Tracheoesophageal Fistula: A Different Surgical Approach

Abstract

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acquired tracheoesophageal fistula (TEF) is a relatively uncommon—but often life-threatening—complication of mediastinal malignancy, occurring in 5%-15% of patients with mediastinal/esophageal malignancies.1 TEFs are mainly treated with esophageal stenting2 or single-stage primary repair of both the airway and an esophageal defect with tissue flap interposition.3 We present a patient whose TEF was repaired by surgical creation of a “pseudodiverticulum” with a remnant esophageal pouch after definitive chemoradiation. CASE PRESENTATION: This 66-year-old man with esophageal squamous cell cancer was found to have a mass in the mid-esophagus. Bronchoscopy showed no airway involvement of the tumor. The patient opted for definitive chemoradiation. After treatment, he noted coughing while eating. Workup showed a TEF (Fig. 1). Because he had not tolerated previous stenting, he decided to proceed with esophagectomy. The patient underwent a planned right thoracotomy with intercostal muscle flap, but intraoperatively, the TEF was larger than expected, and its surrounding tissue was fibrotic. Due to concern that the esophagus was fused to the airway (and attempts at dissection would result in a larger fistula or more severe tracheal defect), the esophagus was transected 1 cm above the TEF. The distal esophagus was dissected and staple transected just above the hiatus. A spit fistula was created. After recovery and improvement of nutrition, the patient was brought back to the OR for reconstruction with a substernal gastric interposition. Now 3 years out from his original diagnosis, the patient is able to tolerate oral intake and shows no evidence of recurrent disease. Recent upper endoscopy showed widely patent gastric anastomosis and a stable-appearing pseudodiverticulum, with a small esophageal remnant on the posterior side of the proximal left mainstem bronchus (Fig. 2). DISCUSSION: The benefits vs. risks of surgical intervention for treatment of acquired TEFs must be carefully considered. This patient refused stenting due to prior negative outcomes, but given his presentation and esophageal fusion to the airway, the risk of additional complications by dissecting the fistula was too great. Instead of traditional stenting or standard TEF takedown and repair, we resolved his TEF by leaving the esophagus attached to the airway, transecting the esophagus above and below the fistula, and leaving a small pseudodiverticulum at the level of the fistula. This ultimately allowed him to eat without recurrent aspiration. CONCLUSIONS: Acquired TEFs may be successfully managed using this technique when traditional methods are unavailable or in patients for whom the risk of complications is higher (e.g., those with dense fibrosis and adhesions after radiation). Reference #1: Marulli et al. Eur J Cardiothorac Surg 2013;43(6):e155-161 Reference #2: Silon B et al. Dig Dis Sci. 2017;62(2):424-431 Reference #3: Puma F et al. J Thorac Dis. 2017;9(2):278-286 DISCLOSURE: The following authors have nothing to disclose: Taylor Ipsen, Paul Banks, Ross Bremner, Jasmine Huang No Product/Research Disclosure Information