Ann Thorac Surg 2007;83:705-706
© 2007 The Society of Thoracic Surgeons
How To Do It
Repair of Large, Iatrogenic, Tracheo-Esophageal Fistulae
Vicky L. Chappell, MD,
Herman A. Heck, Jr, MD*
Department of Surgery, Section of Cardiothoracic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
Accepted for publication April 17, 2006.
* Address correspondence to Dr Heck, Section of Cardiothoracic Surgery, LSU Health Sciences Center, 2020 Gravier St, Suite 753, New Orleans, LA 70112. (Email: hheck{at}lsuhsc.edu).
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Abstract
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Closure of large, iatrogenic, tracheo-esophageal fistulae present a formidable technical challenge. Our method of repair is presented, which describes the exposure and subsequent closure that relies on creating a new "membranous" trachea using remnant flaps of the esophageal wall of the fistula.
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Introduction
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Thoracic surgical literature regarding closure of tracheo-esophageal fistulae primarily describes relatively small, acquired lesions and emphasizes debridement and primary closure or patching of the membranous tracheal wall and primary closure of the esophagus, along with sternocleidomastoid muscle interposition to prevent recurrence [1]. However, this is not applicable to very large, post-intubation fistulae, which may be 5 to 7 cm in length associated with total destruction of the entire membranous septum. We introduce here a technique that we have successfully used with 2 recent patients. Appropriate IRB approval for their retrospective inclusion and analyses was obtained.
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Technique
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Airway control in these patients, whose fistulae may extend from the cricoid cartilage to within 3 cm of the carina, requires expert anesthetic induction and fiber optically controlled placement of the endotracheal tube. For the larger fistulae, such a tube should extend a minimal distance beyond the cuff, tailored if necessary, so as to prevent selective ventilation of only one bronchus.
Positioning of the patient in hyperextension, with the head rotated to the right and with the arms tucked by the sides, assists in optimizing the exposure of the distal end of the fistula and mobilization of the pectoralis muscle, which is used as the interposition flap between the repaired trachea and esophagus. The initial incision extends along the medial border of the sternocleidomastoid muscle to the manubrium at which point it angles down the sternal midline to within a few centimeters of the xyphoid (Fig 1, inset). The medial half of the manubrium and the proximal portions of the clavicle and first rib are excised, which allows adequate exposure of the trachea and esophagus just under the aortic arch. At this distal-most point, the innominate artery crosses the trachea and will require isolation and retraction with a vessel loop. Therefore arterial monitoring should be done through the left radial artery. Chronic inflammatory changes and initial difficulty in circumferentially accessing the esophagus distal to the fistula are pertinent differences in the neck dissection. Generally the recurrent laryngeal nerve can be identified and avoided; however, neuropraxia, or permanent damage may occur as a result of retraction during repair of the fistula.
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Fig 1. Exposure (inset) is obtained by widening the thoracic inlet with resection of the left half of the manubrium and proximal portions of the clavicle and first rib (dotted lines). An almost full sternal skin incision (dashed line) allows development of a broad left pectoral rotational flap that will be necessary for interposition between the suture lines. The fistula is entered through the esophagus allowing an adequate rim attached to the trachea to reestablish the "membranous" portion of the trachea.
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The esophagus is now incised approximately 1 cm away from the inflammatory fusion of the trachea with the esophagus, and extended cephalad to the cricoid cartilage, and distally to the septum that defines the inferior-most extent of the fistula (Fig 1). For larger fistulae, lateral retraction of the innominate artery will be necessary to adequately expose this area. The endotracheal cuff is readily apparent within the esophagus. A vein retractor or small malleable retractor is now placed over the balloon and gently retracted anteriorly so as to not rupture or displace the balloon. This will expose the entire circumferential extent of the fistula and, in particular, the opposite cartilaginous tracheal wall (Fig 2). A plane between the esophagus and trachea just distal to the caudad-most extent of the fistula is developed and a right-angled clamp is inserted to define the opposite wall of the esophagus. The esophagus is incised from within the fistula a centimeter from its juncture with the opposite tracheal wall, and this incision is extended circumferentially to connect with the anterior esophageal incision. This effectively isolates the esophagus from the trachea.
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Fig 2. Adequate distal exposure of the fistula requires retraction of the innominate artery. Separation of the esophagus and trachea is accomplished with circumferential excision of the esophagus through the fistula providing an adequate rim attached to the far trachea for reconstruction of the "membranous" portion (dashed line).
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The far esophageal wall is dissected from adjacent inflammatory tissue and the gaping defect of the esophagus is primarily closed with an appropriate running, single-layer closure using monofilament suture, placing a nasogastric tube under direct vision prior to completing the closure. In a similar fashion, the remnant flaps of esophageal wall attached to the cartilaginous trachea are closed primarily to create a new "membranous" trachea (Fig 3). The majority of the pectoralis major muscle is now mobilized based on its acromioclavicular vascular pedicle, advanced between the repaired trachea and the esophagus, and secured with multiple sutures to the scar tissue on the far side of the separated aerodigestive tract, ensuring complete coverage of the entire suture line. The wound is then primarily closed with appropriate closed suction drainage of the mobilized pectoral area.
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Fig 3. The large defects in the separated aerodigestive organs are primarily repaired with a single layer linear closure.
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Comment
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Despite the advent of improved endotracheal tube cuffs, tracheo-esophageal fistula continues to complicate long-term intubation. Over-inflation of the cuff and associated risks of excessive tube motion, hypotension, infection, steroids, malnutrition, and diabetes contribute to the subsequent development of large fistulae [2]. Several different techniques of repair have been described [3]. However, most of these are not applicable to large defects. The repair herein described allows primary closure of both defects. The esophagus, being dilated at the level of the fistula, permits redundant esophageal tissue left attached to the cartilaginous trachea to be used for the tracheal closure. Chronic, inflammatory, neovascular connections of the isolated esophageal flaps with tracheal blood supply apparently prevent ischemic necrosis from developing. Adequate viable tissue to cover such a long suture line is achieved by a rotated pectoralis major muscle flap.
We have used this technique with 2 patients during the past year. The first patient had already had an attempted previous repair using bovine pericardium to close the defect, which had dehisced causing recurrence of the fistula. She also had sustained a right recurrent laryngeal nerve injury. After her second repair through scar tissue with the previous technique just described, she required a permanent tracheostomy because of injury to her left recurrent nerve. However, she was eating and gaining weight at follow-up 1 year later, without evidence of recurrence, and with marked improvement in her quality of life. The second patient was a severe asthmatic who required reintubation 24 hours postoperatively for severe bronchospasm and subsequent pneumonia, eventually necessitating a temporary tracheostomy for persistent respiratory insufficiency. This was eventually removed without sequelae and she evinced no recurrent nerve injury or fistula when seen at last outpatient follow-up.
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References
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- Reed MF. Tracheoesophageal fistula Chest Surg Clin N Am 2003;13:271-289.[Medline]
- Mathison DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired nonmalignant tracheoesophageal fistula Ann Thorac Surg 1991;52:759-765.[Abstract]
- Macchiarini P, Verhoye JP, Chapelier A, Fadel E, Dartevelle P. Evaluation and outcome of different surgical techniques for post-intubation tracheoesophageal fistulas J Thorac Cardiovasc Surg 2000;119:268-276.[Abstract/Free Full Text]
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Abstract
Introduction
