Intra- and Extrathoracic Malignant Tracheoesophageal Fistula—A Differentiated Reconstructive Algorithm

Abstract

Background: Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients. Patients and methods: 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, n = 1), jejunum (n = 3) or combined ALT–jejunum flaps (n = 2). Results: Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF. Conclusion: TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.

Analysis of the Application Value of Different Esophagography Techniques in the Diagnosis of H-Type Tracheoesophageal Fistula in Neonates

“…The results were highly similar to the findings in the literature [ 20 ]. The TPR of esophagography, bronchoscopy, and multidetector row spiral CT in 10 cases of H-TEF were 83%, 72.1%, and 20.0%, respectively, which showed that the TPR of esophagography and bronchoscopy was relatively higher and most patients could be diagnosed through these two techniques [ 21 ].…”

Treatment of tracheoesophageal fistulas following laryngectomy by customized prostheses—A bicentric case series

“…Unfortunately, the majority of patients die from recurrent aspiration pneumonias in the long run. 24 Individual fistula prostheses represent an ultima ratio treatment option in difficult to treat TEF.…”

“…According to the presented data as well as clinical experience, these restrictions can last for months and years. Unfortunately, the majority of patients die from recurrent aspiration pneumonias in the long run 24 . Individual fistula prostheses represent an ultima ratio treatment option in difficult to treat TEF.…”

A case of advanced hypopharyngeal cervical esophageal cancer treated by curative resection with management of tracheoesophageal fistula

“…Although there are reports of improved survival [ 13 , 14 ], stenting remains a palliative treatment, and its disadvantages are the possibility of fistula enlargement and the difficulty of surgical manipulation due to stenting. Surgery may be an option, but most patients undergo esophageal bypass surgery [ 15 , 16 ] or muscle flap coverage [ 9 , 17 ] as palliative treatments. There are reports of two-step surgery for TEF caused by lung cancer [ 18 ] and TEF caused by malignant lymphoma that was closed after continued chemotherapy [ 19 ], but we were unable to find any reports of radical surgery for TEF caused by esophageal cancer.…”