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J Thorac Cardiovasc Surg 2006;132:716-717
© 2006 The American Association for Thoracic Surgery

Brief Communication

Repair of gastrotracheal fistula with a pedicled pericardial flap after Ivor Lewis esophagogastrectomy for esophageal cancer

Suk-Won Song, MD, Hyun-Sung Lee, MD, Moon Soo Kim, MD, Jong Mog Lee, MD, Jae Hyun Kim, MD*, Jae Ill Zo, MD, PhD

Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Republic of Korea.

Received for publication April 25, 2006; accepted for publication May 17, 2006.

* Address for reprints: Jae Ill Zo, MD, PhD, Center for Lung Cancer, National Cancer Center, 809 Madu1-dong, Ilsandong-gu, Goyang, Gyeonggi, 411-769, Korea (Email: jaylzo{at}ncc.re.kr).


Figure 1
Drs J. Lee, H. Lee, Zo, Kim, and Song (left to right)


A benign fistula between the trachea and the intrathoracic stomach after a total esophagectomy is a rare but potentially fatal complication.1Go One such complication occurred in our series of 253 esophagectomies for carcinoma during a 4-year period. The present report describes the successful surgical repair of the fistula with a pedicled pericardial flap.

Clinical Summary

A 73-year-old male patient with a squamous cell carcinoma of the lower third of the esophagus underwent a transthoracic esophagectomy, a 2-field lymphadenectomy, and an intrathoracic esophagogastrostomy through a right-sided thoracotomy. Other than having non–insulin-dependent diabetes mellitus and hypertension, the patient was in good health. The postoperative course was uneventful. The initial esophagogram with barium swallow on the seventh postoperative day showed no evidence of anastomotic leakage or passage disturbance. However, the patient experienced mild coughing with aspiration while swallowing food. Vocal cord examination revealed no evidence of paralysis. Examination with a fiberoptic bronchoscope on the 18th postoperative day showed mucosal irregularity with granulation tissue about 5 cm above the carina. An esophagogastroscopy showed an approximately 4-cm ischemic mucosal area covered with exudate beneath the anastomosis. Chest computed tomographic scans showed multiple air densities around the anastomotic surgical staple line and a beak-like lesion to the left side of the membranous portion of the lower trachea. On the basis of these observations, a minor anastomotic leak and a small gastrotracheal fistula were diagnosed. Because the patient was in very good general condition without any severe pulmonary or mediastinal infection, spontaneous healing was anticipated after conservative management for about 2 weeks with nothing by mouth (NPO) and total parenteral nutrition with simultaneous gastric and thoracic drainage. However, esophagography after 2 weeks of conservative management showed a definite "H-type" fistula between the intrathoracic stomach and the trachea (Figure 1).


Figure 1
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  		Figure 1. Esophagogram on the 32nd postoperative day revealing a definite "H-type" fistula (arrow) connecting the intrathoracic stomach and the trachea.

 
On the 33rd postoperative day an exploratory thoracotomy was performed through the previous incision site. The intrathoracic stomach and trachea were divided meticulously. The gastrotracheal fistula was 2 x 1.5 cm, oval, and associated with severe inflammation. All necrotic tissues of the stomach including the anastomosis site were excised completely to the point of exposure of the intact mucosa. We decided to use pedicled pericardium to the diaphragmatic level. The tracheal defect on the membranous portion was closed with a pedicled pericardial flap and absorbable polydioxanone 4-0 interrupted sutures (PDS; Ethicon, Inc, Somerville, NJ), with the inner side of the pericardium toward the lumen of the trachea, twisting the pedicled pericardium. Esophagogastric continuity was restored with an end-to-end anastomosis using an EEA 25 mm circular stapling device (Auto Suture Anastomotic Gun; Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn), after remobilization of the entire portion of the intrathoracic stomach (Figure 2). On the seventh day after reoperation, sips of water were allowed after confirming the absence of anastomotic leaks using a barium esophagogram, and a full liquid diet was implemented the following day. At 8 months the patient was progressing satisfactorily without any respiratory or swallowing problems.


Figure 2
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  		Figure 2. Repair of a gastrotracheal fistula with a pedicled pericardial flap (arrows) and reanastomosis of the esophagus and gastric conduit. A, Operative photograph just before reanastomosis. B, Schematic illustration after reanastomosis. SVC, Superior vena cava.

 
Comment

A benign fistula between the airway and intrathoracic stomach replacing the esophagus after Ivor Lewis surgery for esophageal cancer is rare but potentially fatal.1Go According to the literature, a benign neoesophagus-tracheal fistula is particularly related to a supraradical transthoracic procedure with devascularization of the trachea resulting from extensive dissection of the upper mediastinum.2Go

Possible causes are tracheal erosion by the gastric staple line, gastric erosion by the tracheostomy tube, overinflation of the endotracheal tube balloon, preoperative radiotherapy, gastric tube ulcers, anastomotic insufficiency, and any local inflammatory processes in the trachea, mediastinum, or neoesophagus.3Go

Symptoms at presentation may range from mild (eg, coughing associated with oral intake) to severe (eg, recurrent bronchopneumonia) to life-threatening (eg, mediastinitis).1Go

Treatment depends on the severity of symptoms, the size and location of the fistula, and accompanying conditions. In the absence of severe mediastinal or pulmonary infection, such as in our case, conservative treatment (ie, NPO with or without antimicrobial agents) may be considered. However, with severe symptoms necessitating surgery, the procedure of choice is a complete excision of the fistula and closure of the tracheal and neoesophageal defects. Interposition of a pedicled pleural, omental, or muscle flap has proved useful. The intrathoracic stomach should be left in place unless judged an unviable option. In such cases, esophageal diversion using a cervical esophagostomy and delayed re-establishment of esophagogastric continuity with the colon is indicated.4,5Go If mediastinitis is present, elimination of the septic focus and extensive drainage of the mediastinum are mandatory.1Go

In the present case, the gastrotracheal fistula was successfully treated with a transposed pedicled pericardial flap and reanastomosis of the esophagus and gastric conduit.

References

  1. Buskens JC, Hulscher JBF, Fockens P, Obertop H, van Lanschot JJB. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg 2001;72:221-224.[Abstract/Free Full Text]
  2. Fujita H, Kawahara H, Hidaka M, Nagano T, Yoshimatsu H. An experimental study on viability of the devascularized trachea. Jpn J Surg 1988;18:77-83.[Medline]
  3. Kron I, Johnson A, Morgan RF. Gastrotracheal fistula. a late complication after transhiatal esophagectomy. Ann Thorac Surg 1989;47:767-768.[Abstract]
  4. Furst H, Hartl WH, Lohe F, Schildberg FW. Colon interposition for esophageal replacement. an alternative technique based on the use of the right colon. Ann Surg 2000;23:173-178.
  5. DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, McGill JE, et al. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 1988;208:460-474.[Medline]



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STAGED REPAIR OF BENIGN TRACHEO-NEO-ESOPHAGEAL FISTULA 12 YEARS AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Chest Meeting Abstracts, October 1, 2009; 136(4): 56S - 56S.
[Abstract]

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