Eur J Cardiothorac Surg 2001;20:1025-1029
© 2001 Elsevier Science NL
Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae
V.V. Sokolov,
M.M. Bagirov
Kiev Clinical Hospital No. 17, Kiev, Ukraine
Received 19 February 2001;
received in revised form 29 June 2001;
accepted 8 August 2001.
Corresponding author. Laboratorniy Provoulok, 20 Kiev, 01133, Ukraine. Tel./fax: +380-44-269-2247
e-mail: clinic17{at}health.kiev.ua
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Abstract
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Objective: To evaluate surgical options of treatment in combined tracheo-esophageal injuries and their sequelae and elaborate new ones. Methods: The overlooked diagnosis of combined tracheo-esophageal injury would lead to severe stenosis of the esophagus and trachea with tracheo-esophageal fistula. This condition requires a complex surgical intervention to be performed with non-standard procedure in every single case. Forty patients with combined tracheo-esophageal injuries were treated in our institution. Nine patients were urgently operated while others were transferred to us from other hospitals with chronic sequelae of the initial trauma. Results: In the majority of cases the cause of the injury was penetrating (17 patients) or iatrogenic (13 patients) trauma followed by blunt neck and chest trauma (six patients) and caustic burn (four patients). Three patients had total cut off of the esophagus and trachea, which were repaired with end-to-end anastomoses. Another six patients had tracheal and esophageal disruptions within one-half to three-quarters of circumference. In these cases both the trachea and esophagus were mobilized within wall laceration and sutured by interrupted Vicryl® 4/0. One of them died due to pre-existing disease. Thirty-one patients with sequelae of the trauma were also operated on. In spite of the complexity and extent of the tracheo-esophageal stenosis and fistula the surgical treatment was aimed to one-stage reconstruction of both the esophagus and trachea. For this purpose we performed an originally developed surgical intervention, which was to be modified in accordance with patients diagnosis. The main point of the procedure is that after mobilization of the trachea and esophagus we resect an involved part of the trachea, but preserve a pedicled flap fashioned from the tracheal membrane. Then we remove the mucosa from the flap, resect an involved esophageal wall, repair esophageal mucosa and replace the defect of the muscular layer of the esophagus with the tracheal flap. Then a tracheal or laryngo-tracheal anastomosis is established. There were no postoperative mortality and complications among patients with the sequelae. Conclusion: Combined tracheo-esophageal injury requires the precise preoperative diagnosis and well organized plan of surgical treatment, which may be unique for every single patient. The main purpose of the treatment is to restore the continuity of both the esophagus and trachea in one-stage intervention.
Key Words: Trachea • Esophagus • Injury • Stenosis • Aerodigestive fistula
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1. Introduction
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Reconstructive procedures of combined tracheo-esophageal injuries and their sequelae represent a major challenge in general thoracic and trauma surgery. We found only three relatively major series published during last 15 years with total number of 82 patients treated [1–3] and some case studies [4,5]. It is easier to diagnose and repair this type of injury primarily than to treat late complications, combined stenosis of the trachea and esophagus with tracheoesophageal fistula. Development of surgical procedures in this type of injury has passed through several stages.- Tracheostomy and gastrostomy or reconstruction of one organ at a time, but stomy of the second one;
- Several stage reconstructions;
- One-stage reconstructions with restoration of continuity of both the trachea and esophagus (with closure of both stomas).
Bartlett in 1976 [7] proposed to mobilize the trachea and esophagus, resect the stenosis of the esophagus with esophagostomy and closure of the distal end. The resected part of the esophagus was used to repair the trachea with subsequent colon substitution of the esophagus. Gerhardt [8] closed tracheo-esophageal fistulas through the tracheal lumen by anterior tracheotomy. These procedures have significant shortcomings: a need for additional tracheotomy to close the fistula; non-complete reconstruction in cases when esophago-tracheal fistula is associated with tracheal and/or esophageal stenosis; high probability of subsequent tracheal stenosis in place of tracheal repair; need for esophago-coloplasty.
Surgical treatment of injuries of the trachea and esophagus soon after the trauma represented complication rate up to 74% [2]. Esophageal leaks, tracheo-esophageal fistulas and mediastinal abscesses were the most common. So, treatment details of this complex injury have to be refined.
We have reviewed the results of 40 such cases operated over a period of 15 years. Our group consisted of patients treated during the first hours after the trauma as well as of those with chronic sequelae of combined tracheo-esophageal injury overlooked at the initial presentation or treated improperly. This report provides an overview of one-stage surgical procedures and their technical details.
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2. Patients and methods
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2.1. Patient characteristics
This is a retrospective study of all patients who underwent surgical treatment of combined injuries of the trachea and esophagus and their sequelae in one institution from 1985 to 2000. Patient's characteristics are summarized in Table 1. The most common cause of injury was penetrating trauma (Table 2) followed by blunt trauma and tracheostomy. Prolonged tracheal intubation or tracheostomy tube may cause the pressure necrosis of the tracheal membrane and anterior esophageal wall with subsequent formation of the fistula.
Diagnostic follow-up of patients with injury of the trachea and esophagus is dependent on the mechanism and severity of trauma, associated life-threatening injuries and timing of patient presentation from trauma event. In acute cases we recognize stable and unstable patients. In stable patients and those with chronic sequelae standard radiographs of the chest, flexible endoscopy of the airways and esophagus followed by contrast studies of the esophagus with water-soluble contrast were performed. In unstable patients with respiratory failure and/or shock a patent airway and vascular access must be established rapidly, adequate ventilation ensured and medications administered as needed. Upon stabilization the injured patient was approach in the same manner as a stable one. Among total number of 40 patients with combined tracheo-esophageal injuries we urgently operated on nine patients. The others were operated in different institutions in the acute phase of injury (Table 3). All 31 patients developed postoperatively combined tracheo-esophageal stenosis with (23 patients) or without (five patients) tracheo-esophageal fistula or isolated esophageal or tracheal stenosis. These patients had elective surgery in our institution.
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Table 3. Surgical procedures in patients with chronic sequelae of combined injuries of the trachea and esophagus urgently done at the initial presentation in other institutions
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2.2. Anaesthetic technique
Anesthesia was maintained with the single lumen tube with short tube cuff. Anesthesia went through the sequence of four stages in dependence with the type of surgical intervention: (a) ventilation before mobilization and resection of the trachea and/or esophagus; (b) ventilation during tracheal resection; (c) ventilation while establishing the tracheal anastomosis; and (d) postoperative maintenance of the airways. In urgent repair of the trachea and esophagus or in closure of tracheo-esophageal fistula all stages of the procedure were done under single lumen tube anesthesia. In cases of circular resection of the trachea mediastinal shunt ventilation and/or high frequency jet ventilation were used during resection and reconstruction. When combined resection and reconstruction of the trachea and larynx was indicated, we completed operation with prolonged (3–7 days) naso-tracheal intubation. We do not advocate short-term tracheostomy after laryngo-tracheal reconstructions.
2.3. Surgical procedures
The choice of the incision was made on the basis of injury location. Longitudinal or U-shape cervical approach was employed in cervical and upper thoracic tracheo-esophageal wounds. An isolated injury at the level of the middle thoracic trachea was operated through the upper partial sternal split. A standard right posterolateral thoracotomy was done in the sequelae of the lower thoracic trachea. Cervical incision was employed in 27 cases accompanied by sternotomy in ten cases. Thoracotomy was made in three cases. Combination of cervical approach and laparotomy was used in one patient when colon substitution and repair of tracheo-esophageal fistula were needed. As a suture material we prefer Vicryl® or PDS® (3/0 or 4/0). Having used all types of the suture material in reconstructive surgery of the trachea during 30 years and evaluated healing of tracheal anastomosis we have come into conclusion that the ideal sutures for this purpose are monofilament slowly absorbable ones. These sutures preclude the development of local inflammatory response and subsequent growth of granulations and stenosis. All types of surgical procedures performed are presented in Table 4.
Among nine urgently operated patients, five patients had complete transection of the trachea in the laryngo-tracheal junction with fracture of cartilages and mucosal tears, combined in two cases with longitudinal esophageal rupture or complete esophageal cut off in three cases. In two cases associated injuries of internal jugular vein and internal carotid artery were identified and sutured. After debridement and repair of laryngeal mucosa we sutured esophageal tear or established end-to-end anastomosis in one layer with subsequent laryngo-tracheal anastomosis or tracheal repair to complete the procedure. Esophageal suture line was buttressed with sternocleidomastoid muscular flap to isolate it from the tracheal anastomosis.
Technical difficulties were encountered in surgery of traumatic sequelae. All the procedures were directed towards one stage restoration of the functioning of both the trachea and esophagus and, depending on the type of tracheal and esophageal involvement were individualized. For this purpose we have performed a new procedure in 12 patients (Fig. 1). The larynx and trachea are mobilized. The later is incised and cut off at the lower margin of the stenosis. Endotracheal tube is inserted into the distal portion of the trachea through the operative field and ventilation is ensured. The tracheal cartilages of the stenosis are resected upwards till a normal tracheal cartilage or the larynx so that the tracheal membrane remains in place. The mucosa of the membrane is excised and, by dissecting it from the anterior wall of the esophagus, we create a tracheal flap. Then the esophageal fistula is resected and the mucosa of the esophagus is mobilized and closed with interrupted sutures. The gap of the esophageal muscular layer created during resection of the fistula is replaced with the tracheal flap. The tightness of the esophageal suture line is confirmed with methylene blue solution injected into the naso-gastric tube to avoid undesirable leaks. Finally a laryngo-tracheal or tracheal anastomosis is established to complete the procedure.
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Fig. 1. One-stage procedure in combined stenosis of the trachea and esophagus (1). Circular resection of the trachea, closure of tracheo-esophageal fistula (2), reconstruction of the trachea and esophagus according to Avilova and Bagirov [17] (3).
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In eight patients we closed tracheo-esophageal fissure with repair of both organs. We used non-standard surgical treatment in 11 patients. Thus, in seven patients the repair of tracheo-esophageal fistula was combined with wedge (three patients) or circular (one patient) resection of the trachea, esophagus (one patient) or right main bronchus (one patient) with end-to-end anastomosis. All the patients had either naso-gastric or gastrostomy tube to bypass the fistula and provide their enteral feeding. Fortunately we did not observe gastro-esophgo-tracheal reflux in any patient. So esophageal exclusion or anti-reflux operation was not required. Retrosternal esophago-coloplasty was performed in one patient with subtotal benign stenosis of the esophagus as a result of caustic burn. Combined reconstructive procedures of the pharynx, trachea and esophagus were used in four patients.
2.4. Postoperative complications, results and mortality
Prevention of postoperative complications was aimed to provide free air passage through the airways, suction of the bronchial secretions and treatment of infection, so as all patients with tracheo-esophageal fistula had bronchitis due to long-term aspiration of the mouth content. We routinely use antibiotics during 7 or more days, when indicated. Thorough nursing care, early patients’ mobilization and physical therapy have provided uneventful postoperative course in the majority of patients.
Postoperative complications occurred in five cases. One urgently operated patient with stab wounds of the larynx, trachea, esophagus and chest developed chylothorax on 4th postoperative day. Left lateral thoracotomy was employed with ligation of the transected ductus thoracicus with complete recovery. One patient died having made up the total mortality rate of 2.5%. The female, suffered of schizophrenia, after repair of stab wounds of the esophagus and trachea had severe exacerbation of her co-morbid condition and pneumonia that was the cause of her death.
Complications also developed in three patients operated on with chronic sequelae: anastomosis insufficiency and mediastinitis in one, laryngeal dysfunction in one and non-sufficient restoration of the lumen of the upper airways in caustic stenosis in one patient. In the former two patients conservative management was successful so that they were discharged on 30th postoperative day without tracheostomy and gastrostomy. The later, 4-year-old boy had epiglottis insufficiency after repair of the trachea, pharynx, esophagus and epiglottis. We performed tracheostomy but esophageal continuity was completely restored. Complication rate was 12.5%.
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3. Discussion
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Combined tracheo-esophageal injuries and their sequelae is a rare condition in general thoracic and trauma surgery. The cause of the injury may be gunshot [1,9] or stab [10] wound, blunt chest trauma [4], fracture of the cervical vertebrae [6], foreign bodies of the esophagus [5] [11], combined therapy of thyroid cancer [12], inadvertent esophageal and tracheal perforation during emergency intubation [13], caustic burns and bouginage [14] and injury during neck surgery. Anterior location of the larynx and trachea predispose them to injury in blunt and penetrating trauma of the neck. This can be easily suspected due to rapidly expanding subcutaneous emphysema on the neck and voice tone changes. However, an esophageal tear would be overlooked due to the low index of suspicion. Major vessels surround cervical esophagus, so a surgeon pays much attention to them not to the esophagus. Missed esophageal tears rapidly leads to mediastinitis progression, septic multiple organ failure and ultimately death. The most dramatic and impressive type of injury is total transection of both the trachea and esophagus. We operated three such patients and found three more cases in the available literature [1,15]. The important point in treatment of total transection is to reveal the diagnosis on the basis of endoscopy and/or wound inspection before induction of general anesthesia. Surgeon must retrieve the distal end of the trachea in penetrating or blunt trauma under local anesthesia. After induction of general anesthesia, the anesthesiologist will be unable to pass the tube beyond the laceration into the distal portion of trachea because it contracts and goes down to the mediastinum. Circular tracheal and esophageal anastomosis end-to-end is a definite treatment in these cases.
In spite of the existing possibility for conservative management of penetrating injuries of the trachea or esophagus [16] we advocate active surgical approach in combined injuries to both organs. Missed or inappropriately treated combined injury may lead to devastating consequences. As a result, a combined stenosis of the trachea and esophagus with/without tracheo-esophageal fistula develops that makes patients lead ‘two-tube lifestyle’, tracheostomy and gastrostomy tubes. The limited number of the cases and varying expertise in surgical treatment of tracheal and esophageal diseases in different institution predispose these patients to several stages of reconstructive procedures. Treatment results in such circumstances are not always satisfactory. Our procedures proposed would have significant advantages and would be highly effective. These are one-stage procedures. Air passage through the larynx and trachea is restored completely. Uninvolved esophageal wall is preserved and the suture line is reinforced with simultaneous replacement of the muscular layer. So the usual food passage through the esophagus is also restored. During 10 days postoperatively patients receive enteral feeding through the naso-gastric tube. Integrity of the esophageal wall is then confirmed by contrast studies. In 38 out of 40 of our patients the surgical treatment according to the methods proposed was effective. Even in the patient who died postoperatively due to pneumonia we did not find insufficiency of tracheal or esophageal anastomoses at autopsy.
In conclusion, the surgery of combined tracheo-esophageal injuries require a surgeon to be experienced and skillful in treatment of both tracheal and esophageal diseases. Special anaesthetic techniques have to be used which is a prerequisite of a favorable outcome. In urgent situations attention should be paid to patient's ABC and stabilization of life-threatening injuries that are followed by repair of both the trachea and esophagus. In cases of combined stenosis of the trachea and esophagus with/without tracheo-esophageal fistula it is better to perform one-stage procedure, which restore patient's breathing and food intake per vias naturalis.
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Footnotes
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Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.
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Appendix A. Conference discussion
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Dr P. Macchiarini (Hannover, Germany): When you performed the circular tracheal and esophageal anastomosis, are you afraid about the fact that both anastomoses are at the same level?
Dr Sokolov: Certainly the esophageal anastomosis was isolated by sternocleidomastoid muscle in all cases.
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Abstract
1. Introduction
