Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer

Abstract

Background: Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.

Case presentation: A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.

Conclusion: A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.

Keywords: Gastric conduit ulcer; Pectoralis major muscle flap; Tracheoesophageal fistula.

Fig. 1

a Gastrointestinal endoscopy showed an ulcerated lesion on the right wall of middle of gastric tube. b Horizontal and c sagittal enhanced computed tomography image showed an irregular ulceration on the anterior wall of the descending aorta, no extravasation, and absence of the descending aortic wall and gastric wall, suggesting sealed rupture of the descending aorta (yellow arrow)

Fig. 2

Patient’s clinical course

Fig. 3

a Bronchoscopy showed the fistula on the membranous portion of trachea; a bubble arose from the fistula (white arrow). b Gastrointestinal endoscopy revealed a pinhole in the stump of the esophagus and the staple line (white arrow). c Sagittal computed tomography image showing the tracheoesophageal fistula on the cervicothoracic border (white arrow). d Schema of the tracheoesophageal fistula

Fig. 4

a Cervical incision line. b The cervical esophagus was accessed through a cervical approach, and the fistula was ligated (white arrow). c A pectoralis major muscle flap was fixed to the fistula site, underneath the trachea. Pectoralis major muscle flap under the trachea (white arrow). d Esophageal reconstruction using the pedunculated jejunum with a microvascular anastomosis was performed via a subcutaneous route. e A schema of the operation