Repair of post-intubation tracheoesophageal fistulae through the left pre-sternocleidomastoid approach: a recent case series of 13 patients

Abstract

Objective: Post-intubation tracheoesophageal fistula (TEF) is a late complication of tracheotomy, while membranous trachea laceration during percutaneous dilational tracheostomy is implicated in the generation of early post-tracheotomy TEF. Surgical repair is the only viable option for these patients and the technique of repair depends on a variety of factors.

Methods: Totally 13 patients (mean age: 54.1±12.6 years; male: 8) with post-intubation TEF were managed between 2007 and 2013. The diagnosis was always made through esophagoscopy followed by endoscopic gastrostomy and bronchoscopy for repositioning of the tracheal tube just above the carina. Repair of the fistula was made in all patients through a left pre-sternocleidomastoid incision followed by dissection of the fistulous tract, suturing of esophagus and trachea and interposition of the whole pedicled left sternocleidomastoid muscle (SCMM) between the two suture lines.

Results: Five out of the 13 procedures were performed in mechanically ventilated patients; 3 of them died from septic complications during the postoperative period while fistula recurred in 1 of those 3 patients due to extensive inflammation of the tracheal wall. The rest 8 patients underwent fistula repair after weaning from mechanical ventilation and the results of repair were excellent. The additional procedure of temporary T-tube insertion was obviated in one patient to manage extensive tracheomalacia.

Conclusions: The left pre-sternocleidomastoid incision is an excellent access for the repair of a post-intubation TEF without tracheal resection. The interposition of the whole left pedicled SCMM between the suture lines of trachea and esophagus avoids fistula recurrence and offers the best chance for cure.

Keywords: Tracheoesophageal fistula (TEF); complications of tracheotomy; dilational tracheotomy; post-intubation tracheo-esophageal fistula; pre-sternocleidomastoid approach; tracheotomy.

Figure 1

The initial access to the prevertebral fascia via the left pre-sternocleidomastoid incision. Special attention is required during retraction of the trachea—larynx—thyroid because the retractors can produce injury to the left laryngeal nerve.

Figure 2

Intraoperative images of the fistulae. (A,B) The fully mobilized and encircled with tapes esophagus and the protrusion of the tracheal tube cuff through the membranous trachea opening after dissection of the fistulous tract; (C) the esophageal opening after dissection of the fistula with the nasogastric tube lying within the esophageal lumen.

Figure 3

(A) The fully dissected whole left SCMM before the transection of the muscle insertion to the mastoid process; (B) interposition of the left SCMM between the suture lines of membranous trachea and esophagus. The muscle is fixed to the prevertebral fascia. SCMM, sternocleidomastoid muscle.

Figure 4

CT scan showing the left SCMM fixed to the prevertebral fascia. The muscle separates well trachea and esophagus avoiding that way fistula recurrence and making the technique suitable to repair TEF in mechanically ventilated patients (when absolutely necessary). SCMM, sternocleidomastoid muscle.