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Ann Thorac Surg 1999;68:561-562
© 1999 The Society of Thoracic Surgeons

Case Reports

Gastric tube-to-tracheal fistula closed with a latissimus dorsi myocutaneous flap

Koji Hayashi, MDa, Nobutoshi Ando, MDa, Soji Ozawa, MDa, Kazuyuki Tsujizuka, MDa, Masaki Kitajima, MDa, Tsuyoshi Kaneko, MDb

a Department of Surgery Keio University School of Medicine, Tokyo, Japan
b Department of Plastic Surgery, Keio University School of Medicine, Tokyo, Japan

Address reprint requests to Dr Hayashi, Department of Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160, Japan


   Abstract
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 Abstract
Introduction
 Comment
 References
 
A gastric tube-to-airway fistula is a very rare complication after esophageal reconstruction. A patient with a gastric tube-to-tracheal fistula that developed more than 9 years after surgery for cancer of the cervical esophagus was treated with transposition of a pedicled latissimus dorsi myocutaneous flap. Careful perioperative respiratory management helped save the patient’s life.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Peptic ulcers that occur in the gastric tube after esophageal resection and reconstitution for cancer are rare entities that often cause hemorrhage, perforation, and penetration [1]. If such an ulcer penetrates into the trachea or bronchus, a gastric tube-to-airway fistula is created. This is a life-threatening condition that necessitates surgical treatment. In this report, a patient with a gastric tube-to-airway fistula, which developed more than 9 years after surgery, is presented.

A 52-year-old woman presented with complaints of a productive postprandial cough for 1 month. Her past medical history was significant for a transhiatal total esophagectomy, pharyngo-laryngectomy, and total thyroidectomy with gastric pull-up through the posterior mediastinum for advanced cancer of the cervical esophagus. This operation had been performed over 9 years earlier. The staging of the esophageal cancer was p-stage III [T4 (trachea, thyroid), N1, M0]. Pathological examination revealed well-differentiated squamous cell carcinoma. She received two courses of postoperative adjuvant chemotherapy (cisplatin 72 mg and pepromycin 15 mg) and radiotherapy (40 Gy to the superior mediastinum and the supraclavicular area). There was no evidence of tumor recurrence over the follow-up period. She had undergone upper gastrointestinal endoscopic examination once a year, which revealed neither chronic ulcers nor erosions in the gastric tube. Of note, she had undergone modified radical mastectomy for left breast cancer 1 year prior to this admission. On examination, rales were audible in the right lower lung field. A gastric tube-to-airway fistula was suspected.

Chest radiographs demonstrated infiltration shadows of the right lower lobe. Laboratory examination revealed a leukocyte count of 11,800/µL, and a squamous cell carcinoma antigen concentration of 0.8 ng/mL within normal limits. Upper gastrointestinal endoscopy showed a gastric tube-to-tracheal fistula with a diameter of 2 cm on the anterior wall of the gastric tube, 8 cm distal to the pharyngogastric anastomosis. The bifurcation of the trachea could be seen through the fistula (Fig 1). Bronchoscopic examination demonstrated the fistula in the membranous portion of the trachea, just above the bifurcation. Pathologic features of biopsy specimens from around the fistula showed chronic inflammation and partial necrosis. Computed tomography confirmed the location of the fistula, and failed to demonstrate a mass.



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  		Fig 1. Upper gastrointestinal endoscopy showing a gastric tube-to-tracheal fistula (2 cm diameter) on the anterior wall of the gastric tube is 8 cm distal from the pharyngogastric anastomosis. The bifurcation of the trachea is seen through the fistula.

 
A tube was placed via nose for gastric drainage. Antibiotics were administrated for the treatment of aspiration pneumonia. Surgery was performed 43 days after admission. A spiral endotracheal tube (6 mm diameter) was inserted into the left main bronchus. A catheter providing a steady flow of oxygen was inserted into the right main bronchus and then general anesthesia was administered. With the patient in the left lateral decubitus position, the skin incisions were marked to allow for thedevelopment of a latissimus dorsi myocutaneous flap. The latissimus dorsi muscle was mobilized. A W-shaped incision was made in the right axilla in order to elevate the flap on the thoracodorsal vascular pedicle. The right thorax was entered thorough the fifth intercostal space. The azygos vein was ligated and divided. Then, the middle thoracic portion of the gastric tube was freed from the posterior mediastinum, taking care not to damage the right gastroepiploic artery. Umbilical tapes were placed around the gastric tube, oral and caudad to the fistula, for retraction. The fistula was then exposed. No neoplastic changes were noted. The wall of the fistula was cut sharply, taking care to avoid tearing of the membranous portion of the trachea. The fistula orfice in the gastric wall was closed primarily in layers. The latissimus dorsi myocutaneous flap was introduced through the second intercostal space. The cutaneous part of the flap was sutured over the fistula orifice in the trachea. Pathologic examination of the resected fistula revealed chronic inflammation and fibrosis.

Postoperativelly, artificial ventilation was not performed in order to keep the airway pressure low. The patient underwent bronchoscopy four times a day for pulmonary toilet. Bronchoscopic examination revealed a stenosis of the left bronchus, which was attributed to edema in the flap on the first postoperative day. However, this was improved by the 9th day. On the 21st day, feeding was started after a gastrograffin swallow demonstrated no leaks. The patient was discharged on the 39th day. Over the postoperative follow-up period of 3 years, there has been no evidence of recurrence or stenosis of the left bronchus.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Gastric tube-to-airway fistulas are a very rare postoperative complication. Only 12 cases have previously been reported. Of these, 11 were from Japan over the last 10 years. The causes of the reported fistulas included a peptic ulcer (n = 4), bronchial ischemia (n = 3), radiation (n = 2), an abscess in the mediastinum (n = 2), and an ischemic ulcer due to impaired blood flow by traction on the gastric pedicle (n = 1) [2–3].

In our case, the fistula was likely caused by penetration of an acute peptic ulcer into the trachea. This is based on the fact that the interval between the onset of fistula formation and the esophageal cancer surgery was greater than 9 years, that there was no macroscopic or microscopic evidence of cancer recurrence, and that upper gastrointestinal endoscopy 1 year earlier had demonstrated no erosive changes or chronic peptic ulcers.

Myocutaneous or muscle flaps, because of their rich blood supply, are usually interposed between the gastric tube and the trachea for closure of the fistula and prevention of recurrence of the fistula. The latissimus dorsi muscle, pectoralis major, intercostal, and rectus abdominis muscles have all been used in this setting. In our case, a latissimus dorsi myocutaneous flap was used for a number of reasons. First, it was thought that epithelization from the tracheal mucous membrane would be delayed due to the old radiation damage. If only a muscle flap has been used for fistula closure, poor granulation would grow into the airway before the completion of epithelization of the flap, causing a stenosis of the airway. The latissimus dorsi muscle was available for use, because the patient had not undergone a thoracotomy in the past. Furthermore, the subcutaneous tissue was thin enough that a myocutaneous flap would not cause airway stenosis due to excessive bulk.

Most patients with a gastric tube-to-airway fistula suffer from pneumonia and pulmonary dysfunction. Thus we placed our patient in the left lateral decubitus position, to prevent intraoperative hypoxia and performed postoperative bronchoscopy, four times a day for pulmonary toilet. Because of this aggressive approach, our patient had an uneventful recovery, and was discharged home.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Uchida Y., Tomonari K., Murakami S. Occurrence of peptic ulcer in the gastric tube used for esophageal replacement in adults. Jpn J Surg 1987;17:190-194.[Medline]
  2. Jefly M.S., Patrick J.H., Gail E.D. Gastrobronchial fistula. Ann Thorac Surg 1994;58:886-887.[Abstract/Free Full Text]
  3. Tsujinaka T., Ogawa M., Kido Y. A giant tracheogastric tube fistula caused by a penetrated peptic ulcer after esophageal replacement. Am J Gastroenterol 1988;83:862-864.[Medline]
Accepted for publication January 7, 1999.




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This Article
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