A 31-year-old male, non-smoker, presented to us with a history of attacks of chronic intermittent cough since childhood. These attacks usually last for two to three days. Sometimes initiated and aggravated after heavy meals. It was also associated with recurrent chest infections. No significant history of hemoptysis, shortness of breath, difficulty of swallowing, or chocking was reported. Systemic examination was unremarkable. He used inhalers and cough suppressants as required.
Chest X-ray showed bilateral apical pleural thickening with fibroatelectatic changes at the right upper lobe. Barium studies showed significant dilatation of the whole esophagus, more at the proximal 3rd, with free passage of the contrast into the stomach without any stricture or narrowing at the distal end or at gastroesophageal junction; these findings were suggestive of some neurological causes or esophageal motility disorder. For further evaluation, the patient underwent esophageal manometry study and upper gastro-intestinal (GI) endoscopy. Esophageal manometry showed aperistaltic esophagus, but the lower esophageal sphincter could not be assessed. Upper GI endoscopy revealed the presence of smooth tracheoesophageal opening (fistula) in the upper 3rd of the anterior wall of the esophagus at 25 cm from the incisor teeth [Figure 1]; however, biopsy and wash aspiration from this fistula was negative for tuberculosis (TB) culture.
Computed tomography (CT) scan of chest confirmed the presence of the TEF at the level of sternoclavicular joint along with dilated esophagus. Also, there was evidence of cystic, cylindrical, and varicose bronchiectatic changes in both the right upper, middle lobes, and in the lingula. There were also subpleural fibroatelectatic changes in the posterior segment of the right upper lobe, most likely due to recurrent aspirations [Figure 2a-b].
Patient explored in the operating room through cervical approach along the anterior border of the left sternocleidomastoid muscle. Fistula was identified between the posterolateral wall of the trachea and the anterior wall of the esophagus. Adhesions separated and the fistula isolated completely and then closed by endo-GI stapler. Esophageal side reinforced with muscular patch to buttress this repair and to minimize the postoperative esophageal leak and to prevent long-term recurrence. Postoperative recovery was uneventful. Patient started oral fluids on the second postoperative day, the drain removed on the third day, and he was discharged home on fourth postoperative day. Patient remained asymptomatic and well at 12-month regular follow-up, as he underwent during this follow-up a barium swallow study which showed normal swallowing process and no hold up of the contrast with no evidence of gastroesophageal reflux and there was no evidence of recurrence of the TEF; however, he remained under regular follow-up with the gastroenterologist team for the esophageal motility disorder which has improved significantly clinically and radiologically.
". CT scan chest demonstrating bronchiectatic changes in the right middle lobe, "see arrow".