaziosmanpaşa Hospital, Gaziosmanpaşa, Turkey
| | - Reşit Atalan
- Department of Pediatrics, Bahat Hospital, Sultangazi, Turkey
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Diagnosis and management of complete tracheal rings with concurrent tracheoesophageal fistula. Int J Pediatr Otorhinolaryngol 2020; 133:109971. [PMID: 32179205 DOI: 10.1016/j.ijporl.2020.109971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/25/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Characterize patients with complete tracheal rings and tracheoesophageal fistula (TEF) and summarize management options. METHODS A systematic review of patients under 18 years of age with complete tracheal rings and TEF was conducted. Authors were contacted for additional patient information and new cases were added. Patients with iatrogenic TEF and tracheal stenosis due to other causes were excluded. RESULTS Sixteen patients with a median (IQR) follow-up of 10 months (3-12 months) were identified. All had a distal TEF with complete tracheal rings distal to the TEF. There were 10 (63%) type C esophageal atresia + TEF (EA/TEF), and 1 (6%) type D (5 missing data). Median (IQR) airway diameter was 2 mm (1.5-2.2 mm). Complete tracheal rings were diagnosed prior to TEF repair in 5 (31.3%) patients, after ≥1 failed extubation in 3 (12.5%) patients, and intra-operatively during respiratory distress in 1 patient. Ten patients (62.5%) were intubated with an endotracheal tube and one with a 6 Fr flexible aortic canula (5 missing data). Four patients with an endotracheal tube for TEF repair developed ventilatory problems. Complete tracheal rings were repaired in 9 (56%) patients (8 slide tracheoplasty, 1 pericardial patch) and followed conservatively in 3 (19%). One patient required tracheotomy. Four patients died. CONCLUSIONS Complete tracheal rings with concurrent TEF is a rare entity that pose challenges for ventilatory management during operative repair. Bronchoscopy prior to TEF repair is critical to allow for proper preoperative planning.
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Abstract
PURPOSE Tracheoesophageal fistula (TEF) is a bellwether for a country's ability to care for sick newborns. We aim to review the existing literature from low- and middle-income countries in regard to management of those newborns and the possible approaches to improve their outcomes. METHODS A review of the existing English literature was conducted with the aim of assessing challenges faced by providers in LMIC in terms of diagnostic, preoperative, operative and post-operative care for TEF patients. We also review the limited literature for performing thoracoscopic repair in the developing world context and suggest methods for introduction of advanced thoracoscopic procedures including techniques for providing anesthesia to these challenging babies. RESULTS While outcomes related to technique from LMIC are comparable to the developed world, rates of secondary complications like sepsis and pneumonia are higher. In many areas, repairs are conducted in a staged fashion with minimal utilization of thoracoscopic approach. The paucity of resources creates strain on intraoperative and post-operative management. CONCLUSION Clearly, not all developing world contexts are ready to attempt thoracoscopic repair but we outline suggestions for assessing the existing capabilities and a stepwise gradual implementation of advanced thoracoscopy when appropriate.
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Tracheal Intubation: The Proof is in the Bevel. J Emerg Med 2018; 55:821-826. [PMID: 30316622 DOI: 10.1016/j.jemermed.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 08/02/2018] [Accepted: 09/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. DISCUSSION The ETT bevel orientation is the main determinant of which mainstem bronchus the ETT enters when advanced too distally, despite a common belief that attributes a higher incidence of right mainstem bronchial intubation to the straighter angle sustained by the right mainstem bronchus. Likewise, a bougie- or fiberscope-assisted tracheal intubation can be impeded by the ETT tip hooking onto laryngeal structures; a 90-degree counterclockwise turn of the ETT (such that the bevel is facing posteriorly) prior to advancing it toward the larynx produces a first-pass success rate of 100%. Similarly, a posterior-facing bevel is believed to improve the ease of passage through the back of the nasal cavity when performing nasotracheal intubation. If resistance is met after the ETT tip has reached the laryngeal vicinity, further counterclockwise rotation may change the plane and incident angle of the ETT tip, facilitating passage through the vocal cords. Clockwise twisting of the ETT reduces the incident angle in the sagittal plane, thereby facilitating videolaryngoscopy-assisted tracheal intubation. Finally, a posterior-facing ETT bevel is the least likely to intubate a tracheoesophageal fistula. CONCLUSIONS Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.
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Tollinche LE, Chawla M, Lee EW, Rolando Peralta A. Collaborating with interventional pulmonology in managing a massive tracheoesophageal fistula that extends from cricoid to carina: a case report. JA Clin Rep 2018; 3:62. [PMID: 29457105 PMCID: PMC5804658 DOI: 10.1186/s40981-017-0133-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/24/2017] [Indexed: 11/18/2022] Open
Abstract
Tracheoesophageal fistulas (TEF) present a perioperative management challenge. A 62 year-old man with esophageal carcinoma presented with a large tracheoesophageal fistula extending most of the trachea. Previously, the patient had two overlapping esophageal and one tracheal stent placed, but he developed progressive tracheal disruption due to esophageal stent perforation near the level of the cricoid. This case describes the anesthetic management of tracheal stent placement for an expanding TEF. Management included a spontaneous breathing inhalation induction followed by ventilation through a supraglottic device—laryngeal mask airway (LMA). Finally, during rigid bronchoscopy, a combination of bag ventilation and jet ventilation was utilized.
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Affiliation(s)
- Luis E Tollinche
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C330F, New York, NY 10065 USA
| | - Mohit Chawla
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C330F, New York, NY 10065 USA
| | - Eunice W Lee
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C330F, New York, NY 10065 USA
| | - A Rolando Peralta
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C330F, New York, NY 10065 USA
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Ultrasound-guided selective intubation in a preterm neonate undergoing type-C esophageal athresia correction. Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Yu Y, Zhu C, Qian X, Gao Y. Tracheoesophageal fistula induced by invasive pulmonary aspergillosis. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:345. [PMID: 27761449 DOI: 10.21037/atm.2016.09.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Invasive pulmonary aspergillosis (IPA) is commonly seen in immunocompromised patients, and tracheoesophageal fistula (TEF) induced by IPA is rare and seldom reported. Management of these critically ill patients is challenging and often requires a multidisciplinary approach. The authors reported an adult suffering from aplastic anemia who developed TEF caused by IPA. The diagnosis was confirmed following bronchoscopy and histopathological examination. Antifungal and bronchoscopic intervention provided a cure without any recurrence as yet.
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Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Cheng Zhu
- Department of Emergency, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Xiaozhe Qian
- Department of Thoracic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Yuan Gao
- Department of Critical Care Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
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