Ann Thorac Surg 2002;73:1298-1299
© 2002 The Society of Thoracic Surgeons
Case report
Histological confirmation of healing of gastrobronchial fistula using a muscle flap
Manabu Okuyama, MD*a,
Reijiro Saito, MDa,
Satoru Motoyama, MDa,
Michihiko Kitamura, MDb,
Jun-ichi Ogawa, MDa
a Second Department of Surgery, Akita University School of Medicine, Akita Japan
b Department of Surgery, Isawa Prefectural Hospital, Iwate, Japan
Accepted for publication July 31, 2001.
* Address reprint requests to Dr Okuyama, Second Department of Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan
e-mail: oku{at}doc.med.akita-u.ac.jp
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Abstract
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We report a case of gastrobronchial fistula that developed after esophagectomy for esophageal cancer. The fistula was repaired successfully by transposing a pectoralis major muscle flap. Complete healing was confirmed histologically by epithelialization of the fistula site and at autopsy 12 months after surgery. Muscle flap transposition effectively repairs gastrobronchial fistula.
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Introduction
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Bronchial or tracheal fistulas of the reconstructed stomach are rare complications of esophagectomy, but they are nonetheless life threatening and difficult to manage clinically. Although several groups have previously reported the successful repair of gastrobronchial fistula using muscle flaps [1–4], no evidence of the healing process has been documented to date. In this article, we confirm the successful repair of a gastrobronchial fistula using a muscle flap from histological findings. The perioperative management of this patient is documented in the Japanese literature [2], and the current report focuses on epithelialization observed at 12 postoperative months as well as autopsy findings of complete healing of the fistula. This report provides histological evidence of complete healing of gastrobronchial fistula following muscle flap transposition.
A 72-year-old man was admitted to our institution in February 1998 due to dyspnea. Two years previously, he had undergone total thoracic esophagectomy with right thoracotomy accompanied by reconstruction of the stomach via the posterior mediastinal route for esophageal cancer. He received preoperative chemoradiation therapy and separate courses of postoperative chemotherapy and radiation therapy.
Upon admission for sudden-onset dyspnea, bronchoscopy revealed the presence of a fistula localized to the membranous portion of the right intermediate bronchus, while gastroscopy revealed a fistula in an ulcerated area of the stomach. A biopsy specimen obtained from this ulcerated region showed no evidence of malignancy. The fistula gradually enlarged and the patient developed severe respiratory failure on the 10th day of hospitalization.
An emergency operation to close the fistula was performed. In the dorsal position, a right pectoralis major muscle flap with a vascular pedicle consisting of the pectoral branch of the acromiothoracic trunk was mobilized. A segment of the right second costal cartilage was removed for transposition of the flap through the thorax. In the lateral position, the stomach was dissected from the trachea via a right thoracotomy. The opening in the stomach (3 cm in diameter) was closed directly by an absorbable interrupted suture. As the bronchial defect (1 cm in diameter) was too large to be closed directly, a muscle flap was used for indirect closure. The flap was sutured around the bronchial defect with an absorbable interrupted suture, and also interposed between the stomach and bronchus.
Bronchoscopy to monitor the operative site and tracheobronchial toilet were conducted daily. The fistula was seen to be completely closed by the muscle flap. Granulation tissue gradually accumulated within the bronchus between 2 and 5 months after surgery, but decreased spontaneously. The fistula was undetectable endoscopically 10 months after surgery.
Despite a good recovery from the gastrobronchial fistula repair, the patient died of renal failure 12 months after surgery. An autopsy revealed that the gastrobronchial fistula had indeed completely healed and was visible only by a fine white scar. No narrowing or stricture of the bronchus was observed. Histologic examination found that ciliated epithelial cells partially covered the accumulation of granulation tissue at the bronchial defect (Figs 1 and 2).
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Fig 1. Histological findings at the site of fistula. The arrow identifies the border between normal bronchial tissue (A) and scar tissue (B). A layer of the transposed pectoralis major muscle (C). (Hematoxylin and eosin stain; original magnification x40.)
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Fig 2. Ciliated epithelial cells together with normal pseudostratified epithelium partially cover the granulation tissue. (Hematoxylin and eosin stain; original magnification x100.)
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Comment
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Although the literature contains several reports of the successful repair of gastrobronchial fistulas using muscle or myocutaneous flaps, none of these provide histological evidence of healing. The present study presents such histological evidence following muscle flap repair of a gastrobronchial fistula. Histological findings of the partial covering of granulation tissue with ciliated cells and normal pseudostratified epithelium indicate the effectiveness of indirect closure of a gastrobronchial fistula using a muscle flap.
This procedure facilitated the bronchial defect to heal by allowing for the formation of scar tissue and migration of epithelial cells. In addition, essentially normal mucociliary function can be expected following indirect closure. Tracheal toilet initially had to be facilitated by catheter suction or bronchoscopy in the present patient, although a clear airway could be spontaneously maintained following epithelialization. It has been thought that, unlike a myocutaneous flap, a muscle flap would cause stenosis of the airway [3]. Granulation tissue did indeed form in the airway 2 months after surgery, but it decreased spontaneously and did not cause stenosis.
Despite the relative rarity of gastrobronchial fistula as a complication of esophagectomy, we have indirectly closed such gastrobronchial or gastrotracheal fistulas in 3 other patients by transposing a pectoralis major muscle flap. None of these patients experienced reopening of the fistula or stenosis of the airway and, currently, 1 patient has survived for more than 5 years after surgery. Given these clinical findings, recovery of the epithelium of the bronchial mucosa and mucociliary function by indirect closure of a bronchial fistula using a muscle flap appears to be a safe and reliable procedure.
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References
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Saito H., Minamiya Y., Hashimoto M., et al. Repair of reconstructed gastric tube bronchial fistula after operation for esophageal cancer by transposing a pedicled pectoralis major muscle flap: report of three successful cases. Surgery 1998;123:365-368.[Medline]
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Okuyama M., Suzuki H., Saito R., et al. A successful case of surgery using extracorporeal membrane oxygenation for reconstructed gastric tube bronchial fistula after operation of esophageal cancer. Jpn J Gastroenterol Surg 2000;33:102-106.
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Hayashi K., Ando N., Ozawa S., Tsujizuka K., Kitajima M., Kaneko T. Gastric tube-to-tracheal fistula closed with a latissimus dorsi myocutaneous flap. Ann Thorac Surg 1999;68:561-562.[Abstract/Free Full Text]
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Stal J.M., Hanly P.J., Darling G.E. Gastrobronchial fistula: an unusual complication of esophagectomy. Ann Thorac Surg 1994;58:886-887.[Abstract/Free Full Text]
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Abstract
Introduction
