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• W1976727373 abstract "The clinical details of a 60-year-old woman with bronchoesophageal fistula is reported. This lesion probably persists into adulthood because initial pulmonary symptoms are mild and are not fully investigated. Cine esophagogram is recommended, on review of the literature, to be the most rewarding diagnostic procedure. The clinical details of a 60-year-old woman with bronchoesophageal fistula is reported. This lesion probably persists into adulthood because initial pulmonary symptoms are mild and are not fully investigated. Cine esophagogram is recommended, on review of the literature, to be the most rewarding diagnostic procedure. Congenital fistulous communications between the esophagus and the tracheobronchial tree are usually associated with esophageal atresia and are readily diagnosed in the neonatal period. There is, however, (3-4 percent of this anomaly) the so-called H-type, in which there is no atresia of the esophagus.1Haight C Tracheosophageal fistula without atresia.In Pediatric Surgery. (2nd Ed). Vol 1. Year Book, Chicago1969Google Scholar The esophagus may be entirely normal except for the fistula and symptoms of respiratory difficulty are minimal and may be masked for varying lengths of time depending on the site and size of the fistulous tract. These patients seldom reach adulthood before diagnosis is made. We recently had the opportunity to treat such a patient and the purpose of this presentation is to report the clinical details and briefly review similarly reported cases. A 60-year-old woman was admitted to the hospital because of progressively worsening cough and choking sensation upon ingestion of liquids during the preceding six months. She had a longstanding history of cough, expectoration of frothy sputum, wheezing, dyspnea, and sometimes hemoptysis. Clinical investigations performed in another institution many years previously had not revealed the cause of her symptoms. She was also known to have coronary artery disease confirmed by arteriography.Examination of her chest showed clear percussion note, but wheezes and expiratory râles were heard in both lung bases. The cardiovascular system was unremarkable. There was slight bilateral ankle edema. There was no clubbing of the fingers.An electrocardiogram showed no abnormalities and the chest roentgenogram revealed a prominent left ventricle and slight accentuation of the pulmonary markings. Hemogram and blood chemistries were within normal limits. Cineesophagogram revealed a fistula between the esophagus and the right lower lobe bronchus with mild aspiration into the right bronchial tree (Fig 1). Bronchographic examination revealed no abnormalities and bronchoscopic examination demonstrated the presence of a fistulous opening at the posterior wall of the right lower lobe bronchus.Right thoracotomy was performed. A few adhesions between the parietal and visceral pleura of the right lower lobe were taken down and the esophagus dissected out below the azygos vein. A fistulous tract, 1 cm in length, was found joining the esophagus, at about 6 cm below the azygos vein, and the right lower lobe bronchus. It was stapled on the bronchial side, excised and the esophageal side sutured. The fistula was smooth and symmetrically round. The lumen was about 5 mm in diameter. The patient did well after operation and was discharged after ten days. In a recent review2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar of 260 patients with congenital esophago-pulmonary fistulas without atresia among both children and adults, only 71 patients had bronchoesophageal fistulas. The remainder had tracheoesophageal fistulas. Fifty-one (75 percent) of the bronchoesophageal fistulas were considered in the adult population since they were diagnosed after the age of 15 years. Braimbridge and Keith3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar had previously found reference to 20 cases and added three of their own for review. We have found six additional case reports in adults.4Le Roux BT Williams MA Congenital oesophago-bronchial fistula with presentation in adult life.Br J Surg. 1968; 55: 306-308Crossref PubMed Scopus (16) Google Scholar, 5Kinley CE Lang HB Congenital bronchoesophageal fistula in an adult: a case presenting with massive hemoptysis.Canad Med Assoc J. 1969; 100: 2-390Google Scholar, 6Paulin R Longtin L Madhavian F Congenital bronchoesophageal fistula in an adult.Canad Med Assoc J. 1970; 102: 964-966PubMed Google Scholar, 7Smith DC A congenital broncho-esophageal fistula presenting in adult life without pulmonary infection.Br J Surg. 1970; 57: 398-400Crossref PubMed Scopus (30) Google Scholar There are possibly not more than 70 cases reported to date. Even though there are certainly many more cases of adult congenital bronchoesophageal fistulas encountered than have been reported, the condition is rare. The abnormal communication results from a developmental malformation in which there is failure of complete closure of the laryngotracheal groove.1Haight C Tracheosophageal fistula without atresia.In Pediatric Surgery. (2nd Ed). Vol 1. Year Book, Chicago1969Google Scholar Smith7Smith DC A congenital broncho-esophageal fistula presenting in adult life without pulmonary infection.Br J Surg. 1970; 57: 398-400Crossref PubMed Scopus (30) Google Scholar speculates that the eventual site of the fistula between the esophagus and the pulmonary tree depends on the degree of esophagotracheal separation taking place before the caudal elongation of the trachea. The fistula usually takes an oblique course with the esophageal opening being lower than the bronchial orifice,7Smith DC A congenital broncho-esophageal fistula presenting in adult life without pulmonary infection.Br J Surg. 1970; 57: 398-400Crossref PubMed Scopus (30) Google Scholar,9Demoug CV Grow JB Heitzman GC Congenital tracheoesophageal fistula without atresia of the esophagus.Am Surg. 1959; 25: 156-162PubMed Google Scholar but in the present case report the esophageal opening was higher than the bronchial opening. There may be cystic dilation of the bronchial end, as pointed out by Braimbridge and Keith.3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar Over 60 percent of the reported cases involved the right side. The fistula is almost always lined with squamous epithelium which is surrounded by submucosa and muscularis. There is an outer coat of adventitia. There have been cases in which the lining was columnar epithelium.3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar The median age at diagnosis was 33 years in the review by Blackburn and Amoury2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar and in another review,3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar the duration of symptoms varied from six months to 50 years with a mean of 17 years. Symptoms leading to diagnosis are paroxysmal coughing and choking sensation after liquids, chronic cough, recurrent pneumonia, sputum production, hemoptysis, chest pains, postural symptoms, intermittent fever, belching and gastric complaints. Bronchiectasis and localized pneumonitis as well as lung abscesses have been found on investigation of some patients. The diagnostic tool which has been found most rewarding is barium swallow.2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar,3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar Cine-esophagography with sequential positioning of the patient is the most dependable method of diagnosis. Conventional esophagogram may not show the fistula or demonstrate a spill into the pulmonary tree. It may be pointed out here that since pulmonary symptoms may reflect esophageal disease the esophagus should be investigated more frequently when patients present with respiratory complaints. Esophagoscopy has not been so successful; however, often the bronchial end of the fistula can be seen at bronchoscopy. Bronchography may not show the fistula but more importantly, it will demonstrate the presence of bronchiectasis. Why this lesion sometimes eludes diagnosis in adults until late is not clear. Various explanations including the initial presence of a membrane which subsequently ruptures,8Jackson C Coates GM The Nose, Throat, Ear and Their Diseases. Saunders, Philadelphia1929: 1124Google Scholar adaptation of the patients to the minimal pulmonary symptoms produced2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar and possibly the obliquity of the tract permitting its closure during swallowing9Demoug CV Grow JB Heitzman GC Congenital tracheoesophageal fistula without atresia of the esophagus.Am Surg. 1959; 25: 156-162PubMed Google Scholar have been offered by previous authors. Perhaps there is not a late onset of symptoms, but rather the initial mild complaints have not been thoroughly investigated until complications appear. There is always a long duration of symptoms, as pointed out. All three patients of Le Roux and Wilhams4Le Roux BT Williams MA Congenital oesophago-bronchial fistula with presentation in adult life.Br J Surg. 1968; 55: 306-308Crossref PubMed Scopus (16) Google Scholar had bronchiectasis and in 45 adult patients reviewed by Blackburn and Amoury,2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar 30 had bronchiectasis and 14 had focal interstitial pneumonitis or abscesses. These complications point to a long duration of ignored symptoms. Once diagnosis has been made, the bronchoesophageal fistula should be treated surgically. Simple excision with repair of both the bronchial and esophageal ends of the tract may be all that is required. If, however, there is additional damage of lung tissue this should be resected. Thus, in several reported cases, segmental resection, lobectomy, bilobectomy, or even a pneumonectomy has been performed in addition to resection and repair of the fistula.2Blackburn WR Amoury RA Congenital esophago-pulmonary fistulas without esophageal atresia: An analysis of 260 fistulas in children and adults.Rev Surg. 1966; 23: 153-175PubMed Google Scholar, 3Braimbridge MV Keith HI Oesophago-bronchial fistula in the adult.Thorax. 1965; 20: 226-233Crossref PubMed Scopus (94) Google Scholar, 4Le Roux BT Williams MA Congenital oesophago-bronchial fistula with presentation in adult life.Br J Surg. 1968; 55: 306-308Crossref PubMed Scopus (16) Google Scholar, 5Kinley CE Lang HB Congenital bronchoesophageal fistula in an adult: a case presenting with massive hemoptysis.Canad Med Assoc J. 1969; 100: 2-390Google Scholar, 6Paulin R Longtin L Madhavian F Congenital bronchoesophageal fistula in an adult.Canad Med Assoc J. 1970; 102: 964-966PubMed Google Scholar, 7Smith DC A congenital broncho-esophageal fistula presenting in adult life without pulmonary infection.Br J Surg. 1970; 57: 398-400Crossref PubMed Scopus (30) Google Scholar It cannot be overemphasized that only damaged tissue need be removed and as much lung parenchyma as possible must be preserved. Results have been uniformly satisfactory with complete remission of symptoms and no major postoperative complications." @default.
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• W1976727373 title "Congenital Bronchoesophageal Fistula in the Adult" @default.
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