CRP12.Multidisciplinary Approach to Repairing a Complex Tracheoesophageal Fistula
Presented During: AATS Cardiothoracic Resident Case Report-Poster Display
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Anne Michelle Montal is a PGY3 General Surgery Resident at Montefiore Medical Center in the Bronx. She earned her Bachelor's degree in Biology at Yeshiva University, where she played starting point gaurd for a division 3 NCAA basketabll team. She went on to complete her medical degree at The Technion Israel Institute of Technology: The Ruth and Bruce Rappaport Faculty of Medicine American Medical School. Anne is interested in pursuing a fellowship in Cardiothoracic Surgery. When she's not working in the hospital, Anne can be found trying new recipes or planning her next adventure.
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Los Angeles Convention Center
Room: ePoster Area, Exhibit Hall
Description
Here we report our experience in managing a large iatrogenic tracheoesophageal fistula (TEF) in a 13-yr-old boy likely related to prior tracheostomy. One year prior to presentation to us, he had suffered from Dengue shock in Antigua with subsequent multisystem organ failure. He required tracheostomy and gastrostomy and ultimately recovered allowing for decannulation. Several months following his discharge, he was readmitted with recurrent pneumonias and failure to thrive, at which time an extensive TEF was identified. He was subsequently transferred to our center for further management.
He underwent bronchoscopy and esophagoscopy for initial evaluation. This identified a large, but mature defect, 4cm in length(Figure 1A) that was 7cm from the vocal cards proximally, and 4cm from the carina distally. On the esophageal side, the TEF was 17cm from the incisors. His case was discussed in multidisciplinary fashion with evaluation by thoracic surgery, plastic, and pediatric surgery. Multiple options for reconstruction were considered as the fistula spanning the neck and upper thorax made repair and reconstruction challenging. Tracheal resection with primary repair of the esophageal defect was discussed, but length of the TEF was a concern. We also considered division of the trachea and esophagus followed by primary repair of the esophagus and muscle-flap reconstruction of membranous portion of the trachea. The proximal esophagus was quite dilated making primary repair feasible, and we believed a radial forearm free-flap would provide the necessary rigidity to reconstitute airway anatomy.
Following treatment of pneumonia with antibiotics and several weeks of nutrition repletion, he was taken to the operating room for TEF repair with primary closure of esophageal defect and free-flap tracheal reconstruction. We began with a right sternocleidomastoid(SCM) incision carried down to the upper sternum, and we began our dissection with identification of the anterior wall of the trachea. We quickly identified the need for further exposure to isolate the length of the defect, and performed an upper sternal split down to the second interspace. The innominate vein and artery along with the aorta were mobilized inferiorly in order to create space for exposure of the distal airway. Following dissection of the length of the trachea, we identified the esophagus posteriorly. Once the proximal and distal areas of the fistula were fully mobilized we encircled both with umbilical tapes for further traction. We then sharply opened the fistula, thereby separating the esophagus and trachea. The dilated esophagus was amenable to primary repair with running absorbable suture. A radial myofascial cutaneous free-flap, harvested by plastic surgery team, was then used to cover the posterior tracheal defect with the skin side facing into the tracheal lumen using interrupted PDS sutures and ensuring to maintain a taught closure. The flap was then microvascular anastomosed to the right internal mammary vessels with the vascular pedicle brought underneath the sternum and brought out through the second interspace. Once completed, a saline leak test was performed with no evidence of an air leak. A Jackson-Pratt drain was left by the repair sites.
The patient recovered well with repeat bronchoscopy demonstrating an intact repair with viable graft(Figure 1B). His diet was advanced and he has been discharged following successful multidisciplinary repair of his extensive TEF.
He underwent bronchoscopy and esophagoscopy for initial evaluation. This identified a large, but mature defect, 4cm in length(Figure 1A) that was 7cm from the vocal cards proximally, and 4cm from the carina distally. On the esophageal side, the TEF was 17cm from the incisors. His case was discussed in multidisciplinary fashion with evaluation by thoracic surgery, plastic, and pediatric surgery. Multiple options for reconstruction were considered as the fistula spanning the neck and upper thorax made repair and reconstruction challenging. Tracheal resection with primary repair of the esophageal defect was discussed, but length of the TEF was a concern. We also considered division of the trachea and esophagus followed by primary repair of the esophagus and muscle-flap reconstruction of membranous portion of the trachea. The proximal esophagus was quite dilated making primary repair feasible, and we believed a radial forearm free-flap would provide the necessary rigidity to reconstitute airway anatomy.
Following treatment of pneumonia with antibiotics and several weeks of nutrition repletion, he was taken to the operating room for TEF repair with primary closure of esophageal defect and free-flap tracheal reconstruction. We began with a right sternocleidomastoid(SCM) incision carried down to the upper sternum, and we began our dissection with identification of the anterior wall of the trachea. We quickly identified the need for further exposure to isolate the length of the defect, and performed an upper sternal split down to the second interspace. The innominate vein and artery along with the aorta were mobilized inferiorly in order to create space for exposure of the distal airway. Following dissection of the length of the trachea, we identified the esophagus posteriorly. Once the proximal and distal areas of the fistula were fully mobilized we encircled both with umbilical tapes for further traction. We then sharply opened the fistula, thereby separating the esophagus and trachea. The dilated esophagus was amenable to primary repair with running absorbable suture. A radial myofascial cutaneous free-flap, harvested by plastic surgery team, was then used to cover the posterior tracheal defect with the skin side facing into the tracheal lumen using interrupted PDS sutures and ensuring to maintain a taught closure. The flap was then microvascular anastomosed to the right internal mammary vessels with the vascular pedicle brought underneath the sternum and brought out through the second interspace. Once completed, a saline leak test was performed with no evidence of an air leak. A Jackson-Pratt drain was left by the repair sites.
The patient recovered well with repeat bronchoscopy demonstrating an intact repair with viable graft(Figure 1B). His diet was advanced and he has been discharged following successful multidisciplinary repair of his extensive TEF.