Repair of gastro-tracheobronchial fistula after esophagectomy for esophageal cancer using intercostal muscle and latissimus dorsi muscle flaps: a case report

Abstract

Background: Gastro-tracheobronchial fistula after esophagectomy is a rare but life-threatening complication associated with high mortality. Several authors reported postoperative management of tracheobronchial fistula. However, treatment is demanding and challenging, and the strategy is still controversial. Case presentation: A 64-year-old man underwent thoracoscopic esophagectomy with two-field lymph node dissection and gastric conduit reconstruction by an intrathoracic anastomosis for esophageal cancer at a local hospital in June 2013. After surgery, a gastro-tracheal fistula and a gastro-bronchial fistula of the left main bronchus were diagnosed, and the patient was referred to our hospital for the management of the gastro-tracheobronchial fistula. CT and bronchoscopy and esophagogastroduodenoscopy performed at our hospital revealed that the gastro-bronchial fistula of the left main bronchus was cured by packing with the omentum from the gastric conduit and the gastro-tracheal fistula located 3 cm above the carina remained open. We concluded that the fistula would not resolve without further surgical procedure. However, such an operation was expected to be difficult and to need much time due to severe adhesion among the gastric conduit and/or trachea, bronchus, lung, and chest wall. Therefore, a two-stage operation was planned for safety and outcome certainty. The first operation was performed to close the fistula in October 2013. The gastric conduit was separated from the trachea and resected; then, the fistula was sutured and covered by intercostal muscle and latissimus dorsi muscle flaps. A month after the first operation, reconstruction with pedunculated jejunum was performed via the percutaneous route. The patient's postoperative course was uneventful. Conclusion: If the omentum is not observed between the gastric conduit and the tracheobronchus when a gastrotracheobronchial fistula occurs after esophagectomy, surgeons should perform surgical treatment because conservative treatment is unlikely to cure. During surgery, the use of two types of muscle flaps, such as the intercostal muscle and the latissimus dorsi muscle flaps, is helpful for the closure of gastro-tracheobronchial fistulas.

The clinical characteristics, treatments and prognosis of post-esophagectomy airway fistula: a multicenter cohort study

“…As previously reported, surgical management plays an important role in the treatment of type II PEAF patients, which can effectively restore normal nutrition and reduce airway aspiration with a very low risk of recurrence. Surgical management is relatively successful, and includes esophageal exclusion and fistula repaired with a strap muscle (8), intercostal muscle (5,17), latissimus dorsi myocutaneous flap (18,19), pedicled pericardial flap (15), pectoralis major muscle flap (20), and omental and pleural patch (5), as well as reconstruction by the interposition of colon (5) and jejunum (21).…”

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma

“…As patients often present with malnutrition and repeated pneumonia, prompt administration of broad-spectrum antibiotics, gastric drainage, maintenance of fluid and electrolyte balance, and chest physiotherapy are necessary before definitive surgery. Even though there is no standard treatment for GBF, several interventions have been proposed in the past 20 years, such as esophageal stenting, tracheobronchial Y-shaped stenting, over-the-scope clips, fistula plugs, and surgical repair with muscle flaps or bovine pericardium [2,6,9,12–14] . Interestingly, Li et al have demonstrated that surgical repair has a greater long-term survival rate than other non-invasive treatments [10] …”

“…Even though there is no standard treatment for GBF, several interventions have been proposed in the past 20 years, such as esophageal stenting, tracheobronchial Y-shaped stenting, over-the-scope clips, fistula plugs, and surgical repair with muscle flaps or bovine pericardium. [2,6,9,[12][13][14] Interestingly, Li et al have demonstrated that surgical repair has a greater long-term survival rate than other non-invasive treatments. [10]…”

A unique approach for a large intra-thoracic traumatic tracheo-oesophageal fistula: A case report from Syria

“…There have been reports on using latissimus dorsi muscle and pericardial flap instead of intercostal muscle flap [ 9 , 10 ]; as the surgeon believed a tight closure is required for the fistula, the intercostal muscles was used instead of latissimus dorsi which is believed to be better for wide areas but not good to cover a fistula tightly [ 9 ]. Furthermore, although primary repair with pericardial flaps was reported, they are unsafe as they are poorly vascularised and can paradoxically move, mainly with positive pressure ventilation [ 10 ].…”