A rare case of late malignant gastro-tracheal fistula ...

M. Migliore, et al. Surg Chron 2013; 18(1): 34-36.

A rare case of late malignant gastro-tracheal fistula following esophagectomy for cancer Marcello Migliore1, Alessandra Criscione1, Damiano Calvo1, Giuseppina Pulvirenti1, Mariapia Gangemi1, Borrata Francesco1, Palmucci Stefano2, Vincenzo Minutolo3 1

Thoracic Surgery, Department of Surgery, University of Catania, Catania, Italy Department of Radiology, University of Catania, Catania, Italy 3 Department of High Technology and Transplantation, University of Catania, Catania, Italy 2

Abstract The occurrence of gastro-tracheal fistula after esophagectomy for carcinoma with gastric pull-up is an uncommon and lifethreatening event. A 43 year-old male patient underwent transhiatal esophagectomy for esophageal cancer. Two years following the operation the patient developed dyspnea, cough and respiratory distress with an increase in tracheal secretion. A gastrotracheal fistula was diagnosed with a concomitant pneumo-mediastinum and subcutaneous emphysema. A covered metallic tracheal stent was used to close the fistula. This attempt proved successful, and the patient began eating an oral diet and was rd discharged on the 3 postoperative day. The patient died from cachexia 4 months after stent insertion. Key words. Esophagectomy, complications esophageal cancer, tracheal fistula, stent, gastrotracheal fistula, esophagorespiratory, tracheobronchial fistula

Introduction Gastro-tracheal fistulas following esophagectomy for carcinoma with gastric pull-up are rare. They usually occur in the early postoperative period as a surgical complication caused by dissection or ischemic injury. Very few cases have been described as occurring late after esophagectomy following radiotherapic treatment [1,2] or as an evidence of tumor recurrence [3]. We report the case of a late malignant gastrotracheal fistula following transhiatal esophagectomy for cancer successful treated with a covered tracheal stent. Case report A 43 year-old male patient with a middle third spinocellular esophageal carcinoma was surgically treated using a transhiatal approach. The postoperative period was uneventful. Two years later, the patient developed severe dysphagia, and the chest CT-scanning demonstrated a right paratracheal mass of 35 x 30 mm. Biopsy of the mass demonstrated a spinocellular carcinoma. Ten days later his general condition deteriorated with dyspnea, cough and respiratory distress. An increase in tracheal secretions was evident. An additional CT scan demonstrated the existence of a fistulous connection between trachea and the stomach tube and the presence of pneumo-mediastinum (Figure 1), which was treated by the placement of a drain. A contrast agent-enhanced esophagogram showed the pathognomonic tracheo-bronchial opacification, and a flexible fiberoptic bronchoscopy revealed a tracheal defect 15 mm long on the membranous portion just under the vocal

cords, with saliva seen entering the trachea through the fistula. The diagnosis of gastrotracheal fistula was made. The patient was then admitted to our Unit of Thoracic Surgery in poor general condition with bilateral pneumonia, and was immediately treated with ceftriaxone, pantoprazol and ketorolac.

Fig 1: CT scan demonstrating a fistulous connection between the trachea and the stomach tube and the presence of pneumomediastinum and subcutaneous emphysema.

The patient was operated upon by endoscopic stent placement. In the operating room the patient was sedated, and placed in the supine position with the neck extended. The fistula was identified using the bronchoscope, and topical anesthesia was introduced through the operative channel of the bronchoscope. An injection of fibrin glue was 34


made over the fistula. Under bronchoscopic guidance the delivery system was introduced into the trachea using the transoral route, and the 18x40 mm AERO stent (Alveolus Inc, U.S.A.) was deployed into the trachea. A postoperative X-ray scan in the recovery room showed the correct position of the tracheal stent. The day after the procedure, the patient presented no respiratory or swallowing impairment. A contrast agent-enhanced esophagogram demonstrated that the stent completely sealed off the gastrotracheal fistula. The patient continued to be treated with appropriate antibiotics, according to culture sensitivity, and antiulcer therapy. In addition, aerosol inhalation with chymotrypsin and dexametasone was administrated for 7-14 days to dilute sputum and reduce tissue hyperplasia and local edema rd and finally to eliminate local inflammation. On the 3 postoperative day, the patient was allowed to eat an oral diet, and was discharged. The patient was monitored as an outpatient with esophagograms, fiberoptic bronchoscopy and chest CTscans. The successful closure of the gastrotracheal fistula was confirmed (Figure 2 A and B). The patient remained asymptomatic maintaining an oral feeding until he died, 4 months after the placement of the tracheal device. The cause of death was malignant cachexia which was unrelated to the stent insertion.

esophagectomy due to infection, ischemia, surgical staples and experience of the surgeon (4), late malignant GTF is a very uncommon complication of esophagectomy with gastric-pull up, and reports in the literature are very few [3]. Life expectancy in patients with malignant GTF is, at best, poor. Aspiration pneumonia, mediastinitis and malnutrition are common causes of death. Treatment of GTF is individualized and is always difficult. Before the advent of stents, the most used treatment was the surgical repair of the fistula using traditional sutures, intercostal muscles, pleural or pericardial flap interposition [1,5,6,7,8] and polyglactic acid sutures [9]. The surgical approach entails a high risk of postoperative complications [3] especially in debilitated patients. For this reason, a less invasive approach using expandable stents has been proposed. Covered stents are commonly used to release obstruction or to seal malignant esophagotracheal fistulas [10]. The covered stent helps to reduce complications, such as migration and fracture, excessive granulation tissue, mucus plugging and poor patient tolerance. Recently some authors compared survival between groups with and without airway stenting in 59 patients with ERTF. They demonstrated that survival improved in the group with airway stenting for those patients whom surgery is unsuitable (10). Another article specifically on early GTF shows a 30 % mortality, but no patients received tracheal stenting (11). Endoscopic stent placement was successfully accomplished in 4 patients with an anastomotic leak-induced tracheobronchial fistula, of those only one was inserted in the trachea (12). To our knowledge the only available article showing the use of tracheal stent in GTF reports a mean survival of 7 weeks [3]. Our patient had a satisfactory quality of life until he died, 4 months after the procedure. We decided to use the tracheal stent because of the poor general condition of the patient. The parallel insertion of the esophageal stents was avoided since the gastric tube did not allow the endoscopic placement of a prosthesis because of its very large calibre [5], and the chances of stent migration are very high. The endoscopic application of a covered tracheal stent in our high risk patient with late malignant gastrotracheal fistula has proved to be successful.

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Fig 2: A) and B) 3D rendering of the covered stent positioned in the upper third of the trachea.

Discussion Before all it is important to clarify that the gastro-tracheal fistula (GTF) should not be confused with the esophagorespiratory tract fistula (ERTF). The former developes always postoperatively after an esophagectomy with gastric pull-up while the latter is a more known complication of esophageal cancer. Although the occurrence of GTF is often described as an early postoperative complication following

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Corresponding Author Migliore Marcello, MD, PhD Thoracic Surgery, Ospedale Policlinico, Pad 4, 4th Floor Via S. Sofia 78, Catania, Italy Sec. 0039-095-7167840 Office and Fax: 0039-095-3581467 Email: [email protected]; [email protected]

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