Delayed presentation of post tuberculous broncho oesophageal fistula in an adult: Perioperative anaesthetic management.

Sir,

A 42-year-old male had a recurrent cough with expectoration for last 6 months more with supine position and aggravated by the intake of food. He was referred for a pre-anaesthetic checkup for left pneumonectomy with repair of broncho oesophageal fistula (BEF). He had a history of parietal lobe abscess, drained twice with residual left-sided hemiplegia and focal seizures and had completed two courses of antituberculous treatment (ATT) 15 years back.

The patient could lie down only in left lateral position. His investigations were unremarkable. Pulmonary function testing showed moderate impairment of lung function with moderately reduced vital capacity.

X-ray and computerised tomography of the chest showed cystic bronchiectasis in left lower lobe. There were fibrosis and pleural thickening in bilateral lung fields with dilated oesophagus. Communicating tract between the lateral wall of the lower oesophagus and left lower lobe bronchus was seen at D-8 [Figure 1]. Post-inflammatory BEF was suggested in view of surrounding inflammatory changes and mediastinal lymphadenopathy. Barium swallow confirmed the same. Magnetic resonance imaging of the brain revealed post-operative changes with residual ring configuration in right posterior frontal lobe with moderate perilesional oedema.

Figure 1

Computed tomography scan chest showing cystic bronchiectasis in left lower lobe and fistulous communication between oesophagus and left lower lobe bronchus

The patient was accepted under American Society of Anaesthesiologists grade III. Antibiotics, chest physiotherapy, incentive spirometry, deep breathing exercises and all antiepileptic medications were continued till the morning of surgery. The patient was already on continuous Ryle's tube aspiration.

After pre-medication, the thoracic epidural catheter was placed at T6-T7 interspace. Epidural test dose was followed by 3 mg of morphine. Monitoring included continuous electrocardiography, invasive blood pressure, end tidal carbon dioxide, SpO2, temperature, urine output and blood loss.

After nasogastric tube aspiration and pre-oxygenation in the left lateral position, injection fentanyl 50 μg and sleep doses of thiopentone were given. As the patient went asleep, he was turned supine, and the cricoid pressure was applied. Injection rocuronium 50 mg was given to felicitate insertion of right sided double lumen tube (DLT) 41F. Intermittent positive pressure ventilation was avoided. Placement of DLT was confirmed clinically and fibreoptically. The left lung was isolated and collapsed immediately to prevent gastric distension and loss of lung volume. The patient was placed in right lateral position. Anaesthesia was maintained with nitrous oxide, oxygen, isoflurane, and rocuronium. Left pneumonectomy with excision of BEF track was done with blood loss of 2.5 L which was adequately replaced. A nasogastric tube was also placed.

At closure, 6 ml of 0.125% bupivacaine was given through the epidural catheter. After extubation of trachea, the patient was shifted to intensive care unit for observation and made an uneventful recovery.

BEF is rarely reported in the literature.[1] It may be congenital or acquired. Acquired causes include malignancy, trauma, oesophageal diverticulosis, infections such as syphilis, tuberculosis (TB) and actinomycosis. TB is the most common cause of infective BEF.

The development of BEF in TB is related to mediastinal lymph node involvement.[2] Infection and subsequent adhesions between tracheobronchial lymph nodes and oesophagus with subsequent development of a traction diverticulum communicating with the respiratory tree are the mechanism for BEF formation.

The aim during induction of anaesthesia is to avoid gas flow through the fistula which can cause gastric distension and impaired ventilation.[3] Positive pressure ventilation should be avoided. Spontaneous ventilation should be maintained during induction until gentle ventilation by mask provides an effective gas exchange. Double lumen intubation is required which protects the contralateral lung from contamination and provides the ability to ventilate it without applying positive pressure to the fistula.[3] Keeping the same in mind, rapid sequence induction was planned as insertion of DLT under spontaneous ventilation is difficult. Once placed, the diseased lung was isolated and kept collapsed.

A surgical field fire is a known hazard during the surgery for BEF repair.[4] Avoiding the use of electrocautery while the fistula is open, using wet sponges, and decreasing the oxygen concentration in the gases before the division of fistula could reduce this incidence.[4] We instituted one lung ventilation with little loss of gases and a quick repair of the fistula to avoid the same.

Post-tuberculous BEF is a rare entity and scarcely reported in the literature. BEF as a complication of TB can present at varied time intervals. There are reports of both immediate as well as a presentation in the chronic healing phase of TB.[12]

Our patient received two complete courses of ATT 15 years back. BEF developed a decade later during the chronic healing phase of TB. Chronic suppuration not only damaged the left lung but also lead to the development of BEF. To conclude, prompt recognition and meticulous perioperative management lead to the successful outcome of our patient.