Respiratory management and outcome of non-malignant tracheo-bronchial fistula following esophagectomy

Abstract

Tracheo-bronchial lesions with air leak are rare but a catastrophic complications of esophageal resections. We analyzed the management and outcome of 31 patients who developed a non-malignant lesion of the trachea or main stem bronchus after esophagectomy for esophageal cancer. All patients initially required endotracheal intubation to control respiratory distress. A modified respiratory therapy with a reduced tidal volume and high respiratory rate markedly decreased the air leakage from 2.8 to 1.1/min (P < 0.001). Early extubation was possible in 23 patients with a complete healing or decrease of the fistula size. Jet ventilation, endoluminal stenting of the fistula, bronchoscopic fibrin sealing of the fistula, and surgical closure of the fistula with a muscular pedicle flap were attempted with variable success in patients with otherwise not manageable air leaks. Ten of the 31 patients (33%) died during the postoperative course, in eight out of 10 patients, postoperative mortality resulted from an unhealed lesions at the bifurcation or in the left main stem bronchus. These data show that reduction of airway pressure and spontaneous breathing are the key to closure of the airway leak. The entire armamentarium of respiratory, bronchoscopic, and surgical techniques must be available for a successful management of these patients.