Tracheoesophageal fistula treated with esophageal exclusion and cervical esophago-gastric anastomosis via a retrosternal approach

To the editor: Tracheoesophageal fistula (TEF) is an abnormal connection between esophagus and trachea, is usually the sequela of trauma or esophageal cancer in adults. We reported a 38-year-old man who had a TEF after a traffic accident treated unsuccessfully by surgery and stenting. The man presented with coughing when taking food and water orally, after a traffic accident in May 2010. He was diagnosed with TEF in local hospital with a tear at the junction of main bronchi and left main bronchi (0.15 cm × 0.12 cm). He had coughing when taking water only after a right thoracotomy for TEF repair. A month later, he underwent gastrostomy at a local hospital because his coughing got worse and was given food and water by stomach fistula. In January 2011, upper gastrointestinal radiography revealed an unhealed TEF and then esophageal stenting was performed (Figure 1A). The following examination reported complete closure. In June and October 2011, his two upper gastrointestinal radiography examinations revealed an unhealed TEF. Esophageal stent was taken out (Figure 1B) for further surgical treatment. In November 2011, he referred to our hospital for esophageal exclusion and cervical esophagogastric anastomosis via a retrosternal approach (Figure 1D) under general anesthesia. The patient was placed in a 30-degree dorsal position. A left paramedian incision was made to expose and dissociate stomach and then close the stomach fistula. A left neck incision along sternocleidomastoid muscle was used to dissociate and cut esophagus. The sternum was separated with anterior mediastinum by using blunt dissection starting from abdomen. The stomach was pulled up to the neck via a retrosternal approach and anastomosed with esophagus by a linear circular stapler. A drainage tube was placed at the anastomotic stoma of left neck. A nasogastric tube was left for postoperative enteral nutrition. The patient had normal general condition and body temperature 1 day after surgery. Right moist rales and left rough breathing were reported. Bedside X ray showed a massive shadow at the middle lobe of right lung (Figure 1C). A bronchoscope was used to suck sputum. A big fistula at the junction of main bronchi and left main bronchi (1.8 cm × 1.8 cm) and purulent discharge were reported. Cefotiam (3.0 g, bid, ivgtt) was administered for 8 days. Sputum culture was negative. The patient was able to take water and food on days 8 and 9 after surgery respectively. Then nasogastric tube was removed. His follow-up was uneventful 4 months later. He enjoyed orally and his CT showed that pneumonia and pleural effusion disappeared without evidence of apparent secretions (Figure 1F).Figure 1. A:: The stent was implanted after the failure of first surgery repair. B: The stent was taken out when upper gastrointestinal radiography examinations revealed the fistula was unhealed. C: The shadow at the middle lobe of right lung the 1st day after operation. D: The schematic diagram of the approach. E: The CT scan taken in the 9th day after operation when the patient could intake water and food orally shows much effusion in his thoracic cavity. F: The CT scan taken 4 months after his operation shows more or less noting effusion in his thoracic cavity.Traumatic TEF is less common with few cases reported in the literature.1 TEF causes severe complications including aspiration pneumonia and limited food intake orally. There are many methods for treatment of TEF, such as stent implantation, surgical operation and subcutaneous somatostatin injection.2 Choosing a proper method is important for the patients and his quality of life. This patient is enjoying his life with a relatively higher quality of life. Esophageal exclusion and cervical esophago-gastric anastomosis via a retrosternal approach could be used for refractory TEF by gastrointestinal tract reconstruction and ultimately increase patients' quality of life with lower mortality.