Multi-disciplinary treatment of broncho-esophageal fistula in a high-risk single-lung patient

Abstract

Background: A broncho-esophageal fistula (BEF) is a medical and surgical disaster. Treatment of BEF is often limited to palliative stent treatment that may migrate or cause erosions and tissue necrosis. Surgical repair of BEF is the only established definite treatment.

Case presentation: BEF presented in a 40-year-old female patient 8 years after curative treatment with pneumonectomy and radio-chemotherapy for advanced lung cancer. She had autoimmune comorbidity, a single lung, vocal cord paralysis and an extremely hostile thorax. Multi-disciplinary collaboration, close patient involvement and evaluation by the hospital medical ethics committee were key elements in the following treatment course. After temporary stent treatment, a carefully staged surgical marathon was performed: Veno-venous ECMO was established to secure oxygenation, and bilateral thoracotomy and laparotomy performed to access structures in the frozen mediastinum. After extensive thoracoplasty and high-risk dissection, esophagectomy was performed and the 20 × 35 mm bronchial defect repaired by bronchoplasty with a latissimus muscle flap. It was complicated by thrombotic occlusion of the upper venous system, repeated postoperative bleedings and critical illness neuropathy. The patient recovered and was discharged 150 days after surgery. Within 1-2 years bronchoscopy showed a smooth undiscernible bronchoplasty with a stable open left main bronchus. At 5 years the patient lives an independent life at home with her family.

Conclusions: Surgical treatment of BEF in an extremely complex patient may turn out successfully. It demands careful ethical considerations, comprehensive surgical strategy, multi-disciplinary teamwork, and shared decision making with the patient. The patient presented in this case report is closely followed up with good life quality after 5 years.

Keywords: Bronchial stent; Broncho-esophageal fistula; Bronchoplasty; Esophageal stent; Esophagectomy; Non-small lung cancer; Thoracoplasty; Tracheobronchial stent; Veno-venous extracorporeal membrane oxygenation.

Fig. 1

Chest CT scan showing mediastinal abscesses (arrow) between the pneumonectomy cavity, the heart and the diaphragm

Fig. 2

Esophagoscopy detecting necrosis in the anterior wall of esophagus and the broncho-esophageal fistula of 5 mm in diameter (arrow)

Fig. 3

A–C. Bronchoscopy shows: A: The tracheobronchial stent and signs of an accelerating defect (arrow) of bronchus no longer completely covered by the stent, B: The left main bronchus and the muscle patch of the bronchoplasty (arrow) after 2.5 weeks, C: The bronchoplasty (arrow) completely healed and flush with the original wall after 2.5 years

Fig. 4

A–B. Chest CT scan showing locations and crossing of the esophageal and the tracheobronchial self-expanding covered metal stents (arrow)

Fig. 5

Right-sided thoracotomy, esophagus, esophageal stent and the latissimus dorsi muscle flap

Fig. 6

Sutured neck incision access, esophagostoma and customized blue-line tube to cover and protect the bronchoplasty

Fig. 7

Venography shows the thrombotic occlusion of the upper veins system