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CORRESPONDENCE
Year : 2016  |  Volume : 12  |  Issue : 7  |  Page : 225-227

Postesophagectomy airway–gastric fistula successfully treated with subcutaneous fascia flap, tracheal reconstruction, and gastric fistula drainage: A case report and literature review


1 Department of Thoracic Surgery, Zhejiang Key Laboratory of Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China
2 Department of Head and Neck Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China

Date of Web Publication21-Feb-2017

Correspondence Address:
Xun Yang
Department of Thoracic Surgery, Zhejiang Key Laboratory of Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.200599

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 > Abstract 

Airway–gastric fistula (AGF) is a dreaded complication of esophagectomy for esophageal cancer. Its presentations and treatment approaches differ from individual to individual. Herein, we report the case of a patient with postesophagectomy AGF that was successfully treated with a subcutaneous fascia flap twisting trachea, and gastric fistula drainage. On reviewing the related literature, we consider that protecting the airway with living soft tissues and draining the mediastinum are the key steps for the surgical treatment of AGF. Airway stenting may be used as a temporary solution, and conservative therapy can be successful in some carefully selected cases.

Keywords: Airway–gastric fistula, drainage, esophageal cancer, esophagectomy, fascia flap


How to cite this article:
Wang C, Yang X, Zhao J, Chen Q. Postesophagectomy airway–gastric fistula successfully treated with subcutaneous fascia flap, tracheal reconstruction, and gastric fistula drainage: A case report and literature review. J Can Res Ther 2016;12, Suppl S3:225-7

How to cite this URL:
Wang C, Yang X, Zhao J, Chen Q. Postesophagectomy airway–gastric fistula successfully treated with subcutaneous fascia flap, tracheal reconstruction, and gastric fistula drainage: A case report and literature review. J Can Res Ther [serial online] 2016 [cited 2021 Mar 3];12:225-7. Available from: https://www.cancerjournal.net/text.asp?2016/12/7/225/200599


 > Introduction Top


Airway–gastric fistula (AGF) is a rare and severe complication of esophagectomy for esophageal cancer. Principal AGF treatments include stenting [1] pedicled muscle flap insertion [2] and conservative therapy.[3] We report a case of postesophagectomy AGF repaired using subcutaneous fascia flap, tracheal reconstruction and gastric fistula drainage, and review the management of AGF.


 > Case Report Top


A 57-year-old woman presented with a 3-month history of taking pantothenic acid. Endoscopy revealed extensive esophageal mucosal erosion, 27–35 cm from the incisors. Biopsy identified intermediate-to-high-grade squamous cell intraepithelial neoplasia and esophageal carcinoma in situ. Endoscopic resection was ruled out due to the lesion size. Minimally invasive, transthoracic, three-phase esophagectomy (subtotal esophagectomy through a right thoracic approach, cervical esophageal–tubular stomach anastomosis, and jejunostomy) was performed.

Barium contrast swallow on postoperative day 9 showed no anastomotic leakage, and the patient commenced an oral semi-liquid diet. On day 12, she experienced difficulty in drinking. Examination revealed the following: fever (temperature, 39.1°C); blood oxygen saturation, 96%–98% under nasal oxygen inhalation; heart rate, 117–120 bpm, without arrhythmia; and dry rales. Gastric leakage was suspected, and a gastric tube was inserted. Fasting with enteral nutrition through jejunostomy was performed. Antibiotics were prescribed. On day 14, AGF was suspected because negative pressure in the gastric tube was unable to form negative pressure. Emergency contrast-enhanced chest computed tomography confirmed AGF. Bronchoscopy revealed a tracheal fistula 5–6.5 cm proximal to the carina [Figure 1].
Figure 1: (a) Tracheal fistula showed through fiberoptic bronchoscope. (b) The tracheal-gastric fistula filled with meglumine diatrizoate

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AGF repair surgery was performed on day 17. We incised the skin, subcutaneous tissue, and muscle fascia from the lateral margin of the lower one-fourth of the left sternocleidomastoid to 1 cm below the left clavicle, and then to the right sternal margin. Gastric anterior wall necrosis (1.5 cm × 1.0 cm) and a perforation 2 cm distal to the esophagogastric anastomosis were observed. The fistula was adjacent to the perforation at the level of the suprasternal notch [Figure 2]. (a) Using the surgical incision, we prepared a 5 cm × 12 cm flap. The epidermis and dermis of the distal 5 cm of the flap were resected [Figure 2]. (b) The sternum was split open, and the anterior margin of the left sternocleidomastoid was separated from the lateral margin of the left strap muscles to expose the trachea and anastomotic stoma. Tracheal and gastric adhesions were separated to expose the AGF. We rotated the flap along with the trachea from the posterior to anterior, which covered the fistula and separated the trachea and stomach. The upper and lower borders of the flap were sutured with the trachea [Figure 2]. (c) We inserted a gastric tube into the stomach through the gastric fistula and secured it with a purse-string suture. Two drains were inserted into the mediastinum along the posterior and anterior gastric walls [Figure 2]. (d) Intraoperative bronchoscopy confirmed that the flap completely covered the tracheal fistula [Figure 3]. Negative pressure could be established through the gastric tube. The patient developed acute renal failure (due to septic shock) after this surgery but recovered within a month. The patient has been able to eat without difficulty and shown no signs of recurrence for 2 years.
Figure 2: (a) 1 - Anastomotic stoma, 2 - gastric fistula, 3 - tracheal fistula, and 4 - sternum.(b) 1 - Cutaneous fascia flap, 2 - subcutaneous fascia flap, and 3 - trachea.(c) 1 - Cutaneous fascia flap, 2 - rotating the trachea with the subcutaneous fascia flap, 3 - trachea, 4 - clavicle, and 5 ectoralis major muscle. (d) Day 12 after the second surgery

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Figure 3: Schematic of the surgery process

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 > Discussion Top


The course of AGF in our patient was as follows: (1) Severe coughing to promptly eliminate gastric fluid after fistula formation and avoid inhalation pneumonia. (2) Gastric drainage to prevent airway and mediastinal contamination. (3) Interposition of living tissue between the trachea and stomach. (4) Successful repair of tracheal fistula improved respiratory function and prevented the leakage of gastric contents into the mediastinum.

Postesophagectomy AGFs usually progress from digestive fistula formation to medistinal inflammation and abscess and airway fistula. They are commonly accompanied by severe inhalation pneumonia and acute respiratory failure, which necessitate mechanical ventilation and preclude repair surgery. During acute inflammation, tracheal or gastric stenting may be used.[4] Boyd and Rubio [5] reported that the recurrence rate after covered tracheal stenting of postesophagectomy AGFs was 39%. They concluded that covered stents were a temporary solution until the patient was well enough to tolerate surgery. In patients with unresectable esophageal cancer, AGF may be palliated with airway stenting.[1]

Muscle flaps can also be used for AGF treatment. Morita et al.[2] have successfully repaired AGFs with pectoralis major muscle flaps, while Reames and Lin [6] have used an Alloderm patch reinforced with an intercostal muscle flap. None of their patients had severe inhalation pneumonia or required mechanical ventilation, which may have, in part, facilitated their good outcomes. Not all AGF patients can be treated with muscle flaps. Schweigert et al.[4] reported two cases of AGF, in which treatment with muscle flaps failed. Feng et al.[7] performed single-stage repair of 12 AGFs and found that sufficient preoperative nutrition was crucial for surgical success.

In AGF patients with minimal-to-absent bronchopulmonary contamination and stable respiration without sepsis, conservative therapy may be attempted. Zolotarevsky et al.[8] performed a successful endoscopic fistula closure using an over-the-scope clip device providing an effective fistula seal. Tong and Law [3] used fibrin glue injection (three sessions) to repair an anastomotic bronchial defect.

Causes of AGF include intraoperative tracheal injury, postoperative mediastinitis, tumor recurrence, radiation necrosis, and erosion injure.[9] Avoiding intraoperative tracheobronchial injury and performing reconstruction by pulling the gastric tube through the retrosternal route decrease AGF incidence. Hokamura [10] evaluated 97 cases of salvage surgery through the right thoracotomy in esophageal cancer patients. They found that pulling the gastric tube up retrosternally, rather than through the posterior mediastinum, decreased fatal complications such as tracheal necrosis and airway fistula, but did not improve survival.


 > Conclusion Top


Pulling up the gastric tube retrosternally might reduce AGF incidence. Once AGF occurs, digestive fluids and exudates must be prevented from entering the airway. Airway repair and protection with living soft tissues and digestive fluid and mediastinal exudate drainage are the main therapeutic strategies. Sufficient nutrition and antibiotics are essential. Patients requiring mechanical ventilation are unlikely to survive.

Financial support and sponsorship

This study was supported in part by Grants from the Medical and health of Zhejiang Province scientific research project (2014KYA101, 2013KYA031), the Department of Education of Zhejiang Province scientific research project (Y201330062).

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Herth FJ, Peter S, Baty F, Eberhardt R, Leuppi JD, Chhajed PN. Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: A prospective study. Eur Respir J 2010;36:1370-4.  Back to cited text no. 1
    
2.
Morita M, Saeki H, Okamoto T, Oki E, Yoshida S, Maehara Y. Tracheobronchial fistula during the perioperative period of esophagectomy for esophageal cancer. World J Surg 2015;39:1119-26.  Back to cited text no. 2
    
3.
Tong DK, Law S. Post-oesophagectomy anastomotic-bronchial fistula. Hong Kong Med J 2011;17:325-7.  Back to cited text no. 3
    
4.
Schweigert M, Dubecz A, Beron M, Muschweck H, Stein HJ. Management of anastomotic leakage-induced tracheobronchial fistula following oesophagectomy: The role of endoscopic stent insertion. Eur J Cardiothorac Surg 2012;41:e74-80.  Back to cited text no. 4
    
5.
Boyd M, Rubio E. The utility of stenting in the treatment of airway gastric fistula after esophagectomy for esophageal cancer. J Bronchology Interv Pulmonol 2012;19:232-6.  Back to cited text no. 5
    
6.
Reames BN, Lin J. Repair of a complex bronchogastric fistula after esophagectomy with biologic mesh. Ann Thorac Surg 2013;95:1096-7.  Back to cited text no. 6
    
7.
Feng G, Zhi-Yong Z, Yu-Shang C, Li L, Shan-Qing LI, Xiao-Hui X. Surgicai treatment for non-malignant esophageal-tracheal/bronchial fistula. Chin J Clin Thorac Cardiovasc Surg 2012;19:468-71.  Back to cited text no. 7
    
8.
Zolotarevsky E, Kwon Y, Bains M, Schattner M. Esophagobronchial fistula closure using a novel endoscopic over-the-scope-clip. Ann Thorac Surg 2012;94:e69-70.  Back to cited text no. 8
    
9.
Maruyama K, Motoyama S, Sato Y, Hayashi K, Usami S, Minamiya Y, et al. Tracheobronchial lesions following esophagectomy: Erosions, ulcers, and fistulae, and the predictive value of lymph node-related factors. World J Surg 2009;33:778-84.  Back to cited text no. 9
    
10.
Hokamura N. Salvage surgery in esophageal cancer treatment – Its review in this decade and promises for the next decade. Gan To Kagaku Ryoho 2011;38:179-83.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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