Case of successful treatment of a patient with ischemictracheoesophageal and tracheopleural fistulas after a mckeown hybrid esophagectomy

The occurrence of tracheal fistulas of ischemic genesis combined with the failure of esophagogastroanastomosis and the communication between them is a rare and formidable complication after esophagectomy with mediastinal lymphadenectomy due to its anatomical position and extensiveness. However, it is insufficiently documented in the literature, both in terms of treatment and in terms of its causes. This observation aims to demonstrate the rare cause of this complication and the atypical successful treatment. In this case, a patient with squamous cell carcinoma G2 of the middle third of the esophagus and TNM stage cT3NxM0. On the McKeown thoracoscopic-laparotomy esophagectomy intraoperatively a short arterial vessel with a diameter of about 3 mm, which passed through the paracancerous infiltration and supplied blood to the esophagus and trachea revealed. The vessel was not isolated from the infiltrate, but was clipped and crossed between the aorta and infiltrate to maintain surgery ablastic. On the 7th day after the operation the insolvency of esophagogastroanastomosis, the fistula of the trachea with mediastinum and the communication between the leak of esophagogastroanastomosis and the fistula of the trachea were diagnosed. We consider this combination as a special case of esophagogastroanastomosis fistula, complicated by the communication between the right pleural cavity and pneumothorax. According to our experience, partial leak of esophagogastroanastomosis successfully heals by secondary tension within 10–15 days against the background of cervicotomic wound drainage and feeding through a nasointestinal tube. In this case there was a leak of saliva in the mediastinum and its penetration into the lumen of the trachea and the right pleural cavity. Surgical diversion of the fistula and stenting of the trachea were considered, but not applied, as the fistula in our opinion was controlled, but the aggressive content of the gastric conduit prevented healing. The patient was on assisted lung ventilation with minimal pressure support and inflow increased oxygen fractio. For this reason, we considered the best stenting of the esophagogastroanastomosis leak area to be covered with a stent in order to stop the aggressive content of the gastric stem from entering the fistula, which led to the successful treatment of the developed severe complication. It should be noted that this method of treatment may be ineffective in patients who need pressure support during ventilation.

1. Chepurnoi GI, Chepurnoi MG. Transsternal access in the surgical treatment of congenital isolated tracheoesophageal fistula. Medical Bulletin of the North Caucasus. 2019;14(2):320-322. (In Russian). https://doi.org/10.14300/mnnc.2019.14077

2. Parshin VD, Rusakov MA, Parshin VV. Tracheoesophageal fistula surgery. Moscow: “Aldi-Print” Publ., 2016, 263 p. (In Russian).

3. Lambertz R, Hölscher AH, Bludau M, Leers JM, Gutschow C, Schröder W. Management of Tracheo- or Bronchoesophageal Fistula After Ivor-Lewis Esophagectomy. World J Surg. 2016;40(7):1680–1687. https://doi.org/10.1007/s00268-016-3470-9

4. Tatur AA, Leonovich SI, Goncharov AA, Plandovskij AV, Kardis VI, Popov MN, et al. Radical surgical treatment of acquired tracheoesophageal and bronchoesophageal fistulas. Surgery. Eastern Europe. 2012;3(3):145–146. (In Russian).

5. Parshin VD, Ruchkin DV, Bazarov DV, Vishnevskaya GA, Levitskaya NN, Golovinskii SV. Dissociation of a tracheal fistula of an artificial esophagus in a patient after extirpation of the esophagus for squamous cell carcinoma. Hirurgiya. Surgery. Journal named after N.A.Pirogov. 2008;10:68–70. (In Russian).

6. Lindner K, Lübbe L, Müller A-K, Palmes D, Senninger N, Hummel R. Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy. Dis Esophagus. 2017 Feb 1;30(3):1–8. https://doi.org/10.1111/dote.12459

7. Palmes D, Kebschull L, Bahde R, Senninger N, Pascher A, Laukötter MG, et al. Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy. Thorac Cardiovasc Surg. 2020 Mar 1. https://doi.org/10.1055/s-0039-1700970

8. Morita Y, Takase K, Ichikawa H, Yamada T, Sato A, Higano S, et al. Bronchial artery anatomy: preoperative 3D simulation with multidetector CT. Radiology. 2010 Jun;255(3):934–943. https://doi.org/10.1148/radiol.10081220

9. Wada T, Takeuchi H, Kawakubo H, Nakamura R, Oyama T, Takahashi T, et al. Clinical utility of preoperative evaluation of bronchial arteries by three-dimensional computed tomographic angiography for esophageal cancer surgery. Dis Esophagus. 2013 Aug;26(6):616–622. https://doi.org/10.1111/dote.12012

10. Balakrishnan A, Tapias L, Wright CD, Lanuti MX, Gaissert HA, Mathisen DJ, et al. Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula. Ann Thorac Surg. 2018;106(6):1640–1646. https://doi.org/10.1016/j.athoracsur.2018.06.076

11. Rafieian S, Asadi Gharabaghi M. Tracheopleural fistula after thoracoscopic esophagectomy: novel therapeutic approach with pericardial and intercostal muscle flaps. J Surg Case Rep. 2018 Oct;2018(10):rjy277. https://doi.org/10.1093/jscr/rjy277

12. 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 May;41(5):e74-80. https://doi.org/10.1093/ejcts/ezr328