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Bertrand T, Chatellier G, Mercier O. Management of neo-esophagus-airway fistula after esophagectomy for oesophageal cancer: systematic literature review and meta-analysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 39:ivae110. [PMID: 38814807 PMCID: PMC11222295 DOI: 10.1093/icvts/ivae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/22/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES Neo-oesophageal-airway fistula (NEAF) between gastric conduit and airway is a rare but life-threatening complication of oesophagectomy for oesophageal cancer. Optimal treatment remains unknown. A meta-analysis of good-quality case series may help determine whether nonoperative management (NOM) only, upfront surgery (S), or NOM followed by surgery is associated with better 1-year post-treatment mortality, resumption of oral diet and fistula recurrence. METHODS We systematically searched PubMed, EMBASE and Web of Science for publications in English reporting case series of management and survival in patients with NEAF. Of the 177 identified studies, 62 were duplicates and 95 were not relevant to our topic. Three studies were excluded after a full-text review, due to absence of reporting of 1-year survival. Exclusion criteria to identified publications were: abstract only, malignant NEAF, absence of oesophagectomy and esogastric anastomosis, fewer than 5 patients and NEAF not the main focus of the study. Data-extraction was conducted in accordance with MOOSE guidelines. Data were pooled using random-effects model. RESULTS Seventeen studies (302 patients) were included. One-year post-treatment mortality was considerably lower with NOM followed by surgery [33%; 95% confidence interval (CI), 0.17-0.48] than with NOM (68%; 95% CI, 0.39-0.97) or S (67%; 95% CI, 0.36-0.98). Fistula location was not associated with 1-year mortality. Neither resumption of an oral diet nor fistula recurrence differed significantly across treatment strategies. CONCLUSIONS NOM to prepare patients for surgery followed by surgical repair may provide the highest 1-year survival of patients with NEAF. However, patient selection criteria to each of 3 treatment strategies may have affected our findings.
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Affiliation(s)
- Thibaud Bertrand
- Department of Thoracic Surgery and Heart and Lung Transplantation, Hôpital Marie Lannelongue, Université Paris-Saclay, Le Plessis Robinson, France
| | - Gilles Chatellier
- Clinical Research Department, Hôpital Marie Lannelongue, Groupe Hospitalier Paris-Saint-Joseph, Le Plessis-Robinson, France
| | - Olaf Mercier
- Department of Thoracic Surgery and Heart and Lung Transplantation, Hôpital Marie Lannelongue, Université Paris-Saclay, Le Plessis Robinson, France
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Akhras A, Guerrero Vinsard D, Singh A, Deepali F, Bains A, Goyal M, Buttar NS. The final plug: novel use of vascular plug for management of bronchoesophageal fistula. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:69-71. [PMID: 38357023 PMCID: PMC10861856 DOI: 10.1016/j.vgie.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Video 1Successful management of a postsurgical bronchoesophageal fistula with a combination of a self-expanding vascular plug, glue containing cyanoacrylate, and a fully covered metal stent.
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Affiliation(s)
- Aya Akhras
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Anmol Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Fnu Deepali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anmol Bains
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mayank Goyal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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3
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Bertrand T, Mercier O, Leymarie N, Issard J, Honart JF, Fabre D, Kolb F, Fadel E. Surgical cervicothoracic-flap repair of neoesophagus-airway fistula after esophagectomy for esophageal cancer: A retrospective cohort study. JTCVS Tech 2024; 23:123-131. [PMID: 38351987 PMCID: PMC10859646 DOI: 10.1016/j.xjtc.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 02/16/2024] Open
Abstract
Objective To evaluate outcomes of surgical repair of postesophagectomy neoesophagus-airway fistulas (NEAFs). Methods We retrospectively included consecutive patients with NEAF managed by various techniques at our center between August 2009 and July 2021. Result Of the 11 patients (median age, 60 years; interquartile range, 58, 62), 4 had received induction chemoradiotherapy and 4 others induction chemotherapy. NEAF was mainly a complication of anastomotic leakage (n = 6) or attempted stenosis treatment (n = 3). The airway mainly involved was the trachea (n = 8). Airway defects were repaired by resection-anastomosis (n = 5), perforator flaps (n = 4), pedicled pericardium (n = 1), and/or direct suturing (n = 2). Gastric conduit defects were repaired by perforator flaps (n = 6), direct suturing (n = 2), or pedicled pericardium (n = 1). Of the 7 perforator flaps, 4 were internal mammary-artery, two dorsal intercostal-artery, and one supraclavicular-artery flaps. After a median follow-up of 100 months, 2 patients died on early postoperative course from NEAF repair failure and 3 from late NEAF recurrence at 4, 11, and 33 months. Among the remaining 6 patients, 1 died from local tumoral recurrence at 13 months, 1 was last on follow-up at 27 months, alive and eating normally. The other 4 were free from NEAF recurrence and dysphagia or swallowing disorder at 50 months' follow-up. These 4 results were obtained thanks to perforator flap interposition and airway resection anastomosis. Conclusions Surgical NEAF repair using perforator flap interposition may provide satisfactory long-term function after strong prehabilitation.
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Affiliation(s)
- Thibaud Bertrand
- Department of Thoracic Surgery and Heart-Lung Transplantation, Université Paris-Saclay, Marie-Lannelongue Hospital, GHPSJ, Le Plessis Robinson, France
| | - Olaf Mercier
- Department of Thoracic Surgery and Heart-Lung Transplantation, Université Paris-Saclay, Marie-Lannelongue Hospital, GHPSJ, Le Plessis Robinson, France
| | - Nicolas Leymarie
- Department of Reconstructive Surgery, Gustave Roussy, Villejuif, France
| | - Justin Issard
- Department of Thoracic Surgery and Heart-Lung Transplantation, Université Paris-Saclay, Marie-Lannelongue Hospital, GHPSJ, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Department of Thoracic Surgery and Heart-Lung Transplantation, Université Paris-Saclay, Marie-Lannelongue Hospital, GHPSJ, Le Plessis Robinson, France
| | - Frédéric Kolb
- Department of Reconstructive Surgery, University of California, San Diego, San Diego, Calif
| | - Elie Fadel
- Department of Thoracic Surgery and Heart-Lung Transplantation, Université Paris-Saclay, Marie-Lannelongue Hospital, GHPSJ, Le Plessis Robinson, France
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4
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de Groot EM, Kingma BF, Goense L, van der Kaaij NP, Meijer RCA, Ramjankhan FZ, Schellekens PAA, Braithwaite SA, Marsman M, van der Heijden JJ, Ruurda JP, van Hillegersberg R. Surgical treatment of esophago-tracheobronchial fistulas after esophagectomy. Dis Esophagus 2024; 37:doad054. [PMID: 37592909 PMCID: PMC10762505 DOI: 10.1093/dote/doad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/06/2023] [Accepted: 06/12/2023] [Indexed: 08/19/2023]
Abstract
The aim of this study was to evaluate the surgical treatment of esophago-tracheobronchial fistulas (ETBFs) that occurred after esophagectomy with gastric conduit reconstruction in a tertiary referral center for esophageal surgery. All patients who underwent surgical repair for an ETBF after esophagectomy with gastric conduit reconstruction were included in a tertiary referral center. The primary outcome was successful recovery after surgical treatment for ETBF, defined as a patent airway at 90 days after the surgical fistula repair. Secondary outcomes were details on the clinical presentation, diagnostics, and postoperative course after fistula repair. Between 2007 and 2022, 14 patients who underwent surgical repair for an ETBF were included. Out of 14 patients, 9 had undergone esophagectomy with cervical anastomosis and 5 esophagectomy with intrathoracic anastomosis after which 13 patients had developed anastomotic leakage. Surgical treatment consisted of thoracotomy to cover the defect with a pericardial patch and intercostal flap in 11 patients, a patch without interposition of healthy tissue in 1 patient, and fistula repair via cervical incision with only a pectoral muscle flap in 2 patients. After surgical treatment, 12 patients recovered (86%). Mortality occurred in two patients (14%) due to multiple organ failure. This study evaluated the techniques and outcomes of surgical repair of ETBFs following esophagectomy with gastric conduit reconstruction in 14 patients. Treatment was successful in 12 patients (86%) and generally consisted of thoracotomy and coverage of the defect with a bovine pericardial patch followed by interposition with an intercostal muscle.
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Affiliation(s)
- E M de Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B F Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R C A Meijer
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A A Schellekens
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Marsman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J van der Heijden
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Włodarczyk J, Smęder T, Obarski P, Ziętkiewicz M. Treatment of Esophago-Airway Fistula after Esophageal Resection. Healthcare (Basel) 2023; 11:3165. [PMID: 38132055 PMCID: PMC10743300 DOI: 10.3390/healthcare11243165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.
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Affiliation(s)
- Janusz Włodarczyk
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, 31-202 Cracow, Poland
| | - Tomasz Smęder
- Department of Thoracic and Surgical Oncology, John Paul II Hospital, 31-202 Cracow, Poland; (T.S.); (P.O.)
| | - Piotr Obarski
- Department of Thoracic and Surgical Oncology, John Paul II Hospital, 31-202 Cracow, Poland; (T.S.); (P.O.)
| | - Mirosław Ziętkiewicz
- Department of Anesthesiology and Intensive Care, Jagiellonian University Collegium Medicum, John Paul II Hospital, 31-202 Cracow, Poland;
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Post-esophagectomy tracheobronchoesophageal fistula: management and results of a tertiary referral center. Updates Surg 2023; 75:435-449. [PMID: 35996059 DOI: 10.1007/s13304-022-01364-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 08/17/2022] [Indexed: 01/24/2023]
Abstract
A tracheobronchoesophageal fistula (TBEF) is a rare but life-threatening complication after esophagectomy. The existing literature on TBEF management is limited and many previous recommendations are contradictory. We aimed to describe our series of TBEF after esophagectomy and compare it with other reported series. Patients who developed a TBEF after esophagectomy were identified retrospectively. Baseline and intraoperative characteristics, postoperative and TBEF details, treatments for TBEF, and main outcomes are described. A univariate analysis was performed to compare some of the analyzed variables with the overall sample. Finally, our results are compared with the previously described series. Altogether, 16 patients with TBEF (3.11%) were analyzed from 514 patients who received esophagectomies between January 2014 and February 2020. As a first treatment attempt, 14 (87.5%) were treated with surgery, one was treated conservatively, and one was treated endoscopically. Surgery both at a first or second treatment attempt achieved a survival rate of 62.5% and oral intake at discharge of 43.75%. Six patients died during their hospital stay (37.5%). The presence of an anastomotic leak showed a strong association with TBEF development (100% vs. 19.7%; OR 1.163, 95% CI 1.080-1.253, p = 0.000). In our experience, surgical treatment as the first approach for TBEF associated with anastomotic leak after esophagectomy obtained good results. However, there is an urgent need to elaborate treatment guidelines based on international consensus.
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Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel) 2023; 13:life13020287. [PMID: 36836644 PMCID: PMC9968149 DOI: 10.3390/life13020287] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Endoscopic treatment of post-esophagectomy/gastrectomy anastomotic dehiscence includes Self-Expandable Metal Stents (SEMS), which have represented the "gold standard" for many years, and Endoscopic Vacuum Therapy (EVT), which was recently introduced, showing promising results. The aim of the study was to compare outcomes of SEMS and EVT in the treatment of post-esophagectomy/gastrectomy anastomotic leaks, focusing on oncologic surgery. METHODS A systematic search was performed on Pubmed and Embase, identifying studies comparing EVT versus SEMS for the treatment of leaks after upper gastro-intestinal surgery for malignant or benign pathologies. The primary outcome was the rate of successful leak closure. A meta-analysis was conducted, performing an a priori-defined subgroup analysis for the oncologic surgery group. RESULTS Eight retrospective studies with 357 patients were eligible. Overall, the EVT group showed a higher success rate (odd ratio [OR] 2.58, 95% CI 1.43-4.66), a lower number of devices (pooled mean difference [pmd] 4.90, 95% CI 3.08-6.71), shorter treatment duration (pmd -9.18, 95% CI -17.05--1.32), lower short-term complication (OR 0.35, 95% CI 0.18-0.71) and mortality rates (OR 0.47, 95% CI 0.24-0.92) compared to stenting. In the oncologic surgery subgroup analysis, no differences in the success rate were found (OR 1.59, 95% CI 0.74-3.40, I2 = 0%). CONCLUSIONS Overall, EVT has been revealed to be more effective and less burdened by complications compared to stenting. In the oncologic surgery subgroup analysis, efficacy rates were similar between the two groups. Further prospective data need to define a unique management algorithm for anastomotic leaks.
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Huang H, Zhang J, Li L, Zhang G, Zhu D. Anesthesia management for tracheoesophageal fistula closed with a new gastrointestinal occluder device: a case report. J Cardiothorac Surg 2022; 17:287. [PMID: 36384539 PMCID: PMC9670478 DOI: 10.1186/s13019-022-02038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. A new gastrointestinal occluder device provides treatment for TEF patients. However, TEF-related pneumonia and respiratory failure increase the difficulty of anesthesia management, especially in airway management. Case presentation A 64-year-old man with thoracic esophageal cancer underwent esophagectomy and gastric tube reconstruction one year ago. The patient presented with recurrent cough and sputum after surgery. Gastroscopy revealed a fistula between the esophagogastric anastomotic site and membrane of the trachea. Therefore, the patient received implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy. Airway management under general anesthesia was discussed with an interdisciplinary decision, and cuffed endotracheal tube with an inner diameter of 5.5 mm was chosen. This airway management ensured adequate oxygenation during the operation and provided sufficient space for the operation of the tracheoscope in the trachea. Finally, the TEF disappeared after the operation, and the patient was administered an oral diet on the first postoperative day. Conclusions The implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy provides a new treatment for TEF patients. This case report suggests that it is important to select an endotracheal tube with an appropriate inner diameter that can not only meet the requirements of ventilation but also does not affect the operation of tracheoscopy in the trachea. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-02038-8.
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Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome. Cancers (Basel) 2022; 14:cancers14225556. [PMID: 36428649 PMCID: PMC9688292 DOI: 10.3390/cancers14225556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT). METHODS In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies. RESULTS In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches. CONCLUSIONS Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.
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Scognamiglio P, Reeh M, Melling N, Kantowski M, Eichelmann AK, Chon SH, El-Sourani N, Schön G, Höller A, Izbicki JR, Tachezy M. Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting. BMC Surg 2022; 22:309. [PMID: 35953796 PMCID: PMC9367146 DOI: 10.1186/s12893-022-01764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.
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Affiliation(s)
- Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marcus Kantowski
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Eichelmann
- General, Visceral and Transplantation Surgery, University Hospital Münster, Münster, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Nader El-Sourani
- Department for General and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Höller
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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11
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Grass JK, Küsters N, von Döhren FL, Melling N, Ghadban T, Rösch T, Simon M, Izbicki JR, König A, Reeh M. Management of Esophageal Cancer-Associated Respiratory–Digestive Tract Fistulas. Cancers (Basel) 2022; 14:cancers14051220. [PMID: 35267527 PMCID: PMC8909259 DOI: 10.3390/cancers14051220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
Respiratory–digestive tract fistulas are fatal complications that occur in esophageal cancer treatment. Interdisciplinary treatment strategies are still evolving, especially in anatomical treatment stratification. Thus, this study aims to evaluate general therapeutic strategies for this rare condition. Medical records were reviewed for esophageal cancer-associated respiratory–digestive tract fistula patients treated between January 2008 and September 2021. Fistulas were classified according to being surgery- and tumor-associated. Treatment strategies, clinical success, and survival were analyzed. A total of 51 patients were identified: 28 had tumor-associated fistulas and 23 surgery-associated fistulas. Risk factors for fistula development such as radiation (OR = 0.290, p = 0.64) or stent implantation (OR = 1.917, p = 0.84) did not correlate with lack of symptom control for RDF patients. In contrast, advanced lymph node metastasis as another risk factor was associated with persistent symptoms after treatment for RDF patients (OR = 0.611, p = 0.01). Clinical success significantly correlated with bilateral fistula repair in surgery-associated fistulas (p = 0.01), while tumor-associated fistulas benefited the most from non-surgical (p = 0.04) or combined surgical and non-surgical intervention (p = 0.04) and a bilateral fistula repair (p = 0.02) in terms of overall survival. The therapeutic strategy should aim for bilateral fistula closure. A multidisciplinary, stepwise approach might have the best chance for restoration or symptom control with optimized overall survival in selected patients.
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Affiliation(s)
- Julia K. Grass
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
- Correspondence: ; Tel.: +49-040-7410-52401
| | - Natalie Küsters
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Fabien L. von Döhren
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Marcel Simon
- Department of Respiratory Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Alexandra König
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (N.K.); (F.L.v.D.); (N.M.); (T.G.); (J.R.I.); (A.K.); (M.R.)
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12
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Sato Y, Tanaka Y, Suetsugu T, Takaha R, Ojio H, Hatanaka Y, Imai T, Okumura N, Matsuhashi N, Takahashi T, Kato H, Yoshida K. Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review. BMC Gastroenterol 2021; 21:467. [PMID: 34906075 PMCID: PMC8672548 DOI: 10.1186/s12876-021-02051-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The development of esophago-bronchial fistula after esophagectomy and reconstruction using a posterior mediastinal gastric tube remains a rare complication associated with a high rate of mortality. CASE PRESENTATION A 63-year-old man with esophageal cancer underwent a thoracoscopic esophagectomy with two-field lymph node dissection and reconstruction via a gastric tube through the posterior mediastinal route. Postoperatively, the patient developed extensive pyothorax in the right lung due to port site bleeding and hematoma infection. Four months after surgery, he developed an esophago-left bronchial fistula due to ischemia of the cervical esophagus and severe reflux esophagitis at the site of the anastomosis. Because of respiratory failure due to the esophago-bronchial fistula and the history of extensive right pyothorax, right thoracotomy and left one-lung ventilation were thought to be impossible, so we decided to perform the surgery in three-step systematically. First, we inserted a decompression catheter and feeding tube into the gastric tube as a gastrostomy and expected neovascularization to develop from the wall of the gastric tube through the anastomosis after this procedure. Second, 14 months after esophagectomy, we constructed an esophagostomy after confirming blood flow in the distal side of the cervical esophagus via gastric tube using intraoperative indocyanine green-guided blood flow evaluation. In the final step, we closed the esophagostomy and performed a cervical esophago-jejunal anastomosis to restore esophageal continuity using a pedicle jejunum in a Roux-en-Y anastomosis via a subcutaneous route. CONCLUSION This three-step operation can be an effective procedure for patients with esophago-left bronchial fistula after esophagectomy, especially those with respiratory failure and difficulty in undergoing right thoracotomy with left one-lung ventilation.
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Affiliation(s)
- Yuta Sato
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Yoshihiro Tanaka
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan.
| | - Tomonari Suetsugu
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Ritsuki Takaha
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Hidenori Ojio
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Yuji Hatanaka
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Takeharu Imai
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Naoki Okumura
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Nobuhisa Matsuhashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Takao Takahashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Hisakazu Kato
- Department of Plastic and Reconstructive Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
| | - Kazuhiro Yoshida
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu University Graduate School of Medicine, Gifu City, Japan
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13
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Veziant J, Gaillard M, Barat M, Dohan A, Barret M, Manceau G, Karoui M, Bonnet S, Fuks D, Soyer P. Imaging of postoperative complications following Ivor-Lewis esophagectomy. Diagn Interv Imaging 2021; 103:67-78. [PMID: 34654670 DOI: 10.1016/j.diii.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.
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Affiliation(s)
- Julie Veziant
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Martin Gaillard
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Anthony Dohan
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Maximilien Barret
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology and Digestive Oncology, Hôpital Cochin, APHP.Centre, 75014 Paris, France
| | - Gilles Manceau
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Mehdi Karoui
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Stéphane Bonnet
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Philippe Soyer
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
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14
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Wahi JE, Rocco D, Williams R, Safdie FM. Endoluminal management of benign bronchoesophageal fistula. BMJ Case Rep 2021; 14:e245240. [PMID: 34544721 PMCID: PMC8454450 DOI: 10.1136/bcr-2021-245240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/03/2022] Open
Abstract
The ideal management of bronchoesophageal fistulas is a debated topic. While open surgical repair remains the most definitive treatment, not all patients are fit for surgery. In this communication, we present a patient who developed a bronchoesophageal fistula 1 year after an Ivor Lewis esophagectomy that involved the native oesophagus and right mainstem bronchus. Endoluminal vacuum therapy was successful at closing this benign bronchoesophageal fistula.
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Affiliation(s)
- Jessica E Wahi
- Surgery, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Diana Rocco
- Surgery, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Roy Williams
- Surgery, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Fernando M Safdie
- Cardiothoracic Surgery, Mount Sinai Medical Center, Miami Beach, Florida, USA
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15
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Endoluminal Vacuum Therapy for Definitive Management of an Esophagobronchial Fistula. Ann Thorac Surg 2021; 113:669-673. [PMID: 34391698 DOI: 10.1016/j.athoracsur.2021.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/17/2021] [Accepted: 07/03/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Endoluminal vacuum (EVAC) therapy has gained popularity as a minimally invasive option for contained esophageal leaks. EVAC therapy may be useful for esophagogastric anastomotic leak fistulizing to the airway. DESCRIPTION The following describes EVAC therapy of an esophagobronchial fistula with video depicting the conduct of the procedure including technical tips. Video and photo evidence of progression and ultimate resolution are included. EVALUATION Sponge exchanges were completed every 3 to 4 days. EVAC therapy was administered via a transnasal approach. In the presented case, a total of 11 exchanges over 6 weeks were required. EVAC sponge placement was transitioned from intracavitary to endoluminal for the final four treatments. All but 4 exchanges were able to be completed at the bedside in a monitored setting with sedation. CONCLUSIONS Definitive EVAC therapy of an esophageal leak that has fistulized to a main airway is rare and challenging clinical problem. Definitive EVAC therapy for esophageal anastomotic leak with esophagobronchial fistula is a feasible option in select cases.
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16
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Brunner S, Bruns CJ, Schröder W. [Esophagotracheal and esophagobronchial fistulas]. Chirurg 2021; 92:577-588. [PMID: 33630123 DOI: 10.1007/s00104-021-01370-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/25/2022]
Abstract
Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.
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Affiliation(s)
- S Brunner
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Köln, Deutschland
| | - C J Bruns
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Köln, Deutschland
| | - W Schröder
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Köln, Deutschland.
- Chirurgische Leitung "Oberer Gastrointestinaltrakt", Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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17
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Sonomura J, Shimizu T, Taniguchi K, Lee SW, Tanaka R, Imai Y, Honda K, Kawai M, Tashiro K, Uchiyama K. Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report. Medicine (Baltimore) 2021; 100:e24494. [PMID: 33530270 PMCID: PMC7850741 DOI: 10.1097/md.0000000000024494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/07/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited. PATIENT CONCERNS A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close. DIAGNOSES Intractable esophago-bronchial fistula associated with esophageal surgery. INTERVENTIONS AND OUTCOMES On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case. LESSONS We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.
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Affiliation(s)
- Jun Sonomura
- Department of General and Gastroenterological Surgery
| | | | - Kohei Taniguchi
- Department of General and Gastroenterological Surgery
- Translational Research Program, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki city, Osaka, Japan
| | | | - Ryo Tanaka
- Department of General and Gastroenterological Surgery
| | - Yoshiro Imai
- Department of General and Gastroenterological Surgery
| | - Kotaro Honda
- Department of General and Gastroenterological Surgery
| | - Masaru Kawai
- Department of General and Gastroenterological Surgery
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18
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Abbas AE, Sarkaria IS. Specific complications and limitations of robotic esophagectomy. Dis Esophagus 2020; 33:6006411. [PMID: 33241309 DOI: 10.1093/dote/doaa109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/24/2020] [Accepted: 09/12/2020] [Indexed: 12/11/2022]
Abstract
Regardless of the approach to esophagectomy, it is an operation that may be associated with significant risk to the patient. Robotic-assisted minimally invasive esophagectomy (RAMIE) has the same potential for short- and long-term complications as does open and minimally invasive esophagectomy. These complications include among others, the risk for anastomotic leak, gastric tip necrosis, vocal cord palsy, and chylothorax. Moreover, there are additional risks that are unique to the robotic platform such as hardware or software malfunction. These risks are heavily influenced by numerous factors including the patient's comorbidities, whether neoadjuvant therapy was administered, and the extent of the surgical team's experience. The limitations of RAMIE are therefore based on the careful assessment of the patient for operability, the tumor for resectability and the team for surgical ability. This article will tackle the topic of complications and limitations of RAMIE by examining each of these issues. It will also describe the recommended terminology for reporting post-esophagectomy complications.
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Affiliation(s)
- Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital and Fox Chase Cancer Center, Philadelphia, PA, USA, and
| | - Inderpal S Sarkaria
- Division of Thoracic Surgery, Department of Surgery, University of Pittsburg Medical Center, Pittsburgh, PA, USA
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19
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Wang C, Li C, Yang X, Mao W, Jiang Y, Wu J, Zhao Q, Ji A, Chen Q, Li H, Liu J. The classification and treatment strategies of post-esophagectomy airway-gastric fistula. J Thorac Dis 2020; 12:3602-3610. [PMID: 32802439 PMCID: PMC7399427 DOI: 10.21037/jtd-20-284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Airway-gastric fistulas (AGFs) are rare but life-threatening complications after esophagectomy for esophageal cancer. Their effective and reasonable management is challenging and still controversial. This study reports the classification and management strategies of post-esophagectomy AGF based on a retrospective analysis of 26 cases in two large volume centers in China. Methods Between January 2000 and December 2017, 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy. AGF was verified in 26 patients. The patients with AGF were divided into two types based on the anatomic characteristics of the fistula. Type I was characterized by the presence of fistula orifices in digestive tract that were higher than those in the airway and were treated with conservative management. Type II had both fistula orifices located on the same horizontal plane and were treated with surgical management. Pearson Chi-Square (R software) was used to compare mortality rates. Results From January 2000 and December 2017, 26 cases occurred AGF in 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy and the incidence of AGF was 0.4%. Ten of 12 patients with type I AGF survived. Nine of 14 patients with type II AGF died. There was a significantly difference in the mortality rates between patients with AGF type I and II, which was 16.7% (2/12) and 64.3% (9/14) (χ2=6.003, P=0.014), respectively. Conclusions AGF may be classified into two types according to the anatomic characteristics. Type I patients may be cured by conservative management and type II patients, require surgical intervention with pedicled tissues flap wrapping of the airway.
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Affiliation(s)
- Changchun Wang
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Chengqiang Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xun Yang
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Weimin Mao
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Youhua Jiang
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jie Wu
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Qiang Zhao
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Anqi Ji
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qixun Chen
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinshi Liu
- Department of Thoracic Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
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20
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Miyata K, Fukaya M, Nagino M. Repair of gastro-tracheobronchial fistula after esophagectomy for esophageal cancer using intercostal muscle and latissimus dorsi muscle flaps: a case report. Surg Case Rep 2020; 6:172. [PMID: 32666163 PMCID: PMC7359967 DOI: 10.1186/s40792-020-00936-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/08/2020] [Indexed: 11/10/2022] Open
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 gastro-tracheobronchial 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.
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Affiliation(s)
- Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Masahide Fukaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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21
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Abstract
Esophagectomy is a complex operation with many potential complications. Early recognition of postoperative complications allows for the best chance for patient survival. Diagnosis and management of conduit complications, including leak, necrosis, and conduit-airway fistulae, are reviewed. Other common complications, such as chylothorax and recurrent laryngeal nerve injury, also are discussed.
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Affiliation(s)
- Jonathan C Yeung
- Toronto General Hospital, 200 Elizabeth Street 9N-983, Toronto, Ontario M5G 2C4, Canada.
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22
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Douin DJ, Tran TT. Bronchoesophageal Fistula Requiring Venovenous ECMO After Minimally Invasive Esophagectomy. J Cardiothorac Vasc Anesth 2020; 34:2727-2730. [PMID: 32362546 DOI: 10.1053/j.jvca.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO.
| | - Timothy T Tran
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
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23
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Palmes D, Kebschull L, Bahde R, Senninger N, Pascher A, Laukötter MG, Eichelmann AK. Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy. Thorac Cardiovasc Surg 2020; 69:216-222. [PMID: 32114691 DOI: 10.1055/s-0039-1700970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF. METHODS From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome. RESULTS In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously (n = 6, 40%) or metachronously (n = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy (n = 3), stenting (n = 6), or suturing (n = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition. CONCLUSION Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.
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Affiliation(s)
- Daniel Palmes
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Linus Kebschull
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Ralf Bahde
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Norbert Senninger
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Mike G Laukötter
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
| | - Ann-Kathrin Eichelmann
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany
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Mann C, Musholt TJ, Babic B, Hürtgen M, Gockel I, Thieringer F, Lang H, Grimminger PP. [Surgical treatment of esophagotracheal and esophagobronchial fistulas]. Chirurg 2019; 90:722-730. [PMID: 31384993 DOI: 10.1007/s00104-019-1006-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Esophagotracheal and esophagobronchial fistulas are pathological communications between the airway system and the digestive tract, which often lead to major pulmonary complications with a high mortality. Endoscopic treatment is the primary therapeutic approach; however, in cases of failure early surgical treatment is obligatory. METHODS This article describes the clinical course of patients with esophagotracheal and esophagobronchial fistulas treated in this hospital over a period of 10 years. Patients were retrospectively analyzed with respect to the etiology of fistulas, management, in particular to the operative procedures, complications and outcome. RESULTS Between 2009 and 2019, a total of 15 patients with esophagotracheal and esophagobronchial fistula were treated in this hospital. Of these 12 underwent an endoscopic intervention, of which 5 were successful. In total, eight patients needed surgical intervention, six of the eight surgically treated patients recovered fully, one had a recurrent fistula, which was successfully treated by subsequent endoscopy after surgery and one patient died. DISCUSSION Management of esophagotracheal and esophagobronchial fistulas is challenging. This retrospective analysis reflects the published data with a success rate of endoscopic treatment in approximately 50%. Surgical intervention should be carried out after unsuccessful endoscopic treatment or if endoscopic treatment is primarily not feasible. Direct closure with resorbable sutures or reconstruction with alloplastic or allogeneic material should be preferred. For larger defects or high proximal esophagotracheal fistulas local transposition of muscular flaps or free muscular flaps play a major role. During operative closure of high intrathoracic or cervical fistulas, intraoperative neuromonitoring can be useful to prevent nerve damage.
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Affiliation(s)
- C Mann
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - T J Musholt
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - B Babic
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - M Hürtgen
- Klinik für Thoraxchirurgie, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Deutschland
| | - I Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - F Thieringer
- I. Medizinische Klinik, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - H Lang
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - P P Grimminger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Chaddha U, Hogarth DK, Murgu S. Perspective on airway stenting in inoperable patients with tracheoesophageal fistula after curative-intent treatment for esophageal cancer. J Thorac Dis 2019; 11:2165-2174. [PMID: 31285911 DOI: 10.21037/jtd.2018.12.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Udit Chaddha
- Division of Pulmonary and Critical Care, University of Chicago Medical Center, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - D Kyle Hogarth
- Division of Pulmonary and Critical Care, University of Chicago Medical Center, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Septimiu Murgu
- Division of Pulmonary and Critical Care, University of Chicago Medical Center, The University of Chicago Medicine, Chicago, IL 60637, USA
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Wang H, Tao M, Zhang N, Zou H, Li D, Ma H, Zhou Y. Single application of airway stents in thoracogastric-airway fistula: results and prognostic factors for its healing. Ther Adv Respir Dis 2019; 13:1753466619871523. [PMID: 31476949 PMCID: PMC6724482 DOI: 10.1177/1753466619871523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thoracogastric-airway fistula (TGAF) post-thoracic surgery is a rare and challenging complication for esophagectomy. The aim of this study was to explore the effectiveness of airway stenting for TGAF patients and find related factors coupled with healing of fistula. METHODS This is a retrospective study involving patients with TGAF who were treated with airway stentings. Based on different TGAF locations and sizes on chest computed tomography, covered metallic or silicon airway stents were implanted to cover orifices under interventional bronchoscopy. TGAF healing was defined as the primary outcome, and complete sealing of TGAF as the second outcome. The predictors for TGAF healing were analyzed in univariate and multivariate analysis. RESULTS A total of 58 TGAF patients were included, of whom 7 received straight covered metallic stents, 5 straight silicon stents, 3 L-shaped covered metallic stents, 21 large Y-shaped covered metallic stents, 17 large Y-shaped silicon stents, and 5 with Y-shaped covered metallic stents. Healing was achieved in 20 (34.5%) patients, and complete sealing in 45 (77.6%) patients. There were no significant differences in healing rate and complete sealing rate between patients receiving metallic stents and those with silicon stents. In univariate analysis, lacking a previous history of radiotherapy or chemotherapy, nonmalignant fistulas, small fistulas, and shorter postesophagectomy duration were found associated with a higher rate of TGAF healing. Only shorter postesophagectomy duration was associated with TGAF healing in multivariate analysis. CONCLUSIONS Both silicon and covered metallic airway stenting are effective methods to close TGAF. A shorter postesophagectomy period may predict better TGAF healing. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Hongwu Wang
- Department of Oncology, Emergency General Hospital, No. 29 Xibahe Nanli, Chaoyang District, Beijing, 100028, China
| | - Meimei Tao
- Department of Oncology, Emergency General Hospital, No. 29 Xibahe Nanli, Chaoyang District, Beijing, 100028, China
| | - Nan Zhang
- Department of Oncology, Emergency General Hospital, Beijing, China
| | - Hang Zou
- Department of Oncology, Emergency General Hospital, Beijing, China
| | - Dongmei Li
- Department of Oncology, Emergency General Hospital, Beijing, China
| | - Hongming Ma
- Department of Oncology, Emergency General Hospital, Beijing, China
| | - Yunzhi Zhou
- Department of Oncology, Emergency General Hospital, Beijing, China
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Berlth F, Bludau M, Plum PS, Herbold T, Christ H, Alakus H, Kleinert R, Bruns CJ, Hölscher AH, Chon SH. Self-Expanding Metal Stents Versus Endoscopic Vacuum Therapy in Anastomotic Leak Treatment After Oncologic Gastroesophageal Surgery. J Gastrointest Surg 2019; 23:67-75. [PMID: 30374816 DOI: 10.1007/s11605-018-4000-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leak after gastroesophageal surgery is a life-threatening complication. Self-expanding metal stent (SEMS) implantation or endoscopic vacuum therapy (EVT) have been established as alternatives to reoperation. This study compares the outcome of both interventions for anastomotic leak clinical management. METHODS In this retrospective study, we identified all patients who received SEMS or EVT for anastomotic leaks after oncological gastroesophageal surgery between January 2007 and December 2016. Only patients with type II leaks according to the Esophagectomy Complications Consensus Group were included. Sealing rates, intervention-related complications, demographic characteristics, clinical history, leak characteristics, therapy duration, and in-hospital mortality were analyzed. RESULTS One hundred eleven patients who received SEMS (n = 76) or EVT (n = 35) were identified and categorized by primary and final treatment. The overall closure rate in the final treatment analysis was 85.7% for EVT and 72.4% for SEMS (p = 0.152). ICU stay ranged from 0 to 60 days (median 6 days) for EVT and from 0 to 295 days (median 9 days) for SEMS (p = 0.704). EVT patients were hospitalized for 19-119 days (median 39 days) and SEMS patients for 13-296 days (median 37 days; p = 0.812). Demographic factors, comorbidities, and surgical parameters did not correlate with treatment or treatment success. CONCLUSIONS SEMS and EVT show comparable results for anastomotic leak management after oncologic gastroesophageal surgery. No superior outcome could be found for either one of the two treatments options.
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Affiliation(s)
- Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Kleinert
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Balakrishnan A, Tapias L, Wright CD, Lanuti MX, Gaissert HA, Mathisen DJ, Muniappan A. Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula. Ann Thorac Surg 2018; 106:1640-1646. [PMID: 30171850 DOI: 10.1016/j.athoracsur.2018.06.076] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-esophagectomy tracheo-bronchial-esophageal fistula (PETEF) most often develops after anastomotic disruption or gastric conduit necrosis. Ideal surgical management and outcomes for this complication are uncertain. METHODS A retrospective review of 11 patients undergoing surgical repair of PETEF was performed. RESULTS The median time between esophagectomy and surgical repair of PETEF was 61 days (range, 7 days to 28 years). Anastomotic leak or gastric conduit necrosis was responsible for PETEF in 6 patients (54.5%), whereas other causes were erosion of a tracheal appliance (n = 2), gastric conduit staple line erosion (n = 1), anastomotic stricture dilation (n = 1), and recurrent esophageal cancer (n = 1). Membranous airway defects were repaired primarily and buttressed with muscle or omental flaps in 8 patients (72.7%), whereas two (18.2%) were repaired with bio-prosthetic patches and one (9.1%) was repaired with a sleeve resection of the bronchus. Anastomotic and neo-esophageal conduit defects were repaired primarily in 3 patients (27.3%), whereas 7 patients (63.6%) underwent conduit take-down and esophageal or pharyngeal diversion, and 1 patient (9.1%) underwent simultaneous fistula repair and colon interposition. Two patients (18.2%) had recurrent fistulas, with 1 patient dying after second fistula closure and the other was discharged with no further attempt at repair. Three patients (27.3%) died postoperatively. Only 3 patients (27.3%) resumed an oral diet after fistula repair. CONCLUSIONS Surgical treatment is effective for most patients undergoing operative repair of PETEF, notwithstanding a considerable risk of postoperative morbidity and death. Although fistula repair is life saving and prevents further respiratory deterioration, return to oral alimentation is not ensured.
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Affiliation(s)
- Ashwin Balakrishnan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Leonidas Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael X Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Grimminger PP, Goense L, Gockel I, Bergeat D, Bertheuil N, Chandramohan SM, Chen KN, Chon SH, Denis C, Goh KL, Gronnier C, Liu JF, Meunier B, Nafteux P, Pirchi ED, Schiesser M, Thieme R, Wu A, Wu PC, Buttar N, Chang AC. Diagnosis, assessment, and management of surgical complications following esophagectomy. Ann N Y Acad Sci 2018; 1434:254-273. [PMID: 29984413 DOI: 10.1111/nyas.13920] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/13/2018] [Accepted: 06/05/2018] [Indexed: 12/15/2022]
Abstract
Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.
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Affiliation(s)
- Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Damien Bergeat
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital, Rennes, France
| | | | - Ke-Neng Chen
- Department of Thoracic Surgery I, Beijing University Cancer Hospital, Beijing, China
| | - Seung-Hon Chon
- Department of General, Visceral and Tumor Surgery, University Hospital of Cologne, Cologne, Germany
| | - Collet Denis
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Khean-Lee Goh
- Combined Endoscopy Unit, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Caroline Gronnier
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Jun-Feng Liu
- Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Bernard Meunier
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Phillippe Nafteux
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Enrique D Pirchi
- Department of Surgery, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Aaron Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Peter C Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Chang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Fukumoto Y, Matsunaga T, Shishido Y, Amisaki M, Kono Y, Murakami Y, Kuroda H, Osaki T, Sakamoto T, Honjo S, Ashida K, Saito H, Fujiwara Y. Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report. Surg Case Rep 2018; 4:49. [PMID: 29796790 PMCID: PMC5966367 DOI: 10.1186/s40792-018-0458-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/17/2018] [Indexed: 11/22/2022] Open
Abstract
Background Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging. Case presentation A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery. Conclusions Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.
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Affiliation(s)
- Yoji Fukumoto
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan.
| | - Tomoyuki Matsunaga
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Yuji Shishido
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Masataka Amisaki
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Yusuke Kono
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Yuki Murakami
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Hirohiko Kuroda
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Tomohiro Osaki
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Teruhisa Sakamoto
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Soichiro Honjo
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Keigo Ashida
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Hiroaki Saito
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
| | - Yoshiyuki Fujiwara
- Division of Surgical Oncology, Department of Surgery, Tottori University Faculty of Medicine, 36-1 Nishicho, Yonago, Tottori, 683-8504, Japan
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Sakatoku Y, Fukaya M, Fujieda H, Kamei Y, Hirata A, Itatsu K, Nagino M. Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer. Surg Case Rep 2017; 3:90. [PMID: 28831760 PMCID: PMC5567582 DOI: 10.1186/s40792-017-0371-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/17/2017] [Indexed: 12/04/2022] Open
Abstract
Background Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient. Case presentation A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation. Conclusion A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.
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Affiliation(s)
- Yayoi Sakatoku
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masahide Fukaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Hironori Fujieda
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yuzuru Kamei
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Hirata
- Department of Surgery, Shizuoka Kosei Hospital, 23 Kitaban-cho, Aoi-ku, Shizuoka, 420-8623, Japan
| | - Keita Itatsu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Skin Perforator Flap Pedicled by Intercostal Muscle for Repair of a Tracheobronchoesophageal Fistula. Ann Thorac Surg 2017; 103:e571-e573. [DOI: 10.1016/j.athoracsur.2016.12.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/19/2016] [Accepted: 12/26/2016] [Indexed: 11/20/2022]
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