Unusual Surgical Repair of Bronchoesophageal Fistula Following Esophagectomy

Abstract

Radical esophagectomy remains the only potentially curative option in the treatment of esophageal cancer. However, this procedure is burdened with high morbidity and mortality rates, even in high-volume centers. A tracheo- or bronchoesophageal fistula (TBF) is rare but is one of the most difficult life-threatening complications following an esophagectomy for cancer treatment. Several classifications have been proposed regarding the localization of a TBF, its etiology, and the timing of its occurrence; hence, no classification is universally accepted. However, one of the most common etiological explanations for the formation of a TBF is a prior esophagogastric anastomotic leak. Treatment options include a conservative approach, which usually combines several endoscopic methods. Surgical treatment is directed towards fistula closure with direct suturing or, more often, the usage of pediculated flaps. Here, we present a patient with late TBF following a minimally invasive esophagectomy, which was surgically solved in an atypical way. We believe that this type of repair may be useful in patients in whom pedunculated flaps are not an option.

Keywords: airway–gastric fistulas; bronchoesophageal fistula; esophagectomy.

Figure 1

Upper GI endoscopy revealing a fistula orifice (red arrow) at the level of the esophagogastric anastomosis. A gastric tube was placed below (white arrow). At this point, it was obvious that endoscopic treatment of the fistula was not possible. The presence of fibrin around the fistula was indicative of a previous ulcer at the level of the esophagogastric anastomosis and a possible leak that had been clinically undetected.

Figure 2

Contrast X-ray study showing the gastrobronchial leak. The diagnostic modalities include barium swallow, CT imaging, bronchoscopy, and upper gastrointestinal endoscopy. Identifying TEF can be challenging. Esophagoscopy can often miss small or discrete fistulas, even with fluoroscopy. Contrast radiography is a very useful method in terms of establishing this diagnosis. It is actually the confirmatory test for TEF. The appearance of barium in the lumen of the tracheobronchial tree is a direct sign of the fistulization of these structures within the esophagus. This picture shows a clear esophagobronchial leak, which provoked an irritating cough during the patient’s examination.

Figure 3

Intraoperative image showing a defect on the left main bronchus (black arrow) and the esophageal flap prepared for suturing (white arrow). This image was taken after the gastric tube had been disconnected and the esophageal flap prepared. The surrounding tissue was fibrotic. The esophageal flap was well vascularized and had sufficient length.

Figure 4

Bronchoscopy image of the flap covering the defect on the left main bronchus one month after surgery. The flap is well vascularized. The patient did not experience any respiratory symptoms after the surgery (A). Contrast X-ray study 7 days after colon interposition. The esophagocolonic anastomosis is wide; the colon graft is positioned in a linear fashion. There is no contrast leak, and the evacuation of the contrast into the stomach remnant is smooth (B).