Benign tracheo-neo-esophageal fistula after esophagectomy is a rare but potentially fatal complication. We present a case of late presentation of this complication with a successful three-stage surgical repair.
A 60 year old male underwent induction chemoradiation (5400 cGy) followed by McKeown esophagectomy for stage III (T3N1) esophageal cancer. The patient presented 12 years later with bilateral lower lobe pneumonia, nutritional depletion and what appeared to be distal obstruction of the gastric conduit. Flexible bronchoscopy and esophagoscopy disclosed a benign tracheo-neo-esophageal fistula at the carina and a widely patent gastric conduit. He underwent silicone Y stent placement via rigid bronchoscopy followed by biliary diversion with duodenal exclusion, drainage gastrostomy and feeding jejunostomy. Six weeks later, the patient underwent removal of the stent with primary repair of the fistula buttressed by an intercostal muscle flap through a reoperative-right thoracotomy. A barium swallow on post-operative day 6 showed no evidence of leak or fistula. Six weeks later, the patient underwent left thoracoabdominal exploration with intrathoracic Roux-en-Y gastro-jejunostomy, revision of the feeding jejunostomy and removal of the gastrostomy tube. The third-stage post-operative course was complicated by a self-limited gastro-intestinal hemorrhsage from the stapled gastrojejunal anastomosis and a pulmonary embolism from an upper extremity venous thrombus requiring SVC filter placement. Barium swallow showed no evidence of leak, and the patient was discharged on post-operative day 21 tolerating an oral diet. His jejunostomy was removed after six weeks and at 10 months from presentation he is working full-time, eating without dysphagia, swimming one mile per day and has regained his premorbid weight.
The etiology of benign tracheo-neo-esophageal fistula after esophagectomy is variable but is most commonly related to anastomotic leak, endotracheal tube induced trauma, peri-operative chemo-radiation and tracheal erosion from the lesser curvature gastric-tube staple line as we suspect in our case. The common denominators are local devascularization of the membranous trachea and/or main stem bronchi associated with foreign bodies (eg: suture material or staples). Treatment depends on the size and location of the fistula, the clinical presentation and severity of symptoms as well as the accompanying conditions. Conservative management may have a role in certain cases, but surgical repair reinforced with a pedicled flap remains the mainstay of treatment. Proximal/esophageal (salivary) or distal/gastroduodenal (biliary) diversions with a staged reconstruction may be necessary in select cases.
Management of benign tracheo-neo-esophageal fistula remains challenging and should be individualized to achieve favorable outcomes.
Charles Bakhos, No Financial Disclosure Information; No Product/Research Disclosure Information