Abstract
Aim
We present a case of a 71 year old female with a combined anastomotic leakage after ivor-lewis resection and esophagotracheal perforation.
Background & Methods
Anastomotic leakage after esophageal resection is still associated with high morbidity and mortality throughout hospitalization. Nowadays there are several methods to accomplish sufficient closure of the anastomotic leakage such as clipping and using fibrin sealant in smaller leakages. Severe insufficiencies are commonly treated using esophageal stents. In our case the use of such a stent (10cm covered) placed to an anastomotic leak following esophagectomy with high intrathoracic anastomosis lead to an esophagotracheal fistula that was treated in a two-step approach. Firstly a tracheotomy was performed and the cuff of the tracheal cannula was blocked below the esophagotracheal fistula to prevent respiratory insufficiency. The stent was removed and an endosponge therapy was induced in order to manage the anastomotic leak. Finally, the semicircular wound could be covered by a fibrin sealant for final closure. In a second step, via open cervical surgery, the esophagotracheal fistula was resected, followed by overstitching of the pars membranacea and the esophagus and interposition of a muscle flap of the left pectoralis major muscle between trachea and esophagus.
Results
Postoperatively the patient was extubated with spontaneous breathing and the tracheal tube could be removed five days after surgery. After four days, the patient started drinking and enteral nutrition could be increased with a constant sufficiency of the gastric interponate. A postoperative contrast swallow at day 11 showed no leak and a good emptying of the gastric conduit. The control of the recurrent laryngeal nerves showed no abnormalities.
Conclusion
Our experience with endosponge treatment suggests that this is the first choice for successful healing of anastomotic leakage after ivor-lewis resection, especially in patients with a low BMI, to prevent esophageal stent perforations. Furthermore, the combination of an esophagotracheal fistula and an anastomotic leak does not have to result in a cervical outlet and removal of the gastric conduit. Patients should be delivered to specialized upper GI surgical centers, which have a high standard of complex esophageal surgery and endoscopic intervention possibilities.
Endoscopic injection of human fibrin sealant in treatment of intrathoracic anastomotic leakage after esophageal cancer surgery
