Esophagus DOI 10.1007/s10388-014-0416-x
CASE REPORT
Successful conservative management of gastrotracheal fistula after esophagectomy Taro Oshikiri • Takashi Yasuda • Yasuhiro Fujino Masahiro Tominaga
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Received: 28 October 2013 / Accepted: 8 January 2014 Ó The Japan Esophageal Society and Springer Japan 2014
Abstract Gastro-tracheobronchial fistula following esophagogastrostomy is usually fatal, making conservative treatment inadvisable. A 68-year-old man underwent esophagectomy with gastric conduit reconstruction in the posterior mediastinum and neck anastomosis. Despite anastomotic leakage on postoperative day 8, the patient was stable and was managed conservatively. On day 28, a gastric tube–bronchial fistula was diagnosed by esophagogram, gastrointestinal endoscopy, and bronchoscopy. No inflammatory reaction occurred and the patient remained stable, so conservative management was continued. On day 43, gastrointestinal endoscopy and bronchoscopy showed closure of the hole. The patient progressed well on an oral diet and was discharged. Conservative management is possible in limited cases. Keywords Esophageal cancer Esophageal surgery Fistula Postoperative care
Introduction Benign gastro-tracheobronchial fistula (GTF) after esophagectomy is rare (0.3 %) and treatment can be challenging [1]. Esophagogastrostomy leakage and subsequent postoperative development of a mediastinal abscess can result in a fistula with the trachea or main bronchus, requiring urgent revisional surgery [2]. Most fistulae involve direct communication between a dehisced anastomosis and the
T. Oshikiri (&) T. Yasuda Y. Fujino M. Tominaga Department of Gastroenterological Surgery, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, Hyogo 673-8558, Japan e-mail:
[email protected];
[email protected]
adjacent trachea or main bronchus. It has been reported that untreated GTF is usually fatal due to chronic pulmonary sepsis, making conservative treatment inadvisable [3]. We present a particularly rare case, a direct fistula from the trachea into a cervical esophagogastric anastomosis, and discuss its presentation and successful conservative management.
Case report A 68-year-old man was admitted to our hospital with a squamous cell carcinoma in the upper third of the esophagus, with a preoperative TNM classification [4] of T1bN0M0 stage IA. The patient underwent minimally invasive esophagectomy in the prone position with three-field lymph node dissection. A gastric conduit was created by hand-assisted laparoscopic surgery in the posterior mediastinum, with neck anastomosis. On postoperative day 8 the white blood cell (WBC) count and C-reactive protein (CRP) level were elevated at 10,600/ll and 16 mg/dl, respectively. The neck drainage tube was dirty with signs of anastomotic leakage. As the patient’s general condition was stable, he was managed conservatively with antibiotics and intermittent nasogastric tube drainage (repeat absorption and break every 10 s). On postoperative day 28, WBC and CRP returned to normal at 6,900/ll and 0.2 mg/dl, respectively. Neck drainage fluid also normalized. The patient experienced coughing, a unique symptom in this context. We performed an esophagram to confirm anastomotic healing and to verify the presence of a GTF. The upper trachea was imaged with peroral contrast medium, and a GTF was unfortunately diagnosed (Fig. 1a). Gastrointestinal endoscopy showed a healthy gastric tube, but there was a hole in
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Esophagus Fig. 1 a The trachea was imaged using peroral contrast medium (arrows) (POD28). b The trachea was not detected by esophagogram and fistula healing was confirmed (POD43)
the anterior portion of the anastomosis (Fig. 2a). The hole was also visualized via bronchoscopy, along with bubbling at a GTF in the posterior aspect of the trachea (Fig. 3a). A CT scan of the thorax demonstrated air in the anastomosis, the assumed site of fistula communication. No inflammatory reaction was seen and the patient’s general condition was stable. As there was no evidence of gastric tube necrosis and the clinical presentation consisted only of coughing upon swallowing and not fever or recurrent pneumonia, we continued conservative management. The patient was treated with antibiotics and noninvasive respiratory support in the form of humidified oxygen via face mask. Intermittent absorption via gastric tube (vacuum pressure -10 cmH2O, at intervals of 10 s) was performed. For the first 10 days, the nasogastric drainage bag was
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filled with large amounts of air. Inflammatory reaction did not reoccur. On postoperative day 43, the trachea was not detectable on esophagogram (Fig. 1b). Bronchoscopy also showed healing and closure of the hole at the GTF (Fig. 3b). The patient progressed well after beginning an oral diet and was discharged. Follow-up gastrointestinal endoscopy and bronchoscopy about 100 days postoperatively confirmed spontaneous fistula closure (Figs. 2b, 3c).
Discussion Gastro-tracheobronchial fistula represents a potentially catastrophic complication after esophagogastrostomy for esophageal carcinoma. The most common cause is leakage
Esophagus Fig. 2 a Gastrointestinal endoscopy showed a healthy gastric tube, but with a hole in the anterior portion of the anastomosis (arrows) (POD28). b At follow-up 105 days postoperatively, gastrointestinal endoscopy demonstrated fistula healing (arrows)
from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. Since this type of fistula is a fatal complication [2, 5, 6], diagnosis and rapid treatment are essential. Late in the postoperative course, it is unusual to observe the acute onset of coughing upon swallowing, fever, and recurrent pneumonia, together with hemoptysis, and this clinical presentation deserves bronchoscopic assessment with a high index of suspicion for fistula development. There is no standard management for esophago-respiratory or gastro-respiratory fistulae. The presence of mediastinal contamination or gastric tube necrosis requires resection of the gastric tube and fistula closure with transposition of a pedicled muscle flap. Untreated GTF is reportedly usually fatal due to chronic pulmonary sepsis, making conservative treatment inadvisable [3]. While we do not object to early surgery as the standard of care, given the utmost importance of reducing mortality, surgical morbidity is high in these patients. Yasuda et al. reported the clinical characteristics and outcomes of 10 cases of GTF, which they subdivided into 3 types: anastomotic leakage, gastric necrosis, and gastric ulcer. The anastomotic leakage type appeared about 2 weeks (postoperative day 8–35) after esophagectomy, was located in the upper thoracic trachea, and had better outcomes with conservative therapy. Our case met the above conditions for conservative therapy, specifically GTF type,
onset time after esophagectomy, and fistula site [7]. Concerning conservative therapy, Bona et al. reported a case of chronic GTF complicating esophagectomy, which was eventually treated by endoesophageal stenting. A selfexpanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation [8]. Martin et al. described a conservatively managed fistula from the left main bronchus into a cervical esophagogastric anastomosis. They suggested that in carefully selected cases where bronchopulmonary contamination from the fistula is minimal or absent, there is no associated inflammation of the tracheobronchial tree, and the patient is stable from a respiratory point of view without evidence of sepsis, a trial of conservative management may be appropriate [9]. Ussat al. [10] reported a case of GTF in which fibrin glue was applied at the lumen of the fistula repeatedly (22 times) until complete closure was achieved. Thus, both methods were effective, but removal of the digestive tract stent, which is necessary because GTF is a benign disease, is difficult in some cases. Frequent application of fibrin glue under bronchoscopy is rather invasive. The optimal first-line strategy for conservative therapy of GTF, if the situation allows, is simple and minimally invasive neck drainage and intermittent absorption via gastric tube. If this approach is unfeasible or ineffective, stenting and/or fibrin glue may be used.
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Esophagus Fig. 3 Fistula healing monitored via bronchoscopy. a Bronchoscopy demonstrated a hole and bubbling at a gastric tube–bronchial fistula in the posterior aspect of the trachea (POD29). b Bronchoscopy showed healing and closure of the hole at the fistula (POD43). c Spontaneous fistula closure was seen (POD115)
Conservative treatment may be the optimal management approach if the following conditions are met: (1) the clinical presentation does not include critical coughing upon swallowing, fever, or recurrent pneumonia; (2) blood samples reveal no evidence of acute inflammatory reaction; (3) there is no evidence of gastric tube necrosis; (4) the GTF is the anastomotic leakage type and appears about 2 weeks after esophagectomy; and (5) the GTF is located in the upper thoracic trachea. Our patient met the above criteria and our conservative management of his case was successful. Intermittent nasogastric tube drainage may be useful for preventing the influx of digestive juices into the respiratory
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tract system. Given the possibility of sudden changes, however, it is necessary to prepare emergency management procedures, including surgery. In conclusion, our case is a rare report of successful conservative management of a gastrotracheal fistula with a direct communication between a dehisced anastomosis and the adjacent trachea.
Ethical Statement This article does not contain any studies with human or animal subjects performed by any author(s). Conflict of interest conflict of interest.
The authors declare no financial or commercial
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