POLSKI PRZEGLĄD CHIRURGICZNY 2014, 86, 11, 537–539
10.2478/pjs-2014-0095
CASE REPORTS
Successful endoscopic treatment of a postoperative tracheomediastinal fistula caused by anastomotic insufficiency after esophageal resection with fibrin glue Guenter Weiss1, Cora Wex2, Hans Lippert2, Jens Schreiber3, Frank Meyer2 Department of Anesthesiology and Intensive Care, Municipal Hospital, Magdeburg, Germany1 Department of General, Abdominal and Vascular Surgery, University Hospital in Magdeburg, Germany2 Division of Pulmonology, Department of Cardiology, Pulmonology and Angiology, University Hospital in Magdeburg, Germany3 Fistula development after esophageal resection is considered as one of the most serious postoperative complications. The authors reported a case on clinical experiences in the postoperative diagnostic and successful therapeutic management of a tracheomediastinal fistula after esophageal resection, using endoscopic application of fibrin glue. The early approach of an anastomotic insufficiency after esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation including transposition of a re-modelled gastric tube and end-to-side anastomosis 24 hours postoperatively in a 55-year old patient combined i) surgical re-intervention from the periesophageal site (reanastomosis, gastroplication, lavage, local and mediastinal drainage) and, later on, ii) extensive rinsing with consecutive endoscopic fibrin glue application into the tracheal mouth of the subsequently developed tracheomediastinal fistula as a consequence of the inflammatory changes within the surrounding tissue. In conclusion, this approach was successful and beneficial for the patient´s further postoperative course, which was associated with other complications such as pneumonia and acute myocardial infarction. The fistula closed sufficiently and permanently with no further surgical intervention at the tracheal as well as mediastinal site and allowed patient´s later discharge with no further complaints or problems. Key words: tracheomediastinal fistula, esophageal resection, fibrin glue, endoscopic approach
Stage-adapted esophageal resection because of cancer belongs to the most challenging operative procedures in surgery, which shows a broad spectrum of potential complications. Anastomotic insufficiency occurs in approximately 12% of the patients (1). One of the most serious complications is a fistula (2) caused by anastomotic insufficiency with a consecutive connection to the mediastinum and/or trachea as well as possible postinterventional mediastinitis.
Case report A 55-year-old male patient underwent esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation after a previous neoadjuvant radiochemotherapy for downstaging of the tumor lesion including end-to-side esophagogastrostomy after transposition of a re-modelled gastric tube for reconstruction of the upper gastrointestinal tract. On the first
Unauthenticated Download Date | 5/26/16 1:34 AM
538
G. Weiss et al.
postoperative day, the patient imposed with an early anastomotic leakage, which became obvious by clinical examination (in particular, effusion fluid via local drainages) and X-ray (detection of extraluminal contrast medium at the perianastomotic region). The patient underwent immediate right rethoracotomy. The esophagogastrostomy was reanastomosed and the anastomotic region was covered by a gastroplication around the suture area followed by the replacement of the local drainages as well as the placement of a mediastinal drainage and a left thoracic suction drain. During the postoperative course, the patient developed pneumonia, and an acute myocardial infarction, resulting in reintubation and controlled artificial ventilation. The inflammatory parameters such as white blood cell count, CrP, and procalcitonin were highly elevated. Antibiotic treatment was performed with Imipeneme (Zienam ®, MSD Sharp & Dohme GmbH, Haar, Germany). In addition, there was the suspicion of an air leakage indicated by detectable air in the left thoracic suction drain on the 12th postoperative day. Bronchoscopy revealed a defect (possible fistula opening) at the pars membranacea of the trachea (size, approximately 1.5 cm) above its bifurcation (fig. 1A). Control gastroscopy showed the suture region of the previous anastomotic insufficiency with mucosal inflammatory changes of approximately 1/4 of the esophageal circumference but no evidence for a fistula. Therefore, it was interpreted as tracheomediastinal fistula. From the endotracheal site, fistula region was extensively rinsed and filled with 2 x 1 mL of fibrin glue (Tissucol Duo S Immuno, Baxter AG, Unter-
A
schleißheim, Germany) to cover the fistula mouth, resulting in the subsequent closure of the fistula (fig. 1B). In order to reduce the ventilation pressure within the airways and, in addition, to facilitate weaning from artificial ventilation, minimally invasive tracheostomy under bronchoscopic control was performed. After the first injection of fibrin glue into the fistula from the tracheal site, there were no further hints for a persisting air leak. Follow-up bronchoscopy showed granulation at the margins of the fistula interpreted as ongoing healing process (fig. 1C). After a 40-day postoperative course on the surgical ICU, patient was transferred to the medical ward in stable physical condition followed by the discharge after 10 subsequent uneventful days with no further complaints and complications. Discussion The presented case demonstrates the consequences of an anastomotic insufficiency of esophagogastrostomy after esophageal resection such as inflammatory changes at the mucosal and periluminal site and within the mediastinum as well as the rare fistula development (2) to the trachea from the mediastinum. If the anastomotic insufficiency has appropriately been treated by either – an intraluminal approach (endoscopic rinsing or/and subsequent fibrin glue application (2) / stent implantation) or – a surgical approach from outside (such as reanastomosis or/and gastroplication of the
B
C
Fig. 1. Bronchoscopic view: A) tracheal site of the tracheomediastinal fistula, B) injection of fibrin glue into the fistula to close its mouth, C) fistula region on the 14th day after fibrin glue application into the fistula mouth
Unauthenticated Download Date | 5/26/16 1:34 AM
Endoscopic treatment of a tracheomediastinal fistula with fibrin glue
anastomotic region as done here because of the early onset and size of the anastomotic leakage in the presented case) including sufficient drainage of the fistula region and the mediastinum, a minimally invasive attempt to close the fistula from the extraesophageal, endotracheal site can be considered using extensive rinsing and fibrin glue application as done. An early approach is recommendable since the inflammatory changes and infectious complications can be still limited within this time frame, which otherwise might have a disadvantageous impact on the final outcome. Thus: – only one application of fibrin glue was sufficient to close the tracheal fistula mouth permanently indicated by no further detectable air in the suction drainage, – a surgical approach to close the trachea, which might have shown a problematic outcome because of the surrounding inflammation, could be avoided. In summary, the application of fibrin glue can be considered a promising, minimally invasive therapeutic option in the management of postoperative fistula after esophageal resection (2). As an alternative treatment option if fibrin glue does not close the fistula sufficiently, a dynamic stent implanted within the trachea
539
above its bifurcation can be considered although a stent may widen or stretch the fistula and, on the other hand, defects of the pars membranacea may heal spontaneously. However, – the periluminal inflammatory changes can cause further disadvantageous consequences, – a complete closure and tight coverage can not be achieved in each case using a stent as confirmed by an interdisciplinary board with a pulmonologist and otorhinolaryngologist who were consulted in this case, – stent placement at the bifurcational region can become very difficult if the tracheal opening is located within this segment although there are excellent Y-shape stents available, – stent dislocation can occur but probably not in case of Y-stents, – tracheal stenosis can develop (3‑7). Interestingly, if conventional endoscopic measures such as stenting or endo-VAC (-sponge) do not provide adequate therapeutic effect modes of an assisted artificial respiration with low pressure and short phases of apnoe after fibrin glue application might support the crucial initial adhesion of fibrin glue and finally the successful sealing resulting in a sufficient closure of the fistula as Ussat et al. have recently reported (2).
References 1. Huttl TP, Wichmann MW, Geiger TK et al.: Techniques and results of esohageal cancer surgery in Germany. Langenbecks Arch Surg 2002; 387: 125‑29. 2. Ussat S, Lodes U, Wex C et al.: Successful closure of a postoperative esophagobronchial fistula following esophageal resection using fibrin glue. Dtsch Med Wochenschr 2013; 138(27): 1406‑09. 3. Belleguic C, Lena H, Briens E et al.: Tracheobronchial Stenting in Patients with Esophageal Cancer Involving the Central Airways. Endoscopy 1999; 03: 232‑36. 4. Doniec JM, Schniewind B, Kahlke V et al.: Therapy of Anastomotic Leaks by Means of Covered Self-Expanding Metallic Stents after Esophagogastrectomy. Endoscopy 2003; 08: 652‑58.
5. Andreetti C, D’Andrilli A, Ibrahim M et al.: Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered selfexpandable stent. Interact Cardiovasc Thorac Surg 2012; 14(4): 420‑23. 6. Dutau H, Breen DP, Gomez C et al.: The integrated place of tracheo-bronchial stents in the multidisciplinary management of large postpneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent. Eur J Cardiothorac Surg 2011; 39: 1858‑59. 7. Shin JH, Song HY, Ko GY: Esophagorespiratory Fistula: Long-term Results of Palliative Treatment with Covered Expandable Metallic Stents in 61 Patients. Radiology 2004; 232: 252‑59.
Received: 15.12.2013 r. Adress correspondence: Prof. Dr. F. Meyer, Department of General, Abdominal and Vascular Surgery, University Hospital, Leipziger Strasse 44, D-39120 Magdeburg, Niemcy e-mail: [email protected] Unauthenticated Download Date | 5/26/16 1:34 AM
10.2478/pjs-2014-0095
CASE REPORTS
Successful endoscopic treatment of a postoperative tracheomediastinal fistula caused by anastomotic insufficiency after esophageal resection with fibrin glue Guenter Weiss1, Cora Wex2, Hans Lippert2, Jens Schreiber3, Frank Meyer2 Department of Anesthesiology and Intensive Care, Municipal Hospital, Magdeburg, Germany1 Department of General, Abdominal and Vascular Surgery, University Hospital in Magdeburg, Germany2 Division of Pulmonology, Department of Cardiology, Pulmonology and Angiology, University Hospital in Magdeburg, Germany3 Fistula development after esophageal resection is considered as one of the most serious postoperative complications. The authors reported a case on clinical experiences in the postoperative diagnostic and successful therapeutic management of a tracheomediastinal fistula after esophageal resection, using endoscopic application of fibrin glue. The early approach of an anastomotic insufficiency after esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation including transposition of a re-modelled gastric tube and end-to-side anastomosis 24 hours postoperatively in a 55-year old patient combined i) surgical re-intervention from the periesophageal site (reanastomosis, gastroplication, lavage, local and mediastinal drainage) and, later on, ii) extensive rinsing with consecutive endoscopic fibrin glue application into the tracheal mouth of the subsequently developed tracheomediastinal fistula as a consequence of the inflammatory changes within the surrounding tissue. In conclusion, this approach was successful and beneficial for the patient´s further postoperative course, which was associated with other complications such as pneumonia and acute myocardial infarction. The fistula closed sufficiently and permanently with no further surgical intervention at the tracheal as well as mediastinal site and allowed patient´s later discharge with no further complaints or problems. Key words: tracheomediastinal fistula, esophageal resection, fibrin glue, endoscopic approach
Stage-adapted esophageal resection because of cancer belongs to the most challenging operative procedures in surgery, which shows a broad spectrum of potential complications. Anastomotic insufficiency occurs in approximately 12% of the patients (1). One of the most serious complications is a fistula (2) caused by anastomotic insufficiency with a consecutive connection to the mediastinum and/or trachea as well as possible postinterventional mediastinitis.
Case report A 55-year-old male patient underwent esophageal resection because of a squamous cell carcinoma (pT3pN0M0G2) below the tracheal bifurcation after a previous neoadjuvant radiochemotherapy for downstaging of the tumor lesion including end-to-side esophagogastrostomy after transposition of a re-modelled gastric tube for reconstruction of the upper gastrointestinal tract. On the first
Unauthenticated Download Date | 5/26/16 1:34 AM
538
G. Weiss et al.
postoperative day, the patient imposed with an early anastomotic leakage, which became obvious by clinical examination (in particular, effusion fluid via local drainages) and X-ray (detection of extraluminal contrast medium at the perianastomotic region). The patient underwent immediate right rethoracotomy. The esophagogastrostomy was reanastomosed and the anastomotic region was covered by a gastroplication around the suture area followed by the replacement of the local drainages as well as the placement of a mediastinal drainage and a left thoracic suction drain. During the postoperative course, the patient developed pneumonia, and an acute myocardial infarction, resulting in reintubation and controlled artificial ventilation. The inflammatory parameters such as white blood cell count, CrP, and procalcitonin were highly elevated. Antibiotic treatment was performed with Imipeneme (Zienam ®, MSD Sharp & Dohme GmbH, Haar, Germany). In addition, there was the suspicion of an air leakage indicated by detectable air in the left thoracic suction drain on the 12th postoperative day. Bronchoscopy revealed a defect (possible fistula opening) at the pars membranacea of the trachea (size, approximately 1.5 cm) above its bifurcation (fig. 1A). Control gastroscopy showed the suture region of the previous anastomotic insufficiency with mucosal inflammatory changes of approximately 1/4 of the esophageal circumference but no evidence for a fistula. Therefore, it was interpreted as tracheomediastinal fistula. From the endotracheal site, fistula region was extensively rinsed and filled with 2 x 1 mL of fibrin glue (Tissucol Duo S Immuno, Baxter AG, Unter-
A
schleißheim, Germany) to cover the fistula mouth, resulting in the subsequent closure of the fistula (fig. 1B). In order to reduce the ventilation pressure within the airways and, in addition, to facilitate weaning from artificial ventilation, minimally invasive tracheostomy under bronchoscopic control was performed. After the first injection of fibrin glue into the fistula from the tracheal site, there were no further hints for a persisting air leak. Follow-up bronchoscopy showed granulation at the margins of the fistula interpreted as ongoing healing process (fig. 1C). After a 40-day postoperative course on the surgical ICU, patient was transferred to the medical ward in stable physical condition followed by the discharge after 10 subsequent uneventful days with no further complaints and complications. Discussion The presented case demonstrates the consequences of an anastomotic insufficiency of esophagogastrostomy after esophageal resection such as inflammatory changes at the mucosal and periluminal site and within the mediastinum as well as the rare fistula development (2) to the trachea from the mediastinum. If the anastomotic insufficiency has appropriately been treated by either – an intraluminal approach (endoscopic rinsing or/and subsequent fibrin glue application (2) / stent implantation) or – a surgical approach from outside (such as reanastomosis or/and gastroplication of the
B
C
Fig. 1. Bronchoscopic view: A) tracheal site of the tracheomediastinal fistula, B) injection of fibrin glue into the fistula to close its mouth, C) fistula region on the 14th day after fibrin glue application into the fistula mouth
Unauthenticated Download Date | 5/26/16 1:34 AM
Endoscopic treatment of a tracheomediastinal fistula with fibrin glue
anastomotic region as done here because of the early onset and size of the anastomotic leakage in the presented case) including sufficient drainage of the fistula region and the mediastinum, a minimally invasive attempt to close the fistula from the extraesophageal, endotracheal site can be considered using extensive rinsing and fibrin glue application as done. An early approach is recommendable since the inflammatory changes and infectious complications can be still limited within this time frame, which otherwise might have a disadvantageous impact on the final outcome. Thus: – only one application of fibrin glue was sufficient to close the tracheal fistula mouth permanently indicated by no further detectable air in the suction drainage, – a surgical approach to close the trachea, which might have shown a problematic outcome because of the surrounding inflammation, could be avoided. In summary, the application of fibrin glue can be considered a promising, minimally invasive therapeutic option in the management of postoperative fistula after esophageal resection (2). As an alternative treatment option if fibrin glue does not close the fistula sufficiently, a dynamic stent implanted within the trachea
539
above its bifurcation can be considered although a stent may widen or stretch the fistula and, on the other hand, defects of the pars membranacea may heal spontaneously. However, – the periluminal inflammatory changes can cause further disadvantageous consequences, – a complete closure and tight coverage can not be achieved in each case using a stent as confirmed by an interdisciplinary board with a pulmonologist and otorhinolaryngologist who were consulted in this case, – stent placement at the bifurcational region can become very difficult if the tracheal opening is located within this segment although there are excellent Y-shape stents available, – stent dislocation can occur but probably not in case of Y-stents, – tracheal stenosis can develop (3‑7). Interestingly, if conventional endoscopic measures such as stenting or endo-VAC (-sponge) do not provide adequate therapeutic effect modes of an assisted artificial respiration with low pressure and short phases of apnoe after fibrin glue application might support the crucial initial adhesion of fibrin glue and finally the successful sealing resulting in a sufficient closure of the fistula as Ussat et al. have recently reported (2).
References 1. Huttl TP, Wichmann MW, Geiger TK et al.: Techniques and results of esohageal cancer surgery in Germany. Langenbecks Arch Surg 2002; 387: 125‑29. 2. Ussat S, Lodes U, Wex C et al.: Successful closure of a postoperative esophagobronchial fistula following esophageal resection using fibrin glue. Dtsch Med Wochenschr 2013; 138(27): 1406‑09. 3. Belleguic C, Lena H, Briens E et al.: Tracheobronchial Stenting in Patients with Esophageal Cancer Involving the Central Airways. Endoscopy 1999; 03: 232‑36. 4. Doniec JM, Schniewind B, Kahlke V et al.: Therapy of Anastomotic Leaks by Means of Covered Self-Expanding Metallic Stents after Esophagogastrectomy. Endoscopy 2003; 08: 652‑58.
5. Andreetti C, D’Andrilli A, Ibrahim M et al.: Effective treatment of post-pneumonectomy bronchopleural fistula by conical fully covered selfexpandable stent. Interact Cardiovasc Thorac Surg 2012; 14(4): 420‑23. 6. Dutau H, Breen DP, Gomez C et al.: The integrated place of tracheo-bronchial stents in the multidisciplinary management of large postpneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent. Eur J Cardiothorac Surg 2011; 39: 1858‑59. 7. Shin JH, Song HY, Ko GY: Esophagorespiratory Fistula: Long-term Results of Palliative Treatment with Covered Expandable Metallic Stents in 61 Patients. Radiology 2004; 232: 252‑59.
Received: 15.12.2013 r. Adress correspondence: Prof. Dr. F. Meyer, Department of General, Abdominal and Vascular Surgery, University Hospital, Leipziger Strasse 44, D-39120 Magdeburg, Niemcy e-mail: [email protected] Unauthenticated Download Date | 5/26/16 1:34 AM
