Interact CardioVasc Thorac Surg 2009;9:896-898. doi:10.1510/icvts.2009.208637
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Thoracic oncologic |
Successful salvage right upper lobectomy and flap repair of trachea-esophageal fistula due to severe necrotizing pneumonia
Betsy Evansa,
Iain MacKenzieb,
Charles Malatac and
Aman Coonara,*
a Department of Thoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge, CB23 8RE, UK
b Anaesthetics and Intensive Care, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, CB2 0QQ, UK
c Plastic and Reconstructive Surgery and Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, CB2 0QQ, UK
Received 1 April 2009;
received in revised form 25 June 2009;
accepted 7 July 2009
 No previous presentation of this manuscript.
*Corresponding author. Tel.: +441480 364887; fax: +441480 364583.
E-mail address: aman.coonar{at}papworth.nhs.uk (A. Coonar).
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Abstract
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A 55-year-old previously well man developed a severe pneumonia. Endoscopy found tracheal and esophageal fistulae communicating with the right lung and pleural space. Bilateral main bronchi intubation was required. Emergency surgery was performed with a latissimus dorsi and serratus anterior muscle flap to close the tracheal and esophageal fistulae. The right upper lobe was found to be destroyed and resected. It was possible to salvage the patient who was discharged home despite challenging anesthetic and surgical circumstances.
Key Words: Trachea-esophageal fistula; Necrotizing pneumonia; Selective endobronchial intubation; Pedicled muscle flap
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1. Case report
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A 55-year-old previously well, male, smoker was admitted to his local hospital with a fulminant pneumonia. He was intubated approximately 5 h after admission. He continued to deteriorate. Three days after intubation, CT-scan demonstrated a fistula in the distal trachea (Fig. 1) and right main bronchus. Endoscocopy showed air bubbling from the superior esophageal sphincter, and two defects in the trachea, one communicating with the pleural space and another with the esophagus (Video 1). He became refractory to single lumen endotracheal tube ventilation; therefore, the main bronchi were intubated separately with two size five tubes reaching below the fistulae (Video 1). Repeat bronchoscopy revealed enlargement and extension of the fistulae and urgent thoracic surgery review was sought. Stenting was considered but rejected in favor of definitive surgery.
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Video 1. Fiber-optic bronchoscopy demonstrating the preoperative endoscopy findings and bilateral airway intubation (also as supplemental file).
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Through an extended right postero-lateral thoracotomy pedicled latissimus dorsi and serratus anterior flaps were raised on the thoracodorsal vascular pedicle. On entry to the chest pus was visible; the tracheal and esophageal fistulae lay next to each other but were not communicating. The whole lung was emphysematous. He rapidly desaturated on single lung ventilation and therefore most of the operation was performed with two-lung ventilation. The right upper lobe had multiple abscesses with nodules and a mass; it was destroyed along its medial aspect. The tissue quality of the proximal right main bronchus was poor and the right upper lobe bronchus had partly detached from the main bronchus. Urgent intraoperative histological examination of a lung nodule identified a carcinoma. Given his previously good quality of life and uncertainty of stage the immediate goal remained salvage and the operation continued.
A right upper lobectomy was performed expeditiously. This improved exposure, allowing the right endotracheal tube to be positioned better. The esophageal mucosal defect was approximately 5 cm in length. A naso-gastric tube was passed and the esophageal mucosa was then closed with interrupted 4/0 PDS sutures. The muscle flaps were brought into the chest through a window created by partial excision of the third rib. The muscle was positioned to lie over the esophageal fistula separating it from the trachea and sutured onto the esophagus for reinforcement. The tracheal fistula was examined; it was also approximately 5 cm in length and extended to about 50% of the membranous trachea and about 10% of the cartilaginous trachea on the right side. The latissimus dorsi muscle was sutured without tension onto the trachea with multiple interrupted 4/0 polypropylene sutures. Although the tissue quality was poor it was possible to completely close the trachea. The right upper lobe stump was also covered by muscle. The chest was then washed out with dilute iodine and closed over three chest tubes.
The endobronchial tubes were changed for a single size eight endotracheal tube, the tip of which was positioned 1 cm above the repair. This was to avoid pressure by the cuff at the level of the repair. The patient was then returned to the intensive care unit with reduced ventilatory requirements. He was transferred to the specialist thoracic surgery center for ongoing care. Still ventilated 12 days postoperatively he developed an air leak and recurrent sepsis. Bronchoscopy demonstrated that the tracheal fistula had enlarged with partial breakdown of the repair. The membranous trachea at the fistula edge looked necrotic. Urgent repeat thoracotomy was performed, the muscle flap was taken down and the now further enlarged tracheal fistula was debrided to healthier tissue and then closed using the same technique as before (Fig. 2). The esophagus was found to be intact. Following repeat thoracotomy he made a slow recovery, further airway management was with a size eight tracheostomy. Initially, the cuff was placed above the repair, subsequently after changing to an uncuffed tube; the tip was placed just above the carina allowing limited airway stenting. Nutrition was provided with a naso-jejunal tube and then orally. Unfortunately, seven weeks post-surgery he developed a controlled esophageal leak via a former drain site which was confirmed on contrast imaging.
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Fig. 2. Late postoperative bronchoscopy view demonstrating healthy muscle flap and intact tracheal repair.
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Formal histology of the lung nodule identified a poorly differentiated adenocarcinoma but no cancer was found in tracheal and esophageal biopsies. Full staging performed after weaning from the ventilator revealed multiple distant metastases. From this time, due to the advanced stage, palliative management became the agreed goal. He was discharged home 10 weeks after presentation, with the esophageal leak managed by a restriction of oral intake to a soft diet and supplementary jejunal nutrition. Esophageal stenting was planned for three months post-presentation to allow a period of quiescence, possible tissue recovery and improvement in his nutritional status.
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2. Comment
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Severe necrotizing pneumonia is recognized though relatively rare. In this case an aggressive illness with infection may have caused small vessel ischemia and necrosis leaving the trachea and esophagus vulnerable. The mediastinal surface of the right upper lobe had broken down and at surgery an empyema was found. The precise timing of the development of the fistula cannot be determined. This patient needed intubation and it is possible that the low-pressure cuff contributed to development of the fistula. The mechanism of this is speculative as the cuff would have been above the level of the fistula. In our case bilateral endobronchial intubation was then used to temporarily support the patient. The subsequent decision to offer definitive surgery was made because the patient's fulminant course appeared to leave a short time window in which to intervene. The underlying diagnosis of malignancy was unknown and the acute deterioration related to a severe chest infection and fistulae. We considered stenting but chose not to do this as it may have been impossible due to difficult ventilatory needs and carried a high risk of further damaging the fragile airway or esophagus, which may have been terminal.
Severe necrotizing infections may be successfully managed by timely and wide surgical resection. We have not been able to find a similar case in which a patient with fulminant respiratory failure was salvaged with differential intubation followed within a few hours by tracheal and esophageal repair and anatomical lung resection. Intraoperatively it appeared that lobectomy would allow us to clear the main site of infection and that primary reconstruction was technically possible. In this context, we felt that even though the patient may have had advanced malignancy, short-term survival was dependent on successful surgery. We also felt that surgery was justified in view of his good quality of life until a few days before presentation. Surgery for salvage may be controversial but it is the sicker, higher risk patient who may have the most to gain.
Elective repair of tracheal defects by similar techniques as ours is described. Intra-thoracic transposition of the latissimus dorsi muscle for mediastinal reinforcement and filling of spaces was first described as a buttressed repair of a broncho-pleural fistula (BPF) in 1911 by Abrashanoff [1]. Authors suggest that up to half the tracheal circumference can be repaired in this way, and if needed a bone graft can be used to splint the repair [2, 3]. Tracheal and esophageal fistulae are often repaired as elective or semi-elective cases. Emergency repairs are usually for trauma and often direct repair is sufficient. Another situation in which emergency tracheal repair has been well described is for trachea-inominate artery fistula. In some cases an interposition muscle flap has been used as part of the repair [4, 5]. Alloderm® (Lifecell, NJ, USA), an allogeneic acellular dermal matrix has also been used with a muscle flap to reconstruct the membranous trachea [6].
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Acknowledgements
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We would like to acknowledge Dr. P. Sivasothy, Consultant Respiratory Physician, Addenbrookes Hospital, Cambridge UK for his assistance in managing this complex patient.
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References
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- Abrashanoff. Plastiche methode der Schlessung von Fistelgangen, welche von inneren organen kommen. Zentralbl Chir 1911;38:186.
- Dartevelle P, Macchiarini P. Management of acquired tracheo-esophageal fistula. Chest Surg Clin N Am 1996;6:819–836.[Medline]
- Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am 2003;13:271–289.[CrossRef][Medline]
- Meyer AJ, Krueger T, Lepori D, Dusmet M, Aubert JD, Pasche P, Ris HB. Closure of large intrathoracic airway defects using extrathoracic muscle flaps. Ann Thorac Surg 2004;77:397–405.[Abstract/Free Full Text]
- Abolhoda A, Wirth GA, Bui TD, Milliken JC. Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited. Eur J Cardio-thorac Surg 2008;33:928–930.[Abstract/Free Full Text]
- Su JW, Mason DP, Murthy SC, Rice TW. Closure of a large tracheoesophageal fistula using AlloDerm. J Thorac Cardiovasc Surg 2008;135:706–707.[Free Full Text]
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Abstract
1. Case report
