Gen Thorac Cardiovasc Surg DOI 10.1007/s11748-015-0537-8
CASE REPORT
Closure of esophagotracheal fistula after esophagectomy for esophageal cancer Junji Arimoto1 • Atsutoshi Hatada1 • Mitsumasa Kawago1 • Osamu Nishimura1 Shinji Maebeya1 • Yoshitaka Okamura2
•
Received: 9 November 2007 / Accepted: 16 March 2015 Ó The Japanese Association for Thoracic Surgery 2015
Abstract Fistula between the trachea and esophagogastric anastomosis after esophagectomy is rare. We successfully treated a 75-year-old woman with such a lesion by single-stage repair. The patient had undergone radical esophagectomy 20 years ago, and repeatedly developed aspiration pneumonia for recent 5 years. Radiological and endoscopic examinations demonstrated the fistula between the trachea at the level of sternal notch and esophagogastric anastomosis. The fistula was separated and the defects on both sides were closed. A sternocleidomastoid muscle flap was inserted between the two structures. The postoperative course was uneventful. Keywords Esophagotracheal fistula Esophagectomy Sternocleidomastoid muscle flap
Introduction Fistulas between the bronchi and digestive organs in adults are divided into two groups based on their malignant or benign status. A fistula between the trachea and esophagogastric anastomosis (trachea-anastomotic fistula) due to cancer of the esophagus, lungs, or mediastinum is the most common lesion seen in malignant disease [1]. The other
& Atsutoshi Hatada [email protected] 1
Department of Thoracic and Cardiovascular Surgery, Wakayama National Hospital, 1138 Wada, Mihama-chou, Hidaka-gun, Wakayama 644-0044, Japan
2
Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan
group is benign fistulas, among which the trachea-anastomotic fistula is included. The benign fistula is rare [2, 3] but is a potentially fatal complication. The trachea-anastomotic fistula can cause bleeding and aspiration pneumonia [4, 5]. We herein report the case of a woman with the tracheaanastomotic fistula that was successfully treated using a pedicled sternocleidomastoid muscle flap.
Case report A 75-year-old Japanese woman presented with postprandial fever and choking. She had previously undergone curative subtotal esophagectomy with lymph node dissection for cancer of the esophagus 20 years ago. Subtotal esophagectomy had been performed through transcervical, thoracic, and abdominal approaches followed by end-toend esophagogastrostomy. The gastric conduit had been brought up via the posterior mediastinal route and the anastomosis had been made in the neck with a circular stapler. She had undergone without chemotherapy and radiotherapy for cancer of the esophagus. Postoperatively, although she unusually experienced choking, she did not develop aspiration pneumonia. Five years ago, she suffered from postprandial fever and choking. She also had recurrent pneumonia several times. When she visited our hospital, she complained of fever that started a day before her visit and a drop in weight by several kilograms that started the previous year. Computed tomography of the thorax showed pneumonia in the left lower lung field. Barium swallow demonstrated the trachea-anastomotic fistula (Fig. 1) opening through the esophagogastric anastomosis. Bronchofiberscopy specifically showed the fistula in the posterior wall of the trachea (Fig. 2a) and the left vocal cord remained mobile.
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tracheal tear was closed in one layer with interrupted absorbable suture material (Vicryl 4-0; Ethicon). A left sternocleidomastoid muscle flap and parts of strap muscles flap were pedicled to separate the tracheal and esophagogastric suture. On the seventh postoperative day, barium esophagogram showed the absence of anastomotic leakage (Fig. 4) and the patient was allowed to drink water. A full liquid diet was started the following day. One month postoperatively, the patient showed satisfactory progress without any respiratory or swallowing problems. She has never experienced choking and been alive postoperative 7 years.
Comments
Fig. 1 Esophagogram revealing a contrast medium in the tracheobronchial lumen (black arrow) entering from the esophagus at the level of sternal notch
Surgery was performed by median sternotomy and cervicotomy through a neck collar incision. Intraoperative esophagoscopy revealed the fistula arising 18 cm from the incisor teeth (Fig. 2b). The left recurrent nerve was not identified. The trachea-anastomotic fistula was exposed and separated (Fig. 3). The defect of the esophagogastric wall was then closed in two layers with interrupted absorbable suture material (Vicryl 3-0; Ethicon) and the
Fig. 2 a Bronchofiberscopic view of the fistula between the trachea and esophagogastric anastomosis (tracheaanastomotic fistula) (black arrow). b Intraoperative esophagoscopic view of the trachea-anastomotic fistula (black arrow)
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Tracheal injury can occur during esophageal operation from blunt dissection of bulky tumors with tracheal adherence, especially with blind dissection during a transhiatal procedure. Esophagovisceral anastomotic leak is a life-threatening complication of esophageal resection, occurring at an average rate of 10%. Trachea-anastomotic fistula is a rare complication. The trachea-anastomotic fistula is both early and late in the postoperative course. The early trachea-anastomotic fistula is related to postintubation injury. Hyperinflation of the endotracheal tube cuff, not deflation, during mediastinal manipulations and tube repositioning have also been reported as common causes of injury to the membranous trachea weakened by dissection [6, 7]. The most common etiology of the early trachea-anastomotic fistula is a complication of intubation with cuff-related tracheal injury [8]. The late fistula is associated with chronic contained anastomotic
Gen Thorac Cardiovasc Surg Fig. 3 a Repair of the tracheaanastomotic fistula (black arrow) with pedicled sternohyoid muscle flap and platysma muscle flap. Operative photograph just before repair. b Schema of the operative findings showing the tracheaanastomotic fistula (black arrow). c Schema of the operation. A pedicled sternocleidomastoid muscle flap and deep muscles of the neck flap were transposed between the sutured esophagogastric anastomosis and the trachea
A
B Trachea
Esophagus
Trachea Left carotid artery Esophagus Gastric-tube
Left carotid artery Gastric-tube
C deep muscle of the neck
Sternnocleidomastoid muscle
Innominate vein
Fig. 4 Esophagogram on the 7th postoperative day revealing the absence of the trachea-anastomotic fistula
leaks, cancer recurrence, and dilation of an anastomotic stricture. In our case, the trachea-anastomotic fistula was in the proximal side of the anastomosis in late
postoperative course. The endoscopy showed no cancer recurrence around the fistula. Treatment depends on the severity of symptoms, the size and location of the trachea-anastomotic fistula, and accompanying conditions. In the absence of severe mediastinal or pulmonary infection, conservative treatment (i.e., not per oral with antimicrobial agents) may be considered [9]. With severe symptoms necessitating surgery, the procedure of choice is complete excision of the fistula, and closure of the tracheal and esophageal defects. Interposition of a pedicle pleural, omental, or muscle flap has proved useful. Recently, the use of a covered expandable metallic stent for interventional treatment has been reported. This treatment was proven effective for sealing off a fistula. However, the initial clinical success rate of the stent procedure was poor [10]. We, therefore, decided to apply surgical repair of the trachea-anastomotic fistula placing a muscle flap in between the trachea and the esophagus. In fistula cases, symptoms may range from mild (e.g., coughing and fever associated with oral intake) to severe (e.g., recurrent pneumonia). Our patient had no symptoms for 15 years after the initial esophagectomy and the symptoms were still so mild even in the recent 5 years that conservative treatment was the choice. Later, because she developed severe symptoms, we decided on surgical management of the fistula. In conclusion, a trachea-anastomotic fistula was successfully treated with a transposed pedicled sternocleidomastoid muscle flap.
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Gen Thorac Cardiovasc Surg
References 1. Hordijk ML, Dees J, van Blank-Stein M. The management of malignant esophago-respiratory fistula with a cuffed prosthesis. Endoscopy. 1990;22:241–4. 2. Marty-Ane´ CH, Prudhome M, Fabre JM, Domergue J, Balmes M, Mary H. Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy. Ann Thorac Surg. 1995;60:690–3. 3. Buskens JC, Hulscher JBF, Fockens P, Obertop H, van Lanschot JJB. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg. 2001;72:221–4. 4. Saitoh H, Abo S, Kitamura M, Hashimoto M, Izumi K, Tenma K, et al. Closure of reconstructed gastric tube-right main bronchial fistula after operation for esophageal cancer, with transposition of a pedicled pectoralis major muscle flap—report of a successful surgical therapy case. Jpn J Gastroenterol Surg. 1995;28:1819–23.
123
5. McDermott M, Hourihane DO. Fatal non-malignant ulceration in the gastric tube after oesophagectomy. J Clin Pathol. 1993;46:483–5. 6. Smith BAC, Hopkinson RB. Tracheal rupture during anesthesia. Anesthesia. 1984;39:894–8. 7. Gorenstein LA, Abel JG, Patterson GA. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg. 1992;54:784–6. 8. Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin North Am. 2003;13:271–89. 9. Song SW, Lee HS, Kim MS, Lee JM, Kim JH, Zo JIII. Repair of gastrotracheal fistula with a pedicled pericardial flap after Ivor Lewis esophagogastrectomy for esophageal cancer. J Thorc Cardiovasc Surg. 2006;132:716–7. 10. Hoon JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula; long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology. 2004;232:252–9.
CASE REPORT
Closure of esophagotracheal fistula after esophagectomy for esophageal cancer Junji Arimoto1 • Atsutoshi Hatada1 • Mitsumasa Kawago1 • Osamu Nishimura1 Shinji Maebeya1 • Yoshitaka Okamura2
•
Received: 9 November 2007 / Accepted: 16 March 2015 Ó The Japanese Association for Thoracic Surgery 2015
Abstract Fistula between the trachea and esophagogastric anastomosis after esophagectomy is rare. We successfully treated a 75-year-old woman with such a lesion by single-stage repair. The patient had undergone radical esophagectomy 20 years ago, and repeatedly developed aspiration pneumonia for recent 5 years. Radiological and endoscopic examinations demonstrated the fistula between the trachea at the level of sternal notch and esophagogastric anastomosis. The fistula was separated and the defects on both sides were closed. A sternocleidomastoid muscle flap was inserted between the two structures. The postoperative course was uneventful. Keywords Esophagotracheal fistula Esophagectomy Sternocleidomastoid muscle flap
Introduction Fistulas between the bronchi and digestive organs in adults are divided into two groups based on their malignant or benign status. A fistula between the trachea and esophagogastric anastomosis (trachea-anastomotic fistula) due to cancer of the esophagus, lungs, or mediastinum is the most common lesion seen in malignant disease [1]. The other
& Atsutoshi Hatada [email protected] 1
Department of Thoracic and Cardiovascular Surgery, Wakayama National Hospital, 1138 Wada, Mihama-chou, Hidaka-gun, Wakayama 644-0044, Japan
2
Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan
group is benign fistulas, among which the trachea-anastomotic fistula is included. The benign fistula is rare [2, 3] but is a potentially fatal complication. The trachea-anastomotic fistula can cause bleeding and aspiration pneumonia [4, 5]. We herein report the case of a woman with the tracheaanastomotic fistula that was successfully treated using a pedicled sternocleidomastoid muscle flap.
Case report A 75-year-old Japanese woman presented with postprandial fever and choking. She had previously undergone curative subtotal esophagectomy with lymph node dissection for cancer of the esophagus 20 years ago. Subtotal esophagectomy had been performed through transcervical, thoracic, and abdominal approaches followed by end-toend esophagogastrostomy. The gastric conduit had been brought up via the posterior mediastinal route and the anastomosis had been made in the neck with a circular stapler. She had undergone without chemotherapy and radiotherapy for cancer of the esophagus. Postoperatively, although she unusually experienced choking, she did not develop aspiration pneumonia. Five years ago, she suffered from postprandial fever and choking. She also had recurrent pneumonia several times. When she visited our hospital, she complained of fever that started a day before her visit and a drop in weight by several kilograms that started the previous year. Computed tomography of the thorax showed pneumonia in the left lower lung field. Barium swallow demonstrated the trachea-anastomotic fistula (Fig. 1) opening through the esophagogastric anastomosis. Bronchofiberscopy specifically showed the fistula in the posterior wall of the trachea (Fig. 2a) and the left vocal cord remained mobile.
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Gen Thorac Cardiovasc Surg
tracheal tear was closed in one layer with interrupted absorbable suture material (Vicryl 4-0; Ethicon). A left sternocleidomastoid muscle flap and parts of strap muscles flap were pedicled to separate the tracheal and esophagogastric suture. On the seventh postoperative day, barium esophagogram showed the absence of anastomotic leakage (Fig. 4) and the patient was allowed to drink water. A full liquid diet was started the following day. One month postoperatively, the patient showed satisfactory progress without any respiratory or swallowing problems. She has never experienced choking and been alive postoperative 7 years.
Comments
Fig. 1 Esophagogram revealing a contrast medium in the tracheobronchial lumen (black arrow) entering from the esophagus at the level of sternal notch
Surgery was performed by median sternotomy and cervicotomy through a neck collar incision. Intraoperative esophagoscopy revealed the fistula arising 18 cm from the incisor teeth (Fig. 2b). The left recurrent nerve was not identified. The trachea-anastomotic fistula was exposed and separated (Fig. 3). The defect of the esophagogastric wall was then closed in two layers with interrupted absorbable suture material (Vicryl 3-0; Ethicon) and the
Fig. 2 a Bronchofiberscopic view of the fistula between the trachea and esophagogastric anastomosis (tracheaanastomotic fistula) (black arrow). b Intraoperative esophagoscopic view of the trachea-anastomotic fistula (black arrow)
123
Tracheal injury can occur during esophageal operation from blunt dissection of bulky tumors with tracheal adherence, especially with blind dissection during a transhiatal procedure. Esophagovisceral anastomotic leak is a life-threatening complication of esophageal resection, occurring at an average rate of 10%. Trachea-anastomotic fistula is a rare complication. The trachea-anastomotic fistula is both early and late in the postoperative course. The early trachea-anastomotic fistula is related to postintubation injury. Hyperinflation of the endotracheal tube cuff, not deflation, during mediastinal manipulations and tube repositioning have also been reported as common causes of injury to the membranous trachea weakened by dissection [6, 7]. The most common etiology of the early trachea-anastomotic fistula is a complication of intubation with cuff-related tracheal injury [8]. The late fistula is associated with chronic contained anastomotic
Gen Thorac Cardiovasc Surg Fig. 3 a Repair of the tracheaanastomotic fistula (black arrow) with pedicled sternohyoid muscle flap and platysma muscle flap. Operative photograph just before repair. b Schema of the operative findings showing the tracheaanastomotic fistula (black arrow). c Schema of the operation. A pedicled sternocleidomastoid muscle flap and deep muscles of the neck flap were transposed between the sutured esophagogastric anastomosis and the trachea
A
B Trachea
Esophagus
Trachea Left carotid artery Esophagus Gastric-tube
Left carotid artery Gastric-tube
C deep muscle of the neck
Sternnocleidomastoid muscle
Innominate vein
Fig. 4 Esophagogram on the 7th postoperative day revealing the absence of the trachea-anastomotic fistula
leaks, cancer recurrence, and dilation of an anastomotic stricture. In our case, the trachea-anastomotic fistula was in the proximal side of the anastomosis in late
postoperative course. The endoscopy showed no cancer recurrence around the fistula. Treatment depends on the severity of symptoms, the size and location of the trachea-anastomotic fistula, and accompanying conditions. In the absence of severe mediastinal or pulmonary infection, conservative treatment (i.e., not per oral with antimicrobial agents) may be considered [9]. With severe symptoms necessitating surgery, the procedure of choice is complete excision of the fistula, and closure of the tracheal and esophageal defects. Interposition of a pedicle pleural, omental, or muscle flap has proved useful. Recently, the use of a covered expandable metallic stent for interventional treatment has been reported. This treatment was proven effective for sealing off a fistula. However, the initial clinical success rate of the stent procedure was poor [10]. We, therefore, decided to apply surgical repair of the trachea-anastomotic fistula placing a muscle flap in between the trachea and the esophagus. In fistula cases, symptoms may range from mild (e.g., coughing and fever associated with oral intake) to severe (e.g., recurrent pneumonia). Our patient had no symptoms for 15 years after the initial esophagectomy and the symptoms were still so mild even in the recent 5 years that conservative treatment was the choice. Later, because she developed severe symptoms, we decided on surgical management of the fistula. In conclusion, a trachea-anastomotic fistula was successfully treated with a transposed pedicled sternocleidomastoid muscle flap.
123
Gen Thorac Cardiovasc Surg
References 1. Hordijk ML, Dees J, van Blank-Stein M. The management of malignant esophago-respiratory fistula with a cuffed prosthesis. Endoscopy. 1990;22:241–4. 2. Marty-Ane´ CH, Prudhome M, Fabre JM, Domergue J, Balmes M, Mary H. Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy. Ann Thorac Surg. 1995;60:690–3. 3. Buskens JC, Hulscher JBF, Fockens P, Obertop H, van Lanschot JJB. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg. 2001;72:221–4. 4. Saitoh H, Abo S, Kitamura M, Hashimoto M, Izumi K, Tenma K, et al. Closure of reconstructed gastric tube-right main bronchial fistula after operation for esophageal cancer, with transposition of a pedicled pectoralis major muscle flap—report of a successful surgical therapy case. Jpn J Gastroenterol Surg. 1995;28:1819–23.
123
5. McDermott M, Hourihane DO. Fatal non-malignant ulceration in the gastric tube after oesophagectomy. J Clin Pathol. 1993;46:483–5. 6. Smith BAC, Hopkinson RB. Tracheal rupture during anesthesia. Anesthesia. 1984;39:894–8. 7. Gorenstein LA, Abel JG, Patterson GA. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg. 1992;54:784–6. 8. Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin North Am. 2003;13:271–89. 9. Song SW, Lee HS, Kim MS, Lee JM, Kim JH, Zo JIII. Repair of gastrotracheal fistula with a pedicled pericardial flap after Ivor Lewis esophagogastrectomy for esophageal cancer. J Thorc Cardiovasc Surg. 2006;132:716–7. 10. Hoon JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula; long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology. 2004;232:252–9.
