Abstract Introduction Tracheoesophageal fistula (TEF) is a pathological connection between trachea and esophagus which can be congenital or acquired in the setting of post intubation injury, malignancy, trauma, or post-operative complications. Diagnosis relies on imaging (chest CT, barium swallow, esophagram) and is confirmed by endoscopic and bronchoscopic evaluation, which is the gold standard. Management centers on stabilizing the patient, preventing aspiration, and definitive surgical repair tailored to fistula type, size, and etiology. Complications include recurrent nerve palsy, tracheal stenosis, and fistula recurrence. Here we present a complex case of iatrogenic TEF with a multidisciplinary approach to management in a critically ill patient. Case A 65-year-old male with history of esophageal adenocarcinoma post neoadjuvant chemotherapy underwent an uncomplicated Ivor Lewis esophagectomy with pyloroplasty. He underwent a routine upper GI on POD 6 showing no evidence of anastomotic leak. On POD 8 he suffered PEA arrest and was intubated. CT chest imaging was concerning for anastomotic dehiscence and TEF (Fig 1a,b). He was taken emergently for thoracic exploration. The proximal gastric conduit was found to be necrotic with significant hematoma and anastomotic dehiscence. The anastomosis was resected and the viable stomach returned to the abdomen. A 2 cm rent was visualized in the trachea just above the carina, which was temporized with a biologic mesh patch. Bilateral chest tubes were placed and a gastrostomy placed within the remnant stomach for enteral access. His right sided chest tube had persistent continuous airleak and interventional pulmonology was involved in care. He underwent rigid bronchoscopy with visualization of 2 cm distal TEF (Fig 1c) and 18 x 60 mm self-expanding metal Y-stent was deployed successfully to cover TEF (Fig 1d). Discussion Both open and thoracoscopic approaches to repair of TEFs remain safe and effective for acquired TEF in adults, with high success rates for fistula closure and restoration of oral intake and respiration. Minimally invasive techniques are less commonly reported but may be feasible in select cases, especially for recurrent or complex fistulae, with comparable safety and efficacy when performed by experienced teams. Here we present a challenging TEF case in a critically ill patient that highlights the importance of a multidisciplinary approach to complex TEF management. This abstract is funded by: N/A
Hoytfox et al. (Fri,) studied this question.