|Ann. Medit. Burns Club - vol. VII - n. 3 - September 1994
TRACHEO-OESOPHAGEAL FISTULA AS A COMPLICATION IN
EXTENSIVE BURNS WITH INHALATION INJURY
Padera L, Kenigova R, Hdjek M.
Burn Centre, Medical Faculty, Charles University,
Prague, Czech Republic
SUMMARY. Two patients with
extensive bums and inhalation injury were treated in our Intensive Care Unit in 1992-93.
The patients were artificially ventilated for three and two months respectively by means
of tracheostomy. The long-term ventilation led to the developmerit of perforation of the
trachea, complicated by a communication with the oesophagus.
fistulae are life-threatening conditions and represent a very difficult area of
comprehensive therapy. The danger of fistulae is mainly represented by the risk of
aspiration and subsequent infection, while at the same time the patient can become
cachectic. The fact that some patients with a fistula can survive for a number of weeks or
months does not decrease the risk of these conditions; on the contrary, prolonged survival
worsens the prognosis of the operation.
The three most important local factors
leading to a tracheal stenosis or a tracheo-oesophageal fistula are:
- lesion of the tracheal mucosa due to inhalation injury;
- tissue ischaemia due to pressure of an expanded
- repeated minor traumas during respiratory tract care.
However, much more important than local
factors are the general aspects - mainly hypoxia, septic conditions affecting the
respiratory tract, and the patient as a Whole. Most significant is the hypermetabolic
state, with 4 low nutritional and protein index and continuing inummodeficiency related to
a critical state.
The diagnosis of fistula is easily established, provided the possibility of its occurrence
is considered. A prompt bronchoscopic and oesophagoscopic examination is indispensable.
Conservative treatment of acquired tracheo-oesophageal fistulae does not come into
consideration at all. A palliative operation which we ourselves had previously tried in
one patient (a gastrostomy) was disappointing because a gastro-oesophageal reflux led to
flooding of the trachea and aspiration. Spontaneous closure of a fistula is unlikely.
An operation is indicated if the patient's prognosis is not hopeless as regards the basic
diagnosis. All patients are at very high risk. The prognosis of recovery after
reconstruction is more favourable in patients with controlled catabolism and without
concomitant sepsis. Technically the operation is performed by preparation of the trachea
and the oesophagus in the neck and chest region, using an auxiliary sternotomy. Both
affected organs must be separated. Finally, a dermal graft is inserted between the two
Materials and methods
We report on two patients with
extensive burns (84% and 91% TBSA) and inhalation injury treated in our Intensive Care
Case 1. A 23-year-old female sustained burns involving the face, neck, trunk, upper
and lower extremities, and the respiratory tract, with TBSA 91% (61% full-thickness
burns). On day 6 post-burn (p.b.) tracheostomy was performed and necrectomies were
started; raw areas were covered with xenografts and subsequently allografts from the
patient's sisters, in combination with autografting. These procedures were successful.
Because of positive bacteriological findings in the tracheostomic tube certain antibioties
were applied (Tab. 1).
|Table 1 - Tracheo-oesophageal fistula as a
complication in extensive bums with inhalation injury
On day 26 p.b. a greenish fluid was
aspirated from the tracheostomic tube which suggested a gastric content. During
oesophagoscopie examination a large fistula was found in the upper part of the oesophagus.
On day 59 p.b. some of the allografts were rejected.
On day 66 p.b. surgical closure of the fistula was carried out.
On day 70 p.b. greenish fluid again appeared in the tracheostomic tube.
On day 74 p.b. a massive bleeding occurred in the respiratory tract owing to rupture of
the necrotic wall of the external carotid artery. This haemorrhage was the immediate cause
of death, eight days after the operation on the fistula, which was a pressure sore due to
the long-term tracheostomic tube. This was confirmed on necroscopy.
Case 2. A 22-year-old male sustained burns involving the face, neck, trunk, upper and
lower extremities, and the respiratory tract, with TBSA 84% (70% full-thickness burns).
Partial pressure of oxygen at 10 to 15 kilopascals was reached only when the concentration
of oxygen in the inspiratory air was maintained at 40 to 70%.
On day 2 p.b. fibrobronchoscopic examination of the respiratory tract was made, with the
finding of whitish slime with soot covering the wall of the terminal subsegments of the
airways. An important laboratory result was a significant decline of blood platelets
On day 9 p.b. tracheostomy was required, followed by necrectomy with xenografting,
allografting and autografting.
On day 30 p.b. a green fluid was aspirated from the tracheostomic tube. On oesophagoscopic
examination a fistula at 10 to 15 mm was again discovered.
Two days later (day 32 p.b.) the fistula was sutured. After one week the patient developed
pneumonia and ileus. Conservative treatment was not successful and gastrostomy according
to Witzel was carried out. Hyperpyrexia (40 to 41'C) continued after the surgical
procedures and on day 59 p.b. the patient died (27 days after the fistula
operation). Necropsy showed relapse of the tracheo-oesophageal fistula at 15 to 40 mm,
inflammation of the oesophagus and trachea, bronchopneumonia, ileus, gastric ulcer,
perforation of the right colic flexure and diffuse peritonitis. The general condition of
this patient was very poor, for which reason we did not re-operate.
Burned patients with inhalation
injury often develop decreased lung compliance due to the adult respiratory distress
syndrome with a different pathophysiology. This results in upper airway pressure, and a
higher intracuff pressure is needed to maintain the cuff's sealing effect. Prolonged
intubation is necessary in these patients. The presence of a wide-bore gastric tube causes
pressure on the sandwiched mucosa between the cuff of the tracheal tube and the gastric
Excessive motion of the tracheal tube
during frequent dressing changes and respiratory care is another predisposing factor.
Local infection worsens the mucosal damage, resulting in perforation. The duration of
artificial ventilation by means of a tracheal tube in these patients exerts a basic
influence on the occurrence of this complication.
RESUME. Les auteurs décrivent deux
patients atteints de brûlures étendues et de lésions aux voies respiratoires traités
dans leur centre de réanimation en 1992-93. Les patients étaient maintenus en
ventilation artificielle pour trois et deux mois respectivement, moyennant la
trachéostomie. La ventilation à long terme a causé le développement de la perforation
de la trachée, aggravée par la complication de la communication avec l'oesophage.
- Tan K.K., Lee J.K., Tan L, Sarvesvaran R.:
Acquired tracheo-oesophageal fistula following tracheal intuba,tion in a burned patient.