What is the management of a corrosive esophageal stricture with a bronchopleural (lung and pleural) fistula?

Management of Corrosive Esophageal Stricture with Bronchopleural Fistula

Immediate surgical resection with esophagectomy is required for corrosive strictures complicated by bronchopleural fistula, as this represents transmural necrosis with extension to adjacent structures and carries extremely high mortality without aggressive intervention. 1

Initial Assessment and Stabilization

Recognize this as a surgical emergency requiring multidisciplinary involvement:

• Obtain contrast-enhanced CT immediately to define the extent of esophageal necrosis, fistula tract anatomy, and degree of mediastinal/pleural contamination 2
• Perform preoperative tracheobronchial endoscopy to assess the extent of airway involvement and identify the fistula site, as this is mandatory before any surgical intervention 1
• Place adequate chest drainage to control pleural contamination and prevent tension pneumothorax 3
• Initiate broad-spectrum antibiotics targeting polymicrobial infection from esophageal and respiratory flora 4

Surgical Management Strategy

The presence of a bronchopleural fistula with corrosive stricture indicates Grade III transmural necrosis requiring emergency surgery:

• Perform stripping esophagectomy through combined abdominal and cervical approach with resection of all necrotic esophageal tissue 1
• Address the bronchopleural fistula with pulmonary patch repair through right thoracotomy, which may be lifesaving in this setting 1
• Create a feeding jejunostomy at the end of the operation for long-term nutritional support 1
• Do NOT attempt immediate esophageal reconstruction, as subsequent stricture formation and ongoing inflammation will compromise functional outcomes 1

Critical Surgical Principles

All obvious transmural necrotic tissue must be resected during the initial operation:

• Preserve the stomach if possible unless transmural gastric necrosis is present 1
• Plan for delayed esophageal reconstruction (typically 6-12 months after initial resection) once inflammation has resolved 1
• Be prepared for extended resections if adjacent organs (spleen, colon, duodenum) show concomitant necrosis 1

When Conservative Management Might Be Considered

Conservative management is contraindicated in your scenario, but if the fistula developed late (months after injury) in a stable patient:

• Oriented pleural drainage with adequate antibiotic therapy combined with endoscopic closure techniques using silver nitrate application through flexible bronchoscopy (3-15 sessions, 3 times per week) has shown 94% success in post-surgical bronchopleural fistulas 4
• Fibrin sealants (Histoacryl or Tissucol) injected bronchoscopically achieved 85.7% closure rates in small fistulas (mean 3.6 mm) 5
• However, these techniques are described for post-operative fistulas, not acute corrosive injury with active necrosis 4, 5

Common Pitfalls to Avoid

Do not delay surgical intervention when transmural necrosis is present:

• Delaying surgery in the presence of Grade III CT injuries leads to perforation, mediastinitis, and death 1
• Do not attempt endoscopic dilation of the stricture when a fistula is present, as this will worsen contamination and increase mortality 1
• Do not perform partial resections when complete resection is indicated, as ongoing necrosis will compromise survival 1
• Do not attempt primary esophageal reconstruction at the emergency operation, as this will fail due to ongoing inflammation 1

Post-Operative Management

After successful resection and fistula repair:

• Maintain chest tube drainage until air leak resolves and pleural space is controlled 3
• Provide long-term parenteral nutrition or jejunostomy feeding as oral intake will be impossible 1
• Plan for delayed esophageal reconstruction (colonic or gastric interposition) after 6-12 months when inflammation has resolved 1
• Mandatory psychiatric evaluation before hospital discharge, as corrosive ingestion is often intentional 1

Prognosis

The standard mortality ratio for patients operated for caustic necrosis is 21.5 compared to the general population, emphasizing the life-changing nature of this intervention 1. However, without appropriate surgical management, mortality approaches 100% when transmural necrosis with fistula formation is present 1.