Airway-Conduit Fistula postEsophagectomy: Bad Problem with Few Options Sudish C Murthy MD, PhD Staff Surgeon Department of Thoracic and Cardiovascular Surgery Cleveland Clinic [email protected] No relevant financial disclosures Periop Death Post-Esophagectomy • Aspiration/pneumonia • Trach/Abx/Cord Injection Periop Death Post-Esophagectomy • Aspiration/pneumonia • Trach/Abx/Cord Injection • MI • Cath Periop Death Post-Esophagectomy • Aspiration/pneumonia • Trach/Abx/Cord Injection • MI • Cath • PE/DVT • Anticoagulation Periop Death Post-Esophagectomy • Aspiration/pneumonia • Trach/Abx/Cord Injection • MI • Cath • PE/DVT • Anticoagulation • Chylothorax • TPN/emboliztion/reop Periop Death Post-Esophagectomy • Aspiration/pneumonia • Trach/Abx/Cord Injection • MI • Cath • PE/DVT • Anticoagulation • Chylothorax • TPN/emboliztion/reop • Conduit Leak/Fistula/Necrosis •? Leak: The Root of All Evils • Technical • • • • • • Stapler misfire Babcock trauma Too narrow a conduit Vascular compromise Tension Staple-on-staple • Radiation Effect • • Late Staple line erosion Leak: The Root of All Evils • Technical • • • • • • Stapler misfire Babcock trauma Too narrow a conduit Vascular compromise Tension Staple-on-staple • Radiation Effect • • Late Staple line erosion • It Just Happened •? Leak Prophylaxis… “Ounce of Prevention” Leak Prophylaxis… “Ounce of Prevention” …and Another Talk on LEAKS… Tips • Maintain Collaterals of the Conduit Tips • Maintain Collaterals of the Conduit • Soft Tissue Coverage of weak areas Tips • Maintain Collaterals of the Conduit • Soft Tissue Coverage of weak areas • Meticulous Cervical dissection Tips • Maintain Collaterals of the Conduit • Soft Tissue Coverage of weak areas • Meticulous Cervical dissection • Orient Staple Lines Tips • Maintain Collaterals of the Conduit • Soft Tissue Coverage of weak areas • Meticulous Cervical dissection • Orient Staple Lines • Imbricate Staple Lines Tips • Maintain Collaterals of the Conduit • Soft Tissue Coverage of weak areas • Meticulous Cervical dissection • Orient Staple Lines • Imbricate Staple Lines • Tension-Free Anastomosis Conduit Leak • Never underestimate the Impact!!! • High index of suspicion • Esophagram can be misleading • Presentation can be sudden/catastrophic • Early endoscopy is as valuable as barium study Case • 68 yo s/p IVOR-Lewis Esophagectomy • EEA Anastomosis • Leaking Bile from Chest tube on POD #2 • Leak into right chest on Swallow (? Two areas) • Transfer in “stable condition” the night of POD#3 (Friday) • O.R. within 8 hrs: Arrived in septic shock and profound hypoxemia Treatment Options • Sit and Suck (i.e Hope and Pray) • TPN/Octreotide • EGD/Stent + chest wash-out • Thoracotomy/Repair-T-Tube/Drain • Complete Diversion Treatment Options • Sit and Suck (i.e Hope and Pray) • TPN/Octreotide • EGD/Stent + chest wash-out • Thoracotomy/Repair-T-Tube/Drain • Complete Diversion Now, for the Harder Problem Mechanisms of Conduit-Airway Fistula • Poorly drained leak • Trach + leak • Thermal Airway injury during dissection • Erosion of Gastric staple line/Ulcer • OTHER TCF Dx • Aspiration • Aspiration pneumonia • Sepsis • Bilioptysis Boyd et al, J Bronchol Intervent Pulmonol, Vol. 19, Number 3, 2012 Reames et al, The Society of Thoracic Surgeons, 2013 Osaki et al, Ann Thorac Cardiovasc Surgery Vol. 14, No. 3 2008 Reames et al, Ann. Thorac Surgery, 2013 BMC Surgery 2009, 9:20 MARTY-ANE ET AL Ann Thorac Surg 1995;60:690-3 BMC Surgery 2009, 9:20 K. Kalmar et al. / European Journal of Cardio-thoracic Surgery 18 (2000) 363-365 Proximal & Distal Fistula Control Split the Airway to Ventilate and Divide the Fistula Close the Fistula Osaki et al, Ann Thorac Cardiovasc Surgery Vol. 14, No. 3 2008 Reames et al, Ann. Thorac Surgery, 2013 Life-Threatening TCF • Preserve THE AIRWAY!!! Life-Threatening TCF • Preserve THE AIRWAY!!! • Forget the Conduit Life-Threatening TCF • Preserve THE AIRWAY!!! • Forget the Conduit • SAVE THE PATIENT!!! Can the Patient be Stabilized? • Stents • NGT/G-TUBE • Abx • Correct hemodynamics if possible Now What? Intraop Considerations • Airway control is Difficult • Can’t ventilate • Abdominal distention • May extend fistula • Lung Isolation is Challenging Veno-Venous ECMO Circuit Intraop Considerations • If No Ecmo? • Permissive hypercapnea • Selective Intubation • Cross-Table Ventilation − Can extend the injury Intraop Considerations • Must Get proximal and distal to Fistula • Endoscope will help locate Conduit • Can imbricate fistula to patch Airway Management of the Airway Defect • Will need some type of Tissue transfer • Latissimus • Pericardium?/Omentum?/Intercostal? • Occasionally may be able to close Primarily • Biologic Matrices work well Airway Patch When primary closure/Resection not possible Decellularized Dermis is preferred over bovine pericardium Must sew to health membranous airway Reames et al, Ann. Thorac Surgery, 2013 Reames et al, Ann Thorac Surg, 2013 Bakhos et al. Ann Thorac Surg, 2010;90:e83–5 Get the Conduit Out of the Chest • Much easier following IVOR-LEWIS • Reduce into the abdomen/Drain • Proximal Esophagus to Left Neck • Debride/Decorticate the Chest • Buttress the Airway Periop Management • Trach/Bronch for Toilet • Separate from positive pressure ASAP • Recovery should be expected Live to Fight Another Day!
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