Abstract
Simple SummaryTracheoesophageal fistulae (TEF) after oncologic resections represent a therapeutic challenge. Reconstructive options vary from the upper to the lower airways and include the complete therapeutic armamentarium from pedicled flaps to chimeric free flaps. Derived from the experience of 18 oncologic patients with TEF, we present a therapeutic algorithm that may guide future treatment strategies and shows that an interdisciplinary approach leads to satisfying success rates. However, disease-specific morbidity has to be anticipated.Background: Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients. Patients and methods: 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, n = 1), jejunum (n = 3) or combined ALT–jejunum flaps (n = 2). Results: Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF. Conclusion: TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.
Highlights
Multimodal treatment options including chemo- and immunotherapy as well as radiotherapy and surgery are usually applied in patients suffering from head and neck cancers as well as esophageal malignancies [1]
The reconstruction of tracheoesophageal fistulae (TEF) can be very challenging, especially in patients suffering from malignancies, because radiation therapy has frequently been applied
The pectoralis major myocutaneous (PMMC) flap was introduced for head and neck reconstruction early and is still a workhorse for reconstruction [34,35]
Summary
Multimodal treatment options including chemo- and immunotherapy as well as radiotherapy and surgery are usually applied in patients suffering from head and neck cancers as well as esophageal malignancies [1]. Significant survival rates can be achieved even in recurrent cases [2,3,4,5,6,7] This multimodal therapy regimen and especially radiotherapy can lead to long-term side effects including tracheoesophageal or enterocutaneous fistulae [1,8]. Morbidity rates of patients suffering from TEF are significant and result from chronic aspiration leading to pneumonia and therapy-resistant cough, bleeding, and esophageal stenosis or occlusion with dysphagia as well as impaired vocal rehabilitation [10,11]. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management
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