Treatment of an acquired esophageal-bibronchial benign fistula using an original combination of techniques

Maurizio Boaron 1 Kenji Kawamukai 1 Sergio Nicola Forti Parri 1 Rocco Trisolini 0 0 Thoracic Endoscopy and Pulmonology Unit, Maggiore and Bellaria Hospitals , Largo B. Nigrisoli 2, 40133 Bologna, Italy 1 Divison of General Thoracic Surgery, Maggiore and Bellaria Hospitals , Bologna, Italy We report on the successful surgical treatment of an esophageal-bibronchial fistula originating from an iatrogenic mediastinal abscess. Endoscopic treatment had been excluded due to the extensive damage to the right main stem bronchus wall. The surgical treatment was carried out as follows: 1) Endoscopic stenting of the left main bronchus with a self-expanding metallic stent followed by selective left main bronchus intubation; 2) Laparotomic harvesting of the omentum pedicled on both gastro-epiploic vessels; 3) Right thoracotomy, complete dissection of both main bronchi and esophageal wall at the site of the leakage; 4) Harvesting of a pericardial vascularized graft; 5) Deployment of a self-expanding metallic stent from the surgical field into the right main stem bronchus; 6) Reconstruction of the right bronchus wall with the pericardial patch; 7) Positioning a T-tube in the esophageal leak; and 8) Intrathoracic transposition of the omental graft for buttressing all sutures and potential leakage points. The postoperative course was uneventful from a surgical point of view and the patient recovered completely. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction Benign broncho-esophageal fistulas are rare complications usually occurring in the cervical and high mediastinal segments, as protracted intubation is the most common etiology. The conservative management by stenting may be impossible due to the excessive length of the gap to be closed and insufficient sound tracts to ensure stability of the prosthesis, as in the case we are presenting. A 64-year-old woman was treated from February 2005 to December 2007 for pulmonary metastases from G3 endometrial carcinoma. In 2008, a CT-scan showed stable bilateral lung nodules, but enlarged lymphnodes in the right paratracheal and subcarinal stations. Chemotherapy was not considered anymore effective, and after bronchoscopic transbronchial needle aspiration (TBNA) of the enlarged nodes showed findings consistent with a sarcoid-like reaction, surgery was considered. As the coexistence of a sarcoid-like reaction with malignant features could not be excluded w1, 2x, surgical sampling of the enlarged nodes was planned as the first step, and easily carried out by a lateral thoracotomy, in the absence of any extranodal adhesion. Since intraoperative pathologic examination confirmed a nodal sarcoid-like reaction and ruled out malignancy, four laser right lung metastasectomies were performed in the same surgical session (definitive histology confirmed both preoperative diagnoses). *Corresponding author. Tel.: q390516478802; fax: q390516478209. E-mail address: (R. Trisolini). 2010 Published by European Association for Cardio-Thoracic Surgery After an uneventful course she was discharged, but readmitted 15 days after surgery due to intense cough following swallowing. As endoscopy documented a wide esophageal fistula opening into both the main right and left bronchi, we believed a conservative procedure would not be effective, and decided for emergency surgery. Stenting of the left bronchus through rigid bronchoscopy under general anesthesia with a 14=40 self-expanding metallic stent was performed as the first step to ventilate the patient without further damaging the bronchus with the tube cuff. A median laparotomy was carried out under general anesthesia using selective left intubation and the omentum was dissected free, vascularized on both gastroepiploic pedicles and left in a parahiatal position. Carina, main bronchi and esophagus were isolated through a posterolateral right thoracotomy and the tissues around the fistula were dissected to expose the gaps, which were 10 mm on the membranacea of the left main bronchus, 20 mm on the postero-lateral wall of the right main bronchus and 30 mm on the esophagus. Repair started by deploying from the operative field, a 14=40 self-expanding metallic stent into the right main bronchus. The insertion was difficult and the prosthesis unstable due to the short distal segment of the sound bronchus before the ostia of the middle lobe and Nelson bronchi. Therefore, the pericardium was dissected to obtain a pedicled 12 cm long and 2 cm wide strip. The graft was passed between aorta and superior vena cava, rolled around the right main stem bronchus and sutured to M. Boaron et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 156158 Fig. 1. (a) Anterior view; (b) Posterior view. The diagram shows the utilization of a pedicled pericardial patch in the repair of a wide gap in the wall of the right main stem bronchus. the edges of the gap by 4y0 reabsorbable single stitches. A Ch 18 silicon T-tube was inserted through the gap of the esophagus and stretched by a purse-string around the long branch which exited the chest laterally (Fig. 1). Opening the hiatus, the omentum was transposed into the chest and positioned to fill the esophago-carinal region, covering all severed tissues and paying particular attention to bringing a large amount of fatty tissue to the most critical areas. The omentum was also utilized to seal the long branch of the T-tube in contact with the pleura, avoiding the risk of intrapleural spilling. The postoperative course was complicated in the intensive care unit, one day after surgery, by respiratory failure due to nosocomial pneumonia, requiring reintubation, early tracheostomy and prolonged mechanical ventilation. Treatment with meropenem and ciprofloxacin was effective with both clinical and radiologic improvement, allowing weaning from respiratory support over an 11-day period. On the 18th day, following an esophageal transit check, the T-Tube was removed. The short branch was pulled out of the patients mouth with an esophagoscope, and cut away, the long branch was retracted through the chest wall with its tip close to the esophageal wall in order, ensuring drainage of the tiny residual fistula (Fig. 2). Within five days, the residual fistula disappeared, and both the long branch and pleural drain were removed. The patient began eating semi-solid food and, within two weeks, was discharged in good condition. Two months after surgery, her general condition was normal, the esophageal transit was regular. Six months after surgery, the bronchial nitinol stents were still in place and patent. 2. Discussion Based on the modality and timing of the occurrence of this bibronchial fistula, we believe the pathogenesis was a sublinical infection in the site of subcarinal dissection. Even if the perifistular tissues were not sampled, pathologic findings from preoperative TBNA and intraoperative nodal samples showed neither tub (...truncated)