Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy
Background Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF.
Methods From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome.
Results In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously (n = 6, 40%) or metachronously (n = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy (n = 3), stenting (n = 6), or suturing (n = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition.
Conclusion Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.
Eingereicht: 19. August 2019
Angenommen: 09. Dezember 2019
01. März 2020 (online)
© 2020. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Bartels HE, Stein HJ, Siewert JR. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 1998; 85 (03) 403-406
- 2 Schweigert M, Dubecz A, Beron M, Muschweck H, Stein HJ. Management of anastomotic leakage-induced tracheobronchial fistula following oesophagectomy: the role of endoscopic stent insertion. Eur J Cardiothorac Surg 2012; 41 (05) e74-e80
- 3 Lambertz R, Hölscher AH, Bludau M, Leers JM, Gutschow C, Schröder W. Management of tracheo- or bronchoesophageal fistula after Ivor-Lewis esophagectomy. World J Surg 2016; 40 (07) 1680-1687
- 4 Maruyama K, Motoyama S, Sato Y. et al. Tracheobronchial lesions following esophagectomy: erosions, ulcers, and fistulae, and the predictive value of lymph node-related factors. World J Surg 2009; 33 (04) 778-784
- 5 Shen KR, Allen MS, Cassivi SD. et al. Surgical management of acquired nonmalignant tracheoesophageal and bronchoesophageal fistulae. Ann Thorac Surg 2010; 90 (03) 914-918 , discussion 919
- 6 Bona D, Sarli D, Saino G, Quarenghi M, Bonavina L. Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy. Ann Thorac Surg 2007; 84 (03) 1036-1038
- 7 Laukoetter MG, Mennigen R, Neumann PA. et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc 2017; 31 (06) 2687-2696
- 8 Marulli G, Loizzi M, Cardillo G. et al. Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae. Eur J Cardiothorac Surg 2013; 43 (06) e155-e161
- 9 Fermin L, Arnold S, Nunez L, Yakoub D. Extracorporeal membrane oxygenation for repair of tracheal injury during transhiatal esophagectomy. Ann Card Anaesth 2017; 20 (Supplement): S67-S69
- 10 Cunningham D, Allum WH, Stenning SP. et al; MAGIC Trial Participants. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355 (01) 11-20
- 11 Nabavizadeh N, Shukla R, Elliott DA. et al. Preoperative carboplatin and paclitaxel-based chemoradiotherapy for esophageal carcinoma: results of a modified CROSS regimen utilizing radiation doses greater than 41.4 Gy. Dis Esophagus 2016; 29 (06) 614-620
- 12 Palmes D, Brüwer M, Bader FG. et al; German Advanced Surgical Treatment Study Group. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396 (06) 857-866
- 13 Müller AK, Lenschow C, Palmes D, Senninger N, Hummel R, Lindner K. [Timing of esophagectomy in multimodal therapy of esophageal cancer: Impact of time interval between neoadjuvant therapy and surgery on outcome and response]. Chirurg 2015; 86 (09) 874-880
- 14 Singer M, Deutschman CS, Seymour CW. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315 (08) 801-810
- 15 Jabłoński S, Brocki M, Kordiak J, Misiak P, Terlecki A, Kozakiewicz M. Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients. ANZ J Surg 2013; 83 (09) 657-663
- 16 McCulloch P, Ward J, Tekkis PP. ; ASCOT group of surgeons; British Oesophago-Gastric Cancer Group. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 2003; 327 (7425): 1192-1197
- 17 Lindner K, Lübbe L, Müller AK, Palmes D, Senninger N, Hummel R. Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy. Dis Esophagus 2017; 30 (03) 1-8
- 18 Tong DK, Law S. Post-oesophagectomy anastomotic-bronchial fistula. Hong Kong Med J 2011; 17 (04) 325-327
- 19 Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 2010; 89 (03) 931-936 , discussion 936–937
- 20 Mennigen R, Harting C, Lindner K. et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. J Gastrointest Surg 2015; 19 (07) 1229-1235
- 21 Buskens CJ, Hulscher JB, Fockens P, Obertop H, van Lanschot JJ. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg 2001; 72 (01) 221-224
- 22 Krüger M, Decker S, Schneider JP, Haverich A, Schega O. [Surgical treatment of acute mediastinitis]. Chirurg 2016; 87 (06) 478-485
- 23 Abu-Omar Y, Kocher GJ, Bosco P. et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017; 51 (01) 10-29
- 24 Shen KR. Management of acquired nonmalignant tracheoesophageal fistula: Surgical pearls. J Thorac Cardiovasc Surg 2017; 154 (06) e123