Broncho-gastric fistula complicating transthoracic esophagectomy

A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer

BACKGROUND

Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection.

CASE PRESENTATION

A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient's postoperative course was uneventful, and he was discharged on the 354th day.

CONCLUSIONS

We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

Management of thoracogastric airway fistula after esophagectomy for esophageal cancer: A systematic literature review

Background

Thoracogastric airway fistula (TGAF) is a serious complication of esophagectomy for esophageal cancer. We conducted a systematic review of the appropriate therapeutic options for acquired TGAF.

Methods

We performed a literature search to identify relevant studies from PubMed, EMBASE, and Web of Science using the search terms “gastric airway fistula”, “gastrotracheal fistula”, “gastrobronchial fistula”, “tracheogastric fistula”, “bronchogastric fistula”, “esophageal cancer”, and “esophagectomy”.

Result

Twenty-four studies (89 patients) were selected for analysis. Cough was the main clinical presentation of TGAF. The main bronchus was the most common place for fistulas (53/89), and 29 fistulas occurred in the trachea. Almost 73% (65/89) of patients underwent non-surgical treatment of whom 87.7% (57/65) received initial fistula closure. Twenty-three patients underwent surgery, including 19 (82.6%) with initial closure. The 1-, 2-, 3-, 6-, and 9-month survival rates in patients who underwent surgical repair were 95.65%, 95.65%, 82.61%, 72.73%, and 38.10%, respectively, and the equivalent survival rates in patients with tracheal stent placement were 91.67%, 86.67%, 71.67%, 36.96%, and 13.33%, respectively.

Conclusion

TGAF should be suspected in patients with persistent cough, especially in a recumbent position or associated with food intake. Individualized treatment should be emphasized based on the general condition of each patient.

Benign gastrobronchial fistula following oesophagectomy in a patient presenting with respiratory failure

Benign gastrobronchial fistula (GBF) is a rare but potentially life-threatening complication of oesophagectomy for malignancy. We present a case of GBF post Ivor-Lewis surgery manifesting as pulmonary sepsis and type II respiratory failure. Clues to the diagnosis were persistent hypercapnia despite high minute ventilation, aspiration of gastric content through the endotracheal tube and accumulation of air in the nasogastric drainage bag. Flexible bronchoscopy confirmed the diagnosis. Surgical exploration identified necrosis of the proximal stomach as causative factor. Despite reconstruction of the oesophagogastric anastomosis and interposition of an intercostal muscle flap, the patient developed a new episode of type II respiratory failure. Bronchoscopy revealed in situ recurrence of the fistula. Patency of the fistula was proven through application of methylene blue with subsequent gastroscopy. A conservative, symptom-based, management was conducted. The patient died 6 hours later.

Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report

Background

Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging.

Case presentation

A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery.

Conclusions

Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

Repairing Bronchoesophageal Tube Fistula Using A Contralateral Latissimus Dorsi Musculocutaneous Flap

A postoperative aerodigestive fistula is one of the rare but critical complications after esophagectomy, and management is challenging. The essential keys to successful treatment of these fistula are thorough debridement and complete closure followed by separation of the respiratory and digestive tract. We present a case of a recurrent bronchoesophageal fistula between the left main bronchus and neo esophagus, which was successfully treated through a contralateral approach. The fistula was debrided and closed primarily through a right thoracotomy, and the interposition of a pedicled latissimus dorsi musculocutaneous flap from the right side was carried out. The patient was able to resume oral feeding at 16th postoperative day.

Development of fistula between esophagogastric anastomotic site and cartilage portion of trachea after subtotal esophagectomy for cervical esophageal cancer: a case report

A 65-year-old man with cT3N2M0 stage III cervical esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the retrosternal route after neoadjuvant chemoradiotherapy. The anastomosis was located adjacent to the left side of the trachea, and a circular stapler was used for anastomosis. Postoperative anastomotic leakage occurred, and an esophagotracheal fistula between the esophagogastric anastomotic site and cartilage portion of the trachea was observed on postoperative day 44. The patient underwent division of the fistula, direct suturing of the anastomotic leakage site, left pectoralis major muscle flap placement, and tracheotomy. He was discharged home on postoperative day 120 on an oral diet. All previous reports of tracheobronchial fistula describe the occurrence of the fistula at the membranous portion of the trachea. The formation of a fistula between the esophagogastric anastomotic site and cartilage portion of the trachea is considered a possible complication when a high esophagogastric anastomosis is created.

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.

Emergency escape surgery for a gastro-bronchial fistula with respiratory failure that developed after esophagectomy

A gastro-bronchial fistula (GBF) is a rare complication after esophageal reconstruction using a gastric tube, but it can cause severe pneumonia, and the surgical procedure is challenging. We herein describe a patient who was successfully managed using a two-stage operation for a GBF. Because the patient had life-threatening pneumonia and respiratory failure caused by the GBF, we first transected the duodenum, established a cervical esophagostomy and gastrostomy and placed a decompression catheter in the gastric tube without a thoracotomy. The patient recovered from pneumonia after the resolution of the salivary inflow and digestive juice reflux into the lungs through the GBF. Two months later, an esophageal bypass was achieved by reconstructing the esophagus using a long segment of pedicled jejunum. The patient was discharged 38 days thereafter. Appropriate treatment for GBF should be tailored to individual patients based on their current status and disease severity.

Esophagectomy for esophageal carcinoma--surgical complications and treatment

AIM

To describe our experience with esophagectomy for esophageal cancer and, the development and treatment of complications arising from the surgery.

MATERIAL AND METHODS

From 2007 to 8/2010, esophagectomy for esophageal carcinoma was performed in 75 patients at the 1(st) Surgical Clinic. Primary esophagectomy was indicated in 20 patients with T1N0 stage or in cases where neoadjuvant treatment was contraindicated. 55 patients with T2,3N0,1 stages received neoadjuvant radiochemotherapy. Esophagectomy was performed via an abdominal approach (transhiatal laparoscopy in 44 patients, laparotomy in 3 patients) and a thoracic approach (thoracoscopy in 10 patients, thoracotomy in 18 patients).

RESULTS

In 18 cases, one or both pleural cavities were opened by means of dissection of the mediastinal pleura during the transhiatal laparoscopic esophagectomy. The morbidity was 26.6% and the following complications were encountered: pulmonary (15 patients), anastomosis dehiscence (5), postoperative bleeding in the mediastinum (1), fistula between trachea and transposition (1), paresis of the left recurrent nerve (8), infectious complications in the abdominal cavity (2), thoracic cavity (1), and early complications (2). The sixty-day mortality was 8% and this was mostly due to pulmonary complications (4 patients) but included coronary thrombosis (1) and transposition necrosis (1).

CONCLUSION

The dominating complications of esophagectomy were pulmonary (20 %). The remaining serious complications cannot be completely eliminated but if diagnosed in time and treated in a correct algorithm they do not have to imminently threaten the lives of patients.

Repair of a postesophagectomy bronchogastric tube fistula with polyglactin mesh supported with a muscle flap

A bronchogastric fistula is a very rare complication of transthoracic esophagectomy. We report a case of bronchogastric fistula after transthoracic esophagectomy caused by dehiscence of the staple line in the gastric tube, with subsequent erosion into the right main bronchus. The patient was managed successfully in two surgical stages. First, the bronchial defect was repaired using a polyglactin mesh covered by a serratus anterior muscle flap. Two months later, the esophagogastric continuity was restored with colon interposition.

Pulmonary-gastric fistula

Pulmonary to gastric fistulae are extremely rare. They can occur secondary to infection or malignancy invading through the lung into the pleural space, through the diaphragm and into the stomach. The case history reports on the successful diagnosis and treatment of a pulmonary to gastric fistula.

Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy

Benign gastro-bronchial fistula is a rare and devastating complication of esophagectomy with gastric replacement. The most likely cause is a leak from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. The clinical presentation includes cough upon swallowing, fever, and recurrent pneumonia. Early surgical treatment is the standard of care. A unique case of chronic gastro-bronchial fistula is reported in this article. The patient, a 57-year-old woman, was referred from another hospital after 6 months of symptomatic therapy and total enteral nutrition. A self-expanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation.

Benign gastro-bronchial fistula - an uncommon complication of esophagectomy: case report

Background

Gastro-bronchial fistula (GBF) is a rare and devastating complication following esophagectomy. Making the correct diagnosis is difficult and there is no agreement on the treatment for this rare condition.

Case presentation

We report the case of a 56-year-old man who presented with features of repeated aspiration and chest infections six years following an esophagectomy for Barrett's esophagus. Despite extensive investigations the cause of symptoms was difficult to determine. The correct diagnosis of fistula from stomach to right main stem bronchus was made at bronchoscopy under general anesthesia. After ruling out local recurrence of cancer, a successful primary repair was carried out by resection of fistula and direct repair of gastric conduit and bronchus. He is well after 6 months of treatment.

Conclusion

Late development of gastro-bronchial fistula is a rare complication of esophageal resection that may be difficult to diagnose.

Surgical resection and direct closure is the treatment of choice, although the method of treatment should be tailored according to the anatomy of the fistula and the patient's condition.