Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report

Abstract

Background: Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging.

Case presentation: A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery.

Conclusions: Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

Keywords: Esophageal cancer; Post-operative complication; Thymus pedicle flap; Tracheoesophageal fistula.

Fig. 1

Image findings before intervention and macroscopic and microscopic findings of resected specimen. a The endoscopic finding of primary esophageal cancer. Type 3 tumor with esophageal stenosis was located in the lower thoracic esophagus. b The preoperative CT image. The arrow indicates neoplastic lesion of the esophagus. c The resection specimen. The arrow indicates neoplastic lesion. d Hematoxylin-eosin staining of the resected specimen. The arrowheads indicate viable cancer cells within the mucosa of the esophagus

Fig. 2

Image findings of postoperative abscess and tracheoesophageal fistula (TEF). a The CT shows the leakage of esophagogastric anastomosis. The arrow indicates the hole of leakage and the arrowheads indicate the abscess. b, c The esophagography shows a TEF. The arrowheads indicate the fistula

Fig. 3

Details of surgery for tracheoesophageal fistula (TEF). a The schema of the incision line. b The intraoperative findings and schemas. The thymus flap (light green) was sutured on the esophagus (brown)

Fig. 4

The findings after surgery for tracheoesophageal fistula (TEF). a CT image. The arrow indicates the thymus pedicle flap. b Esophagography shows no leakage on the esophagogastric anastomotic site (arrowheads)