One stage repair for an oesophageal fistula after pneumonectomy using an omental pedicle flap.

Abstract

ABTRACT A 67 year old man developed an oesophageal fistula after a pneumonectomy that was complicated by an empyema. An omental pedicle flap was brought through the diaphragm to repair the fistula and to fill the empyema space. The outcome was successful.An oesophageal fistula is a rare but serious complication of pneumonectomy. Almost all reports recommend operative intervention, including closure of the fistula; its reinforcement with a pleural or pedicle muscle flap; and obliteration of the empyema cavity. We have used an omental pedicle flap for treatment of the fistula. Case reportA 67 year old man with squamous cell carcinoma of the lung had a left pneumonectomy in December 1986. An empyema developed on the 13th postoperative day. After culture of the pleural fluid, which grew Staphylococcus aureus, Klebsiella oxytoca, and Serratia marcescens, pleural lavage and instillation ofappropriate antibiotics were started. After food debris was noted in the drained liquid on the 25th postoperative day an oesophageal fistula was confirmed by oesophagography (figure) and oesophagoscopy. Oral intake was stopped and nasoduodenal feeding using a DUO tube (Argyle) was instituted. Closed drainage, lavage of the empyema space, and oesophagoscopic application of fibrin glue all failed to close the fistula.In April 1987 direct closure was attempted. The suture line was reinforced with an omental pedicle flap that also ifiled the empyema space. Recovery was uneventful and the patient has been well for 10 months.Surgical technique The patient was placed in the decubitus position with the hips more or less horizontal. A posterolateral thoracotomy disclosed the empyema cavity, which was curetted and washed thoroughly. The peel around the oesophageal fistula was dissected carefully, and the fistula closed with 3-0 Vicryl in one layer. Laparotomy was then performed by a subcostal approach. The omentum was freed by dissection of the right gastro-

Oesophagopleural fistula after pneumonectomy: A systematic review and case series

“… 4 Reinforcement can include harvested pedicled muscle flaps, for example the intercostal bundle, or pleural flap; muscle flaps can also obliterate the cavity. 6 , 17 – 20 Thoracoplasty is a viable alternative to obliterate the empyema 2 , 17 , 21 , 22 space, but is frequently poorly tolerated and can result in chest wall deformity. 21 …”

Successful tubes treatment of esophageal fistula

“…Thoracoplasty, muscle flap repair of the esophagus, surgical stapler, intraluminal stents, tissue adhesive (fibrin glue, etc. ), and endoclips have seen successfully used by doctors (Siddiqui et al, 2007;Fernando and Benfield, 1996;Asaoka et al, 1988;Sethi and Takato, 1978;Adler et al, 2001;Agosti et al, 1978;Hu et al, 2004;Dosios et al, 2005;Marjolein and Peter, 2005;Eng et al, 1994;Solt et al, 1998;Kishi et al, 2005;Chryssostalis et al, 2005;Teitelbaum et al, 2005;Alberti and Alberti-Flor, 2005;Raymer et al, 2003;Okita et al, 2005;Truong et al, 2004;Talbot et al, 2007;Chappell and Heck, 2007;Gutiérrez San Román et al, 2006;Shichinohe et al, 2006;Rieder et al, 2006;Nguyen et al, 2006;Garand et al, 2006;Harries et al, 2004). The morbidity and mortality appear dramatically diminishing.…”

Postpneumonectomy esophageal fistula: a combined radiological-endoscopic technique

“…Once the empyema has resolved the esophagus requires repair (local recurrence of cancer has to be excluded in patients with malignancy). This is usually achieved with a one‐stage treatment that includes a thoracoplasty to obliterate the empyema and a muscle or omental flap to close the fistula 7 . Less frequently, in cases of intraoperative failure or significant comorbidity, a two‐stage approach may be required.…”