A Case of Contralateral Left Main Bronchial-Esophageal Fistula Following Right Lower Lobectomy with Systematic Mediastinal Lymph Node Dissection.

INTRODUCTION

Bronchial or tracheobronchial esophageal fistula following pulmonary resection is a rare complication, and involvement of the contralateral main bronchus is extremely uncommon.

CASE PRESENTATION: A 78-year-old woman underwent right lower lobectomy with systematic mediastinal lymph node dissection for primary lung cancer. Her initial postoperative course was uneventful, and she was discharged on POD 2. On POD 14, however, she presented with coughing and vomiting during oral intake. Further evaluation revealed a bronchoesophageal fistula (BEF) between the contralateral left main bronchus and the esophagus. Review of the intraoperative video did not demonstrate intentional direct manipulation of the left main bronchus or the esophagus; however, inadvertent contact during hemostasis of subcarinal #7 lymph node (LN #7) tissue cannot be completely excluded. Therefore, delayed thermal injury associated with soft coagulation during LN #7 dissection was considered a possible contributing mechanism in this case. The patient was initially managed conservatively with fasting, total parenteral nutrition, and enteral feeding via a jejunostomy, resulting in gradual reduction of the fistula. After adequate resolution of local inflammation, additional endoscopic clipping from the esophageal side was performed, achieving complete closure.

CONCLUSIONS

This case suggests that energy devices, particularly soft coagulation, may be associated with delayed thermal injury even in areas not directly manipulated. Furthermore, a stepwise treatment strategy based on initial conservative management may be effective for small BEFs with localized inflammation in selected cases.