Development of fistula between esophagogastric anastomotic site and cartilage portion of trachea after subtotal esophagectomy for cervical esophageal cancer: a case report

Abstract

A 65-year-old man with cT3N2M0 stage III cervical esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the retrosternal route after neoadjuvant chemoradiotherapy. The anastomosis was located adjacent to the left side of the trachea, and a circular stapler was used for anastomosis. Postoperative anastomotic leakage occurred, and an esophagotracheal fistula between the esophagogastric anastomotic site and cartilage portion of the trachea was observed on postoperative day 44. The patient underwent division of the fistula, direct suturing of the anastomotic leakage site, left pectoralis major muscle flap placement, and tracheotomy. He was discharged home on postoperative day 120 on an oral diet. All previous reports of tracheobronchial fistula describe the occurrence of the fistula at the membranous portion of the trachea. The formation of a fistula between the esophagogastric anastomotic site and cartilage portion of the trachea is considered a possible complication when a high esophagogastric anastomosis is created.

Diagnosis, assessment, and management of surgical complications following esophagectomy

“…Surgical options include pedicled muscle flap (such as sternocleidomastoid, pectoralis major, or, as described below, intercostal muscle) repair for complex cervical fistulas/leaks . If gastric fundic tip necrosis (local ischemia) is present, resection of the necrotic tissue and refashioning of the anastomosis, if possible, are necessary .…”

“…Of the 17 patients, 13 were alive at the time of reporting. Various tissue flaps were described, including three latissimus dorsi flaps, five pectoralis major flaps, two sternocleidomastoid muscle flaps, one intercostal muscle flap, one sternohyoid muscle flap, one skin perforator pedicled by an intercostal muscle flap, five pericardial flaps, and one pleural flap . No clear evidence supports the superiority of any one operative approach.…”

“…Surgical options include pedicled muscle flap (such as sternocleidomastoid, pectoralis major, or, as described below, intercostal muscle) repair for complex cervical fistulas/leaks. 91,92 If gastric fundic tip necrosis (local ischemia) is present, resection of the necrotic tissue and refashioning of the anastomosis, if possible, are necessary. 59 In the face of gross or diffuse ischemia of the gastric conduit, diversion surgery, dismantling the gastric pull-up, and placing a temporary esophagostomy with staged colonic interposition is inevitable.…”

Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report

“…Therefore, surgeons should consider surgical treatment for TEF. According to the literature, if the fistula fails to be cured within 4–6 weeks, patients should be treated surgically [ 10 ].…”

“…Indeed, the advantage of a tissue patch such as the muscular flap for head and neck reconstruction is well known [ 1 , 6 ] because such vascularized tissue can be easily mobilized and adhere to other tissues. There have also been reports that the thymus flap is useful for covering tissue of the bronchial stump in tracheal reconstructive surgery [ 10 ]. The thymus flap is located close to the bronchi and has good vascular flow and sufficient volume compared with other tissues such as muscle flaps such as pleural flap, diaphragmatic flap, and azygos flap.…”