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September 10, 2025

Surgical Repair of Tracheoesophageal Fistulas After Esophagectomy With Bovine Pericardium: Surgical Technique and Outcomes

Key Points

Tracheoesophageal fistula is a rare complication after esophagectomy, affecting 1.3% of patients studied.
Surgical repair with bovine pericardium patch was successful in maintaining digestive tract continuity across cases.
Patients undergoing repair exhibited high morbidity, with 67% suffering Clavien-Dindo grade IV complications during recovery.
Timely surgical intervention and careful perioperative management appeared to lead to favourable outcomes despite resource intensity.

Abstract

Abstract Background Tracheoesophageal fistula (TEF) is a rare but devastating complication after esophagectomy. The anatomical and physiological particularities of this complication as well as the nutritional and overall status of these patients make these cases extremely challenging to manage and there is no consensus treatment. This case series reflects on the experience of a high-volume academic center with a focus to identify approaches associated with successful repair. Methods Patients who underwent elective esophagectomy for cancer between 01/2014 and 01/2025 were identified from a prospectively collected database at a high-volume referral center. Data on demographics, comorbidities, surgical techniques, intra and postoperative complications, length of stay, and mortality were collected. Descriptive statistics were used to analyze patient characteristics and outcomes. Results Of 692 patients in the database, 9 developed post-operative TEF (1.3%). Mean age 70 years and median CCI 5 (IQR 5–6). Six patients (67%) underwent neoadjuvant therapy (chemoradiotherapy n = 4). Resection was minimally invasive in 5 cases (56%) with an intra-thoracic anastomosis in 6 (67%). Airway defect to right main bronchus in 6 cases (67%) and trachea in 3 (33%). Surgical repair of TEF was performed with a bovine pericardium patch in all cases. Median length of stay was 31 days (IQR 16–72). Clavien-Dindo grade IV morbidity occurred in 6 cases (67%) and in hospital mortality in 2 (22%). Conclusion TEF after esophagectomy is a rare but challenging complication that entails high degree of morbidity with reintervention and multi organ dysfunction. The preferred method of repair of the airway defect was the use of a bovine pericardial patch, buttressed with a muscle flap in most cases. Continuity of the upper digestive tract was maintained in all cases and intrahospital mortality was acceptable. TEF management was resource-intensive with prolonged length of hospital stays but favourable early outcomes were possible with a prompt and aggressive surgical approach and multidisciplinary perioperative care.

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