Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series

Abstract

Background: Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation.

Methods: All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized.

Results: Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery.

Conclusion: Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Graphical abstract

FIGURE 1.

Radiologic, endoscopic and clinical images of post-lung transplantation esophageal fistulas. A, CT scan showing a bronchopleural-esophageal fistula, with the bronchial component on the left side (white arrow) and the esophageal component on the right (black arrow). B, Endoluminal view on the fistula (arrow) treated with endoluminal clipping. C, Contrast esophagogram showing contrast leakage of the esophagus to the pleural cavity on the right (arrow) after clipping of the fistula (arrowhead). D, Perioperative image showing the esophageal fistula (arrow) with sutures around the border in the posterior mediastinum. The transplant lung is annotated with an asteria. E, CT scan showing the esophageal fistula (arrow) leading to the paramediastinal collection (asteria). F, Endoluminal view of the esophageal fistula, showing necrosis and cauterization damage of the esophageal wall.