PD02.02. Management of Long-Segment Tracheo-Oesophageal Fistula by Oesophageal Isolation and Proximal Diversion Using a Tubularised Free Forearm Flap to the Pharynx

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Management of tracheo-oesophageal fistula (TOF) following oesophageal cancer treatment is complex and associated with substantial morbidity and mortality. Although palliative stenting is employed in active malignancy, persistent TOF represents a treatment-related complication and definitive surgical intervention is required to achieve durable airway–alimentary separation and restore long-term quality of life. We report the case of a 41-year-old man with proximal oesophageal squamous cell carcinoma located 16 cm from the incisors who developed a long-segment TOF following definitive chemoradiotherapy. He was treated with placement of a partially covered oesophageal stent; however, after 18 months he remained without evidence of disease, and the stent had become chronically embedded with significant tissue ingrowth, rendering endoscopic removal impossible. He continued to suffer from persistent fistulisation and aspiration risk despite conservative measures. Given the extent of the fistula, the chronic stent incorporation, and the failure of non-operative strategies, a staged surgical approach was undertaken with the goals of fistula isolation, stent removal, and creation of a proximal oesophageal diversion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was instituted and then a right thoracotomy through the seventh intercostal space was performed and a pedicled latissimus dorsi(LD) muscle flap harvested. The thoracic oesophagus was opened distal to the stent and removed under direct visualization. The oesophagus was divided at the level of the carina and then oversewn and buttressed with the LD flap, thereby excluding the TOF from gastrointestinal continuity and allowing the remnant esophagus to function as the back wall of the trachea. The proximal oesophagus was strictured closed at the level of the upper oesophageal sphincter from radiation and stent. To create a proximal diversion, a lateral pharyngotomy was created along the border of the thyroid ala, a tubularised free radial forearm flap with the skin forming the luminal surface, reinforced over a salivary stent, and exteriorized to the cervical skin was created to function as a controlled salivary conduit. A tracheostomy was placed for toileting. To prevent blowout of the distal oesophageal closure by positive pressure ventilation, the patient was left on VV-ECMO for 2.5 weeks until the patient could breathe without support. He was discharged home on G-tube feeds, breathing independently with his tracheostomy corked. The salivary stent was removed from the flap and tracheostomy decannulated subsequently. Substernal gastric tube to the forearm flap is planned for reconnection of his gastrointestinal tract.