P1.250. Management of Long-Segment Tracheo-Esophageal Fistula by Esophageal Isolation and Proximal Diversion Using a Tubularized Free Forearm Flap to the Lateral Pharynx

Abstract

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Case Submission Management of tracheo-esophageal fistula (TEF) following esophageal cancer treatment is complex and associated with substantial morbidity and mortality. Although palliative stenting is frequently employed in the setting of active malignancy, it is a non-durable strategy in patients who achieve complete oncologic remission. In this population, persistent TEF represents a treatment-related complication and definitive surgical intervention is required to achieve durable airway–alimentary separation and restore long-term quality of life. We report the case of a 41-year-old man with proximal oesophageal squamous cell carcinoma located 16 cm from the incisors who developed a long-segment TOF following definitive chemoradiotherapy. He was treated with placement of a partially covered oesophageal stent; however, after 18 months he remained without evidence of disease, and the stent had become chronically embedded with significant tissue ingrowth, rendering endoscopic removal impossible. He continued to suffer from persistent fistulization and aspiration risk despite conservative measures. Given the extent of the fistula, the chronic stent incorporation, and the failure of non-operative strategies, a staged surgical approach was undertaken with the goals of fistula isolation, stent removal, and creation of a proximal esophageal diversion. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was instituted and then a right thoracotomy through the seventh intercostal space was performed and a pedicled latissimus dorsi muscle flap harvested. The thoracic oesophagus was opened distal to the stent and the stent removed under direct visualization. The oesophagus was then divided at the level of the carina and then oversewn and buttressed with the latissimus dorsi flap, thereby excluding the TOF from gastrointestinal continuity and allowing the remnant thoracic esophagus to function as the back wall of the trachea. The proximal end of the esophagus was strictured closed at the level of the upper esophageal sphincter from radiation and stent. To create a proximal diversion, a lateral pharyngotomy was created along the border of the thyroid ala, and a tubularized free radial forearm flap with the skin forming the luminal surface, reinforced over a salivary stent, and exteriorized to the cervical skin was created to function as a controlled salivary conduit. A tracheostomy was placed for toileting. To prevent blowout of the distal esophageal closure by positive pressure ventilation, the patient was left on VV-ECMO for 2.5 weeks until the patient could breathe without support. He was discharged home on G-tube feeds, breathing independently with his tracheostomy corked. Over the next months, the salivary stent was removed from the flap and tracheostomy decannulated. Substernal gastric tube to the forearm flap is planned for reconnection of his gastrointestinal tract.