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Ann Thorac Surg 2001;72:221-224
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy

Accepted for publication March 15, 2001.

Address reprint requests to Dr Buskens, Department of Surgery, Academic Medical Center, University of Amsterdam, Suite G4-130, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
e-mail: c.j.buskens{at}amc.uva.nl

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Benign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications.

Methods. Charts of 6 patients with a benign tracheo-neo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed.

Results. Three men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake.

Conclusions. A benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.

	Introduction

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Despite the close anatomical relation between trachea, bronchi, and the esophagus, benign tracheo-neo-esophageal or broncho-neo-esophageal fistulas after esophagectomy are rare. The clinical presentation of these fistulas varies greatly, but they are frequently life threatening because of recurrent bronchopneumonia, respiratory failure, and sometimes mediastinitis.

Various perioperative and postoperative complications may underlie this condition [1]. It can develop postoperatively because of leakage of the anastomosis with inflammatory involvement of the tracheobronchial tree or after endoscopic dilatation of a benign anastomotic stricture [2]. It can also result from ischemia of the trachea after extensive dissection in the upper mediastinum [3], or from traumatic injury to the trachea during surgical dissection [4]. Finally, this complication can be the result of cuff-induced tracheal necrosis during prolonged endotracheal intubation [5]. Although various therapeutic strategies have been described [1], treatment is still a challenge.

In this report, we describe our experience with the management of 6 patients who developed a benign tracheo-neo-esophageal fistula after esophageal resection. Causes, clinical features, and various treatment options of this potentially life-threatening complication are discussed.

	Material and methods

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Between July 1993 and August 1999, 383 consecutive patients underwent subtotal esophagectomy by either transhiatal (n = 269) or transthoracic (n = 114) approach in the Academic Medical Center at the University of Amsterdam (The Netherlands), a tertiary referral center for esophageal surgery. All anastomoses were made in the neck. In 71 patients a two-field lymphadenectomy (chest and upper abdomen) was performed during the transthoracic procedure. Three-field lymph node dissections (including the neck) were not performed.

To assess the incidence and management of benign tracheo-neo-esophageal fistulas after esophagectomy, a retrospective analysis was performed by identifying and reviewing the records of all patients with this complication. Patients with malignant tracheo-neo-esophageal fistulas were excluded.

	Results

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In a consecutive series of 383 patients, 1 patient (0.3%) developed a benign tracheo-neo-esophageal fistula after esophagectomy in our institute. Five other patients with this complication were referred to our hospital during the same period, thus 3 men and 3 women (median age 61 years, range 53 to 69 years) had developed a fistula after a median period of 30 days (range 18 days and 14 months) after esophagectomy. One patient had been treated for an adenocarcinoma and 5 for a squamous cell carcinoma, 2 of whom had received chemotherapy (cisplatin and etoposide) preoperatively. No radiotherapy had been administered.

Two patients had relatively mild symptoms (ie, difficulties with swallowing, weight loss, and cough associated with oral intake). Four patients had aspiration pneumonia, 2 of whom had developed respiratory insufficiency, necessitating artificial ventilation. One patient also had a massive mediastinitis.

In 5 patients the diagnosis was made by a radiologic contrast study that was verified endoscopically in 4. In 1 patient the combination of bronchoscopy and gastrointestinal endoscopy confirmed the clinical suspicion of a fistula.

Case descriptions
Patients 1 and 2
A 53-year-old woman and a 63-year-old man each developed tracheo-neo-esophageal fistula immediately after endoscopic dilation for a benign anastomotic stricture. One of these patients had been operated on in our hospital after neoadjuvant chemotherapy. In both patients symptoms were only mild, and conservative treatment (ie, administration of antibiotic agents and nothing by mouth) was successful.

Patient 3
A 61-year-old woman had developed a salivary fistula due to postoperative anastomotic leakage after a transhiatal procedure. The fistula closed spontaneously after 6 months of conservative management. One year later a secondary fistula developed between the cervical anastomosis and the right main-stem bronchus (Fig 1).

View larger version (72K): [in this window] [in a new window]   Fig 1. Fistula (arrow) between the esophagogastric anastomosis and the right main bronchus in a radiologic contrast study.

Patient 4
After transthoracic esophagectomy and cervical gastric tube reconstruction, leakage of the longitudinal staple line developed in this 61-year-old woman, halfway along the gastric tube, leading to a mild mediastinitis and imminent respiratory insufficiency because of fistulization to the trachea. A cervical esophagostomy was created, while leaving the vital gastric tube in situ. Two drains were placed through the neck into the gastric tube—one for flushing the mediastinal cavity and one for administering enteral feeding in the proximal jejunum. The patient recovered quickly and left the hospital after 40 days. Five months later the general condition of the patient had greatly improved, and continuity of the alimentary tract was reconstructed by subcutaneous colonic interposition.

Patient 5
In this 58-year-old man, a transhiatal esophageal resection was complicated by a high lesion of the posterior wall of the trachea, which was immediately closed after conversion to a thoracotomy and covered by a pleural patch. Two weeks later aspiration pneumonia developed and reintubation was necessary. A tracheo-neo-esophageal fistula was diagnosed. During surgical reexploration with partial sternal split, the gastric tube was partly excised and closed, and the necrotic remnant of the pleural patch was removed. Temporary esophagostomy and tracheostomy were performed and a pedicled intercostal muscle flap was applied to the tracheal defect. After 2 months continuity of the alimentary tract was restored by subcutaneous colonic interposition.

Patient 6
Two weeks after transhiatal esophageal resection, this 69-year-old male patient developed a persisting cough during eating and signs of aspiration pneumonia. Endoscopy revealed these signs appeared to result from partial necrosis of the proximal gastric tube over a distance of a few centimeters, with a secondary fistula to the trachea. Through cervical exploration with partial sternal split, and anterior thoracotomy, the gastric tube was partly excised and closed. The cervical defect of the trachea was primarily closed. During the same procedure a colonic segment was interposed, distally in the retrosternal position and proximally in the prevertebral position, to reinforce the closed tracheal defect with vital tissue (Fig 2).

View larger version (46K): [in this window] [in a new window]   Fig 2. Radiologic contrast study (A), and schematic diagram of a proximal prevertebral and distal retrosternal colonic interposition (B). (1 = esophagocolostomy; 2 = colojejunostomy; 3 = jejunojejunostomy; 4 = distal remnant of gastric tube.)

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
A benign tracheo-neo-esophageal fistula after subtotal esophagectomy is a rare but potentially life-threatening complication. In the present series, the 6 patients had heterogeneous etiology. Five of six fistulas developed after transhiatal resection. In four cases this complication was not related to the transhiatal procedure per se, but to leakage of the cervical anastomosis and secondary fistulization to the trachea, which is probably the most important cause of fistulization [6].

According to the literature, a benign tracheo-neo-esophageal fistula is particularly related to a supraradical transthoracic procedure with devascularization of the trachea and main-stem bronchi due to extensive dissection in the upper mediastinum [3, 7]. This extended (three-field) dissection is not performed in our institute and no fistulas were related to vascular injury to the trachea. A direct traumatic injury to the trachea may also underlie the development of a tracheo-neo-esophageal fistula. After unsuccessful repair, a mediastinal abscess may develop that drains into the neo-esophagus, resulting in a fistula (patient 5). Although this is a feared complication after blunt resection of the esophagus, the incidence of tracheal tears during transhiatal resection is only around 1% [4, 8].

Fistulas induced by the cuff of an endotracheal tube in patients requiring prolonged mechanical ventilation are currently rare because of the availability of low pressure cuffs [5, 9].

In the literature a correlation has been suggested between neoadjuvant chemotherapy and neo-esophageal fistula development [6]. In the present series 2 patients had received neoadjuvant chemotherapy before operation, but the numbers are too small to confirm a supposed correlation.

Tracheo-neo-esophageal fistulas may present with various symptoms. They can be relatively mild (eg, cough associated with oral intake; patients 1 and 2), or more severe (eg, recurrent bronchopneumonia; patients 3 and 6) and even life threatening (eg, mediastinitis; patients 4 and 5) [10].

When a fistula is suspected on clinical grounds, radiologic contrast studies (in upright and supine positions) are preferably used to confirm the diagnosis. Endoscopy can be helpful to localize the fistula. Because identifying a small defect in the folded neo-esophageal mucosa can be difficult, bronchoscopy can be more informative.

There is still considerable diversity of opinion regarding the optimal management of this lesion [11–13]. In our opinion, it is not the etiology but the site and size of the fistula, in combination with the severity of symptoms, that should determine the treatment of a benign tracheo-neo-esophageal fistula after esophagectomy. In the absence of severe mediastinal or pulmonary infection, a conservative treatment regimen (ie, nothing per mouth, with or without antimicrobial agents) may be considered (patients 1 and 2). If the fistula fails to heal within a 4- to 6-week period, conservative management should be abandoned [11].

In the literature good results have been described by endoscopic obliteration [14, 15]. Our experience is limited but disappointing. Even in the patient with a long mediastinal fistula track (patient 3), several endoscopic attempts with fibrin glue and hemostatic clips failed.

If surgical intervention is necessary, a direct approach with closure of the tracheal and esophageal defects is preferred. An omental or pleural patch, or a muscle flap can be applied to fill the dead space and add vital tissue to the defect to prevent recurrent fistulization (patient 5) [16, 17].

If the neo-esophagus cannot be preserved, continuity of the gastrointestinal tract is reconstructed with, for example, colonic interposition [13, 18]. The colon segment is preferably placed in the prevertebral position to reinforce the posterior wall of the trachea. If a distal remnant of the gastric tube precludes prevertebral colonic reconstruction in that area, a distal retrosternal and a proximal prevertebral course of the colon segment can be combined (patient 6, Fig 2).

In 3 patients the gastric tube was (partly) left in situ and secondarily bypassed by an extra-anatomic colonic interposition. Theoretically, this strategy could lead to long-term bacterial overgrowth or even fistulization between the gastric stump and the overlying pneumonary parenchyma. Neither problem was encountered in the present cases (patients 4, 5, and 6). Apparently, drainage from the defunctionalized stomach into the duodenum has been sufficient.

In patients with a severe mediastinitis, elimination of the septic focus (especially resection of the necrotic proximal part of the gastric tube) is of crucial importance. A temporary esophagostomy is created, followed by extra-anatomical reconstruction at a later stage. A subcutaneous colonic interposition can be created to avoid redo-operations in an inflamed area (patients 4 and 5).

A benign tracheo-neo-esophageal fistula after esophagectomy is a rare but serious complication. As indicated by the six presented cases in this study, the site, size, and underlying cause in combination with the severity of symptoms should determine the treatment strategy. Conservative treatment can be justified, but in the presence of severe symptoms, surgical intervention with a tailored approach is inevitable. With an individualized treatment, this potentially life-threatening condition can be managed successfully.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Gudovsky L.M., Koroleva N.S., Biryukov Y.B., Chernousov A.F., Perelman M.I. Tracheoesophageal fistulas. Ann Thorac Surg 1993;55:868-875.[Abstract]
2. Kron I.L., Johnson A.M., Morgan R.F. Gastrotracheal fistula: a late complication after transhiatal esophagectomy. Ann Thorac Surg 1989;47:767-768.[Abstract]
3. Fujita H., Kawahara H., Hidaka M., Nagano T., Yoshimatsu H. An experimental study on viability of the devascularized trachea. Jpn J Surg 1988;18:77-83.[Medline]
4. Hulscher J.B.F., ter Hofstede E., Kloek J., Obertop H., De Haan P., Van Lanschot J.J.B. Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg 2000;120:1093-1096.[Abstract/Free Full Text]
5. Nordin U. The trachea and cuff-induced tracheal injury. An experimental study on causative factors and prevention. Acta Otolaryngol Suppl (Stockh) 1997;345:1-71.
6. Heitmiller R.F., Fischer A., Liddicoat J.R. Cervical esophagogastric anastomosis: results following esophagectomy for carcinoma. Dis Esophagus 1999;12:264-269.[Medline]
7. Bartels H.E., Stein H.J., Siewert J.R. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 1998;85:403-406.[Medline]
8. Bartels H.E., Stein H.J., Siewert J.R. Respiratory management and outcome of non-malignant tracheo-bronchial fistula following esophagectomy. Dis Esophagus 1998;11:125-129.[Medline]
9. Macchiarini P., Verhoye J.P., Chapelier A., Fadel E., Dartevelle P. Evaluation and outcome of different surgical techniques for post-intubational tracheoesophageal fistulas. J Thorac Cardiovasc Surg 2000;119:268-276.[Abstract/Free Full Text]
10. Wychulis A.R., Ellis F.H.J., Andersen H.A. Acquired nonmalignant esophagotracheobronchial fistula. Report of 36 cases. JAMA 1966;196:117-122.[Medline]
11. Semlacher R.A., Bharadwaj B.B., Nixon J.A. Management of post-traumatic tracheo-esophageal fistula following failed primary repair. J Cardiovasc Surg 1994;35:83-86.[Medline]
12. Baisi A., Bonavina L., Narne S., Peracchia A. Benign tracheoesophageal fistula: results of surgical therapy. Dis Esophagus 1999;12:209-211.[Medline]
13. Furst H., Hartl W.H., Lohe F., Schildberg F.W. Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. Ann Surg 2000;23:173-178.
14. Marone G., Santoro L.M., Torre V. Successful endoscopic treatment of GI-tract fistulas with a fast-hardening amino acid solution. Endoscopy 1989;21:47-49.[Medline]
15. Ng W.T., Luk H.T., Lau C.W. Endoscopic treatment of recurrent tracheo-oesophageal fistulae: the optimal technique. Ped Surg Intern 1999;15:449-450.
16. Pairolero P.C., Arnold P.G. Bronchopleural fistula: treatment by transposition of pectoralis major muscle. J Thorac Cardiovasc Surg 1980;79:142-145.[Abstract]
17. Hayashi K., Ando N., Ozawa S., Tsujizuka K., Kitajima M., Kaneko T. Gastric tube-to-tracheal fistula closed with a latissimus dorsi myocutaneous flap. Ann Thorac Surg 1999;68:561-562.[Abstract/Free Full Text]
18. DeMeester T.R., Johansson K.E., Franze I., et al. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 1988;208:460-474.[Medline]

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