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Kaur A, Biswas G. Internal mammary artery perforator flap in the management of tracheoesophageal fistulae. J Laryngol Otol 2024; 138:652-655. [PMID: 38185828 DOI: 10.1017/s0022215123002360] [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] [Indexed: 01/09/2024]
Abstract
BACKGROUND A pathological communication between the trachea and oesophagus - a tracheoesophageal fistula - may be congenital or acquired, benign or malignant, necessitating a multidisciplinary approach. Conservative attempts at closure of this abnormal connection are ineffective; the interposition of healthy vascular tissue offers the least chance of recurrence. METHODS Outcomes of an islanded fasciocutaneous internal mammary artery perforator flap applied for tracheoesophageal fistula management were assessed in four radiated patients with laryngeal carcinoma using retrospective records. RESULTS Four male patients, with an average age of 60.75 years, underwent tracheoesophageal fistula closure between September 2017 and February 2021. A left-sided second internal mammary artery perforator flap was used in all cases, with an average dimension of 10.5 × 4.5 cm. There were no complications of tracheoesophageal leak, flap issues or donor site morbidity on follow up. CONCLUSION Recent advances in angiosomal territory mapping and microvascular dissection techniques, combined with an understanding of tracheoesophageal fistula pathology, have changed management perspectives in these difficult-to-treat patients.
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Affiliation(s)
- Amrita Kaur
- Department of Plastic Surgery, Tata Medical Centre, Kolkata, India
| | - Gautam Biswas
- Department of Plastic Surgery, Tata Medical Centre, Kolkata, India
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Dechong Z, He H, Jigang Z, Cunming L. Airway and anesthesia management in tracheoesophageal fistula closure implantation: a single-centre retrospective study. J Cardiothorac Surg 2024; 19:172. [PMID: 38570837 PMCID: PMC10993449 DOI: 10.1186/s13019-024-02737-4] [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] [Received: 11/11/2023] [Accepted: 03/29/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management. METHOD We searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients' disease course and follow-up records were analyzed and summarized. RESULTS The airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia. CONCLUSION During the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.
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Affiliation(s)
- Zhu Dechong
- Department of Anesthesiology and Perioperative Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Huang He
- Department of Anesthesiology and Perioperative Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zhang Jigang
- Department of Anesthesiology and Perioperative Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Liu Cunming
- Department of Anesthesiology and Perioperative Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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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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Wang C, Dong J, Zhuang X, Yang C, Chen H, Inage T, Velotta JB, Brunelli A, Homma T, Shigemura N, Suen HC, He J, Li S. Intraoperative methods for wrapping anastomoses after airway reconstruction: a case series. Transl Lung Cancer Res 2022; 11:1145-1153. [PMID: 35832451 PMCID: PMC9271447 DOI: 10.21037/tlcr-22-406] [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: 02/21/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
Background Anastomosis management is the main challenge of airway resection and reconstruction, and postoperative anastomotic complications, including ischemia, stenosis, dehiscence, and separation may lead to severe outcomes and a poor prognosis. The anastomotic buttress is vital in airway reconstruction, but the selection of surgical buttress and reinforcement remains controversial. We aimed to demonstrate and evaluate the buttress options of anastomosis, including their preoperative characteristics, the intraoperative process, and the incidence of postoperative complications to help address the controversy regarding anastomosis management. Methods This retrospective study was conducted at a single institution. Patients who underwent airway reconstruction with anastomotic wrapping from Jan. 2019 to Sep. 2021 were enrolled in this study and preoperative characteristics and operational features were collected. All patients were carefully followed up by telephone and outpatient. Their postoperative complications and postoperative status after 6 months were recorded. The surgical procedures and clinical characteristics of the buttress options of anastomosis were assessed. Results A total of 62 patients undergoing either cervical tracheal, thoracic tracheal, carinal, or secondary carinal and main bronchus resection and reconstruction were evaluated. The anastomotic buttress used included mediastinal pleural flap (24/62, 38.7%), anterior cervical muscle (14/62, 22.6%), sternocleidomastoid (2/62, 3.2%), thymus flap (12/62, 19.4%), intercostal muscle flap (2/62, 3.2%), biological patch (2/62, 3.2%), prepericardial fat (1/62, 1.6%), thyroid gland (1/62, 1.6%), pectoralis major flap (2/62, 3.2%), and omental flap (2/62, 3.2%). All procedures produced satisfactory results without short-term anastomotic complications. A follow-up for 6 months was conducted and all patients were alive postoperatively. Tracheomalacia stenosis postoperatively occurred in 3 patients and they were subsequently treated with an endotracheal stent. One patient had tumor recurrence 3 months after surgery and received adjuvant chemotherapy. Conclusions Various anastomotic wrapping materials are used in airway reconstruction. Different utilizations of buttress are selected according to the anatomic characteristics and the reconstruction method used. This study indicated that appropriate surgical buttresses for wrapping anastomoses are legitimate alternatives to reduce the risk of anastomotic complications.
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Affiliation(s)
- Chudong Wang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Junguo Dong
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Xiaoxue Zhuang
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chao Yang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Hanzhang Chen
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Terunaga Inage
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jeffrey B Velotta
- Department of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Takahiro Homma
- Division of Thoracic Surgery, Kurobe City Hospital, Toyama, Japan.,Division of Thoracic Surgery, University of Toyama, Toyama, Japan
| | - Norihisa Shigemura
- Division of Cardiovascular Surgery, Department of Surgery, Temple University Health System, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Hon Chi Suen
- Hong Kong Cardiothoracic Surgery Center, Hong Kong, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Shuben Li
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
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Abstract
Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.
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Affiliation(s)
- Ammara A Watkins
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA.
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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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