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J Thorac Cardiovasc Surg 2008;135:706-707
© 2008 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiovascular and Thoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Received for publication September 18, 2007; accepted for publication November 20, 2007. * Address for reprints: David P. Mason, MD, 9500 Euclid Avenue, General Thoracic/F24, Cleveland, OH 44195. (Email: masond2{at}ccf.org).
Tracheoesophageal fistula (TEF) is an uncommon but devastating complication of prolonged intubation. Pressure exerted from the cuff of an endotracheal tube against a rigid nasogastric tube causes tissue necrosis and breakdown.1
Patients typically present with recurrent aspiration pneumonia. Urgent repair of the fistula with tissue interposition is warranted, although this can be challenging in the ventilated patient because of the need for continued positive pressure ventilation and the paucity of healthy, local tissue to fashion the repair. The present study is a case report of a 65-year-old woman in whom a large TEF developed after bilobectomy and who was successfully treated with AlloDerm (LifeCell Corporation, Branchburg, NJ), a commercially available biologic tissue. In this case, AlloDerm was used as a tissue scaffold to reconstruct the defect in the trachea to serve and enhance the integrity of the repair.2,3
A 65-year-old woman underwent right middle and lower lobectomy for non–small cell lung carcinoma at an outside hospital. Her postoperative course was marked by adult respiratory distress syndrome and prolonged mechanical ventilation that required tracheostomy. Six weeks post-tracheostomy, recurrent pneumonia and sepsis developed in the patient. Subsequently, the patient underwent bronchoscopy and was diagnosed with TEF. She was transferred to the Cleveland Clinic Foundation for management.
In the operating room, fiberoptic bronchoscopy was performed transnasally and through the patient's tracheal stoma. A 4-cm defect involved the entire width of the membranous airway directly posterior to the stoma. The nasogastric tube was clearly visible along this length and confirmed the diagnosis of TEF. The region of the fistula was 3 tracheal rings distal to the cricoid cartilage on the airway side and 15 cm from the gums on the esophageal side. An extended length tracheostomy was reinserted.
Given the size of the TEF, primary repair of the trachea was not possible. We elected to use AlloDerm to reconstruct the membranous trachea, close the esophageal defect primarily, and interpose a muscle flap. The airway and esophagus were approached through an oblique left neck incision anterior to the border of the sternocleidomastoid muscle. The esophagus was dissected out, encircled, and separated from the airway. The entire tracheal and esophageal defects were carefully delineated (
Figure 1). The esophagus was repaired using interrupted 3-0 Vicryl sutures. A 4 x 2.5-cm AlloDerm patch was then parachuted down to reconstruct the membranous trachea and secured to the edges of the cartilaginous airway using 3-0 Vicryl sutures. A pectoralis major muscle flap was then mobilized and interposed between the 2 repairs. Postoperatively, the patient had an uneventful recovery and was weaned from the ventilator. On the fifth postoperative day, a flexible bronchoscopy was performed through the stoma. This revealed an intact, well-approximated AlloDerm graft with no evidence of airway narrowing. The patient was discharged on the 18th postoperative day and decannulated 7 weeks postoperatively in the clinic. Currently, she is tolerating a normal oral diet and doing well at 4 months' follow-up. A follow-up computed tomography scan was performed that demonstrated a widely patent trachea with no residual tracheal defect or fistula (
Figure 2).
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Secure closure of postintubation TEF is a challenge because of global patient debilitation, inadequacy of local tissue for reconstruction, and an inflamed, infected operative field.4 AlloDerm, an acellular dermal matrix derived from donated human skin tissue, has been used in a broad range of tissue reconstruction. Its rigidity and substantial ability to resist infection allowed this repair of a large TEF. Tissue ingrowth appears to prevent shrinkage and stricture. AlloDerm is a useful tool for complex airway reconstructions when options are limited.
References
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 R. V. Shevchenko, S. L. James, and S. E. James A review of tissue-engineered skin bioconstructs available for skin reconstruction J R Soc Interface, February 6, 2010; 7(43): 229 - 258. [Abstract] [Full Text] [PDF]
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 K. G. Reyes, T. W. Rice, D. P. Mason, and S. C. Murthy Acellular Dermal Matrix Closure of Catastrophic Bronchopleural Fistula Ann. Thorac. Surg., February 1, 2010; 89(2): 601 - 603. [Abstract] [Full Text] [PDF]
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 B. Evans, I. MacKenzie, C. Malata, and A. Coonar Successful salvage right upper lobectomy and flap repair of trachea-esophageal fistula due to severe necrotizing pneumonia Interact CardioVasc Thorac Surg, November 1, 2009; 9(5): 896 - 898. [Abstract] [Full Text] [PDF]
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C. R. Morse Repair of Bronchial Esophageal Fistula Using Alloderm Ann. Thorac. Surg., September 1, 2009; 88(3): 1018 - 1019. [Abstract] [Full Text] [PDF]
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