Surgical repair of benign thoracogastric airway fistula after esophagectomy using a pedicled myocutaneous flap

Introduction

Thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication following esophagectomy for esophageal cancer treatment, with an incidence rate of approximately 0.3–1.5% (1,2). This disease is characterized by an abnormal connection between the airway and thoracostomach, causing the flow of gastric contents into the tracheobronchial tree through the fistula, leading to various clinical symptoms. Clinical manifestations of TGAF range from mild to life-threatening, including fever, cough, suffocation, sputum production, burning sensation, chest pain, pneumonia, respiratory distress, and life-threatening hemoptysis. However, early diagnosis and appropriate treatment can prevent the progression of TGAF and improve the quality of life of patients.

There is still controversy over the treatment of TGAF, with the increased use of non-surgical therapies such as endoscopic stent placement (3-5). However, the fistula location is not always amenable to stenting. More importantly, the supportive force provided by the stent may be harmful to the tissue surrounding the fistula, leading to further enlargement of the fistula or even fatal bleeding (6,7). However, surgical repair remains a challenge for surgeons. Although in situ repair of the trachea and thoracostomach is the ideal surgical approach, it is associated with a high risk of infection in the chest cavity if digestive or tracheal fistulas develop, which can endanger patients’ lives. Herein, we report four cases of TGAF repaired with a pedicled latissimus dorsi myocutaneous flap, which involved repair of the airway fistula in Stage I, restoring the integrity of the airway, followed by reconstruction of the digestive tract in Stage II to restore oral intake, greatly reducing the surgical risk. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1029/rc).

Preoperative preparations and requirements

Patients

The surgery was performed by the Esophageal Surgery Department of the Shanghai Chest Hospital. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study protocol was approved by the institutional review board of the Shanghai Chest Hospital (serial number: IS24034). Written informed consent was obtained from all the patients for publication of this surgical technique and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Inclusion criteria

(I) History of esophagectomy with gastric conduit reconstruction; (II) location of the TGAF determined by bronchoscopy and esophagoscopy before surgery; (III) computed tomography (CT) scan performed to evaluate lung infection; and (IV) tumor recurrence or metastasis excluded by positron emission tomography-CT (PET-CT) scan.

Exclusion criteria

(I) Tumor recurrence or metastasis; (II) presence of severe comorbidities, such as impaired cardiac, renal, hepatic, and/or pulmonary function; (III) history of lower abdominal surgery where the jejunum or colon cannot be used as a substitute for the esophagus; and (IV) refusal of this surgical approach for repairing TGAF with a pedicled myocutaneous flap.

Step-by-step description

Stage I surgery: general anesthesia is induced with a left-sided double-lumen endotracheal tube to achieve separate left lung ventilation. The patient is placed in the right lateral decubitus position. A latissimus dorsi myocutaneous flap is prepared based on the location and size of the fistula. Firstly, a posterolateral incision is performed along the fifth intercostal space of the right chest. The skin and subcutaneous tissue are dissected. Then, the latissimus dorsi muscle is exposed. The thoracodorsal artery is used as the blood supply vessel, and the myocutaneous flap along the thoracodorsal artery is designed. The starting point is located at the root of the thoracodorsal artery and the ending point is located at the 11^th to 12^th rib. The skin area is determined by the size of the tracheal fistula.

Through a posterior lateral incision at the fifth intercostal space, the thoracogastric is removed to expose the fistula. If a stent is present in the trachea, it was removed through the fistula. Usually, the third rib, approximately 5 cm in length, is resected at the midaxillary line, through which the myocutaneous flap is transferred into the thoracic cavity. and the skin side of the flap is anastomosed to the tracheal fistula using 4-0 prolene sutures in a continuous pattern. After completion of the anastomosis, no apparent air leakage from the trachea-flap anastomosis is confirmed by filling the chest cavity with water. Then, the chest is closed layer by layer. The operative procedure is illustrated in Figure 1. There are two technical points to note during the thoracic operation: (I) when thoracogastric resection is difficult, the mucosa of the thoracostomach can be removed alone to eliminate its secretory function. This approach is especially suitable for the thoracogastric area located behind the superior mediastinum and can help prevent damage to the surrounding tissues. (II) When the tracheal fistula is small, it can be appropriately enlarged to facilitate the anastomosis. The patient was then placed in a supine position, the cervical esophagus was excluded, and jejunostomy was performed through a midline incision in the upper abdomen.

Figure 1 Schematic diagram of TGAF repair using a pedicled myocutaneous flap. (A) Preparation of a latissimus dorsi flap with the thoracodorsal artery and vein as the pedicle. (B) Right-sided thoracotomy is performed to expose the TGAF. (C) The tracheal fistula is exposed after thoracostomach resection. (D) The latissimus dorsi flap is moved into the chest cavity through the third intercostal space. (E) The latissimus dorsi flap is anastomosed to the tracheal fistula. (F) Observation of the anastomosis within the tracheal lumen after repair completion. TGAF, thoracogastric airway fistula.

Stage II surgery: after 3–6 months, the abdominal cavity is entered through a midline incision in the upper abdomen. The middle colic artery is preserved, and the ileocolon is mobilized and pulled up behind the sternum to the neck to complete the reconstruction of the digestive tract.

Typical case presentation: a 54-year-old male patient who underwent minimally invasive McKeown esophagectomy for esophageal cancer 2 years previously developed TGAF 6 months previously and was treated with a silicone tracheal stent. Preoperative bronchoscopy revealed two fistulas with a diameter of approximately 0.5 mm in the trachea near the carina (Figure 2A). In November 2022, under general anesthesia, the patient underwent thoracogastric resection, repair of the tracheal fistula with a latissimus dorsi flap, cervical esophageal exclusion, and jejunostomy. The patient was first placed in the left lateral decubitus position, and a latissimus dorsi flap with the thoracodorsal artery and vein as the pedicle was designed (Figure 2B). The flap was then freed and prepared (Figure 2C). During the surgery, two small fistulas in the trachea near the carina were observed; the intervening ridge between them was dissected, and the fistula was then enlarged (Figure 2D). Subsequently, the latissimus dorsi flap was moved into the chest cavity through the third intercostal space, and the tracheal fistula and flap were continuously anastomosed with 4-0 prolene sutures (Figure 2E). After the anastomosis was completed, the chest cavity was filled with water, and no significant air leakage from the inflated lung was observed. The chest was then closed layer by layer. Subsequently, the patient was placed in the supine position and underwent cervical esophageal exclusion and jejunostomy. Postoperative bronchoscopy showed good healing of the anastomosis between the trachea and flap (Figure 2F). In April 2023, the patient underwent ileocolic esophageal replacement. Postoperative upper gastrointestinal tract radiography showed a patent anastomosis, and no fistula was observed. The patient resumed oral intake.

Figure 2 A typical case of TGAF repair using a pedicled myocutaneous flap. (A) Preoperative bronchoscopy showing the TGAF. (B) Design of a latissimus dorsi flap with the thoracodorsal artery and vein as the pedicle. (C) A completed pedicled latissimus dorsi flap. (D) Tracheal fistula exposed after thoracostomach resection. (E) The pedicled latissimus dorsi flap was moved into the chest cavity to repair the tracheal fistula, with the skin edge continuously sutured to the trachea using 4-0 prolene sutures. (F) Six-month postoperative bronchoscopy showing good healing of the anastomosis between the trachea and flap. TGAF, thoracogastric airway fistula.

Postoperative considerations and tasks

Four patients with TGAF underwent successful repair with pedicled myocutaneous flaps between June 2022 and December 2023. Among them, three were male and one was female. All four patients developed TGAF after minimally invasive McKeown surgery. Three patients had fistulas located in the trachea, whereas one had a fistula located in the bronchus. Detailed clinical information of the patients is presented in Table 1. Preoperative evaluation included assessment of cardiopulmonary function to ensure that the patient could tolerate the surgical procedures. Comprehensive bronchoscopy and esophagoscopy were performed to evaluate the location and size of the fistulas, and PET-CT was performed to exclude tumor recurrence and metastasis.

The staged repair of TGAF using pedicled myocutaneous flaps appeared safe, with no intraoperative adverse events, including anesthesia accidents, massive bleeding, and severe arrhythmia. One patient developed a tracheal-myocutaneous flap anastomotic leakage 1 week after surgery, resulting in chronic empyema. After 1 month of conservative treatment, follow-up bronchoscopy revealed good healing of the anastomosis. No surgery-related complications occurred in the other patients.

Tips and pearls

When thoracogastric resection is difficult, the mucosa of the thoracostomach can be removed alone to eliminate its secretory function. This approach is especially suitable for the thoracogastric area located behind the superior mediastinum and can help prevent damage to the surrounding tissues. When the tracheal fistula is small, it can be appropriately enlarged to facilitate the anastomosis.

Discussion

There have been reports of fistulas between the airway and gastric conduit following esophagectomy, both in the early and late postoperative stages. Fistulas developing at an early stage may be related to several factors, including injury from intubation, damage to the tracheal membrane from stapling or suturing during esophagogastroanastomosis, and injury to the tracheal membrane from energy devices (8,9). Fistulas that develop at a late stage are associated with chronic anastomotic leaks, cancer recurrence, anastomotic stricture dilation, and radiation or chemotherapy (10-12). All four patients included in this study had late-stage benign TGAFs with no tumor recurrence or metastasis.

The treatment strategy for benign TGAF following esophagectomy can be challenging because it is influenced by the location, size, and pathogenesis of the fistula, as well as the patient’s manifestations and accompanying comorbidities (13,14). Treatment strategies include endoscopic and surgical approaches. Generally, endoscopic stent placement is preferred, but the location of the fistula is not always amenable to stenting. Moreover, the radial force provided by the stent may cause tissue damage around the fistula and lead to fistula enlargement (6,15,16). There have been reports of stent treatment with a high recurrence rate of up to 39% (17). In addition, when a fistula is epithelialized, medical treatment is generally ineffective. All four patients in this study experienced endoscopic stenting failure. However, stenting can also serve as a bridge for surgery. When a patient’s general condition is unstable and the surgical risk is too high, endoscopic stenting can be performed to temporarily prevent continuous contamination of the airway by gastric contents. When a patient’s general condition improves, reintervention with surgical procedures should be considered.

In 2020, Li et al. (7) conducted a systematic analysis of the advantages and disadvantages of endoscopic and surgical treatments for TGAF, including 24 articles with 89 patients. In that review, 23 patients underwent surgical repair, whereas 66 were treated with stents. The 1-month survival rate after surgical repair was 96.65%, whereas that of endoscopic stenting was 91.67%. After 9 months, the survival rate in the surgical repair group was 68.10%, whereas that in the endoscopic stenting group was only 13.3%. Overall, the median survival time of patients undergoing tracheal stent placement (6 months) was significantly shorter than that of patients undergoing surgical repair (35.8 months). Although surgical repair is the most likely curative method for TGAF, it is associated with a high incidence of complications (18). Surgical repair methods include bypass surgery for digestive reconstruction (1), separate repair of the digestive tract and airway with isolation using biological material (19), and tracheal segmental resection + digestive tract repair + interpolation with a muscle flap (20). All the above-mentioned methods have a high risk of surgical complications in patients with TGAF. Owing to the reliable and well-preserved blood supply and strong anti-infection ability of pedicled myocutaneous flaps, they are particularly suitable for tissues that have undergone radiotherapy (21). Therefore, we usually choose myocutaneous flaps as biological patch materials for TGAF repair. All patients in this study underwent staged surgery. Three cases had good healing after fistula repair, while one case developed an anastomotic leak from the anastomosis between the flap and trachea 1 week after surgery, which was eventually cured by conservative treatment. We believe that staged restoration of airway and digestive tract integrity can significantly reduce surgical risks. If tracheal and gastric conduit repairs are performed in situ, the development of a tracheal or gastric conduit fistula may lead to thoracic infection and jeopardize patient safety. Therefore, we prefer thoracogastric resection with tracheal fistula repair in Stage I, followed by digestive tract reconstruction in Stage II. This approach eliminates the possibility of digestive fluid contamination and airway corrosion, thereby reducing surgical risks to a certain extent.

The risk is relatively high during Stage I surgery for TGAF repair using a pedicled myocutaneous flap. The key technique involved in the surgery is thoracogastric resection, which can be challenging due to the dense adhesions between the thoracostomach and the mediastinum. During the surgery, if the resection becomes difficult, we use an incision to open the thoracostomach and only remove the thoracogastric mucosa, thus eliminating its endocrine function. This approach has two benefits. First, it can prevent further damage to the tracheal membrane. Second, owing to dense adhesions in the mediastinum, dissection of the left recurrent laryngeal nerve is often challenging. By removing only the thoracogastric mucosa, the probability of injury to the left recurrent laryngeal nerve can be reduced.

When anastomosing the flap to the tracheal fistula, it may be necessary to enlarge the fistula to facilitate accurate anastomosis. In cases of anastomotic leaks after surgery, it is necessary to ensure adequate chest drainage and, if necessary, to place a temporary tracheal stent to ensure pulmonary re-expansion. According to the principles of chronic empyema management, chest drainage should be opened gradually once complete pleural adhesion is achieved, and the chest tube should be gradually removed.

In summary, TGAF is a rare postoperative complication of esophageal cancer surgery, and its treatment remains challenging in the absence of established protocols. The management of TGAF requires multidisciplinary knowledge and individualized strategies, and proactive surgical repair can lead to survival benefits for appropriate patients.

Conclusions

The key to successful treatment is the staged restoration of the integrity of the airway and digestive tract, which can reduce the perioperative risks associated with surgical repair of TGAF. Successful repair using a pedicled myocutaneous flap may provide a reference for treating this type of disease.

Acknowledgments

We also would like to thank Editage (www.editage.cn) for English language editing.

Funding: This work was sponsored by Program of Shanghai Academic/Technology Research Leader (No. 22XD1402900) to Z.L., and 2020 “Hospital New Star” Young Medical Talent Program of Shanghai to C.L.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1029/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1029/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1029/coif). Z.L. serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2024 to April 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study protocol was approved by the institutional review board of the Shanghai Chest Hospital (serial number: IS24034). Written informed consent was obtained from all the patients for publication of this surgical technique and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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