Eur J Cardiothorac Surg 2003;24:463-465
© 2003 Elsevier Science NL
Plastic reconstruction of an extended corrosive injury of the posterior tracheal wall with an autologous esophageal patch
R. Pfitzmanna*,
D. Kaiserb,
H. Weidemanna,
P. Neuhausa
a Department of Surgery, Humboldt University Berlin, Charité, Campus Virchow-Clinic, Augustenburger Platz 1, 13353 Berlin, Germany
b Department of Thoracic Surgery, Zentralklinik Emil von Behring, Department of Lung Clinic Heckeshorn, Berlin, Germany
Received 27 January 2003;
received in revised form 7 May 2003;
accepted 12 May 2003.
* Corresponding author. Tel.: +49-30-450-552001; fax: +49-30-450-552900
e-mail: robert.pfitzmann{at}charite.de
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Abstract
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We report on a patient with an extended corrosive injury of the posterior tracheal wall and left-sided tracheo-esophageal fistula after severe inhalative trauma. Resection of the fistula and necrotic tissue was followed by reconstruction of the posterior tracheal wall with an esophageal patch. Interposition of the stomach was performed to restore upper gastro-intestinal continuity. Revision was necessary due to an anastomotic insufficiency and a recurrent fistula between the trachea and the esophago-gastrostomy on the left side. The stomach was resected and the fistula was covered with a sternocleidomastoideus muscle flap. Several weeks later interposition of the right hemicolon was performed to establish the gastro-intestinal tract and the patient recovered completely, thereafter.
Key Words: Tracheal corrosive injury/defect • Posterior wall • Plastic reconstruction • Esophageal patch
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1. Introduction
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Extended corrosive injuries of the posterior tracheal wall are rare and difficult to manage, especially in the presence of inflammation and necrosis of the wall. To date only few reports have been published on plastic reconstruction of tracheal defects or fistulas [1–9]. Most authors report about covering the defect with various isolated or pedicled muscle flaps, or reconstruction with either meshes or conduits, as well as epithelialized or autologous mucosa lined grafts. However, these techniques show limitations with regard to reconstruction of the posterior tracheal wall (pars membranacea). Especially extended defects require special surgical treatment. We report on the first case of an extended tracheal corrosive injury of the posterior wall and an additional left-sided tracheo-esophageal fistula after severe inhalative trauma, who underwent successful reconstruction of the tracheal corrosive injury with an autologous esophageal patch.
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2. Case report
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A 40-year-old alcohol dependant female was admitted to hospital in 02/2000 after severe inhalative trauma caused by hot fumes during a domestic fire. Subsequently she developed adult respiratory distress syndrome (ARDS), requiring long-term mechanical ventilation in 02/2000. After 5 weeks the patient was extubated, however, 4 days later, she was reintubated due to respiratory insufficiency and a tracheotomy had to be performed. At this time, CT scan and endoscopy revealed an extended tracheal corrosive injury of the whole posterior wall of approximately 8 cm length, reaching from 2.5 cm below the larynx to 1 cm above the tracheal bifurcation. In addition, a tracheo-esophageal fistula was found in the proximal third on the left side of the trachea. Six weeks after the initial trauma, the patient underwent stenting of the trachea (Polyflex® stent, Boston Scientific Comp., USA) and the esophagus (Ultraflex® stent, Boston Scientific Comp., USA) with coated stents (Fig. 1 ). Thereafter, the clinical course was complicated by recurrent pneumonia, sepsis and renal insufficiency requiring intensive care until 09/2000. After recovery she was transferred extubated to our clinic in 09/2000 for surgical reconstruction of the posterior tracheal wall. In the operation room both stents were removed and double tube intubation was performed. Then, ulcerated and necrotic areas of the inflamed posterior tracheal wall and the tracheo-esophageal fistula were resected through a combined cervical (along the right anterior margin of the sternocleidomastoideus muscle) and thoracic (median sternotomy) approach. After complete transverse separation of the esophagus 1 cm below the larynx and at the tracheal bifurcation a vertical incision in the middle of the anterior esophageal wall was performed. Then the extended corrosive injury was patched with the prepared esophagus with single-knot-sutures on both lateral walls of the trachea with Vicryl 3-0 with a length of about 8 cm. The upper gastro-intestinal continuity was restored simultaneously by interposition of the stomach with cervical anastomosis. Postoperatively mechanical ventilation was necessary for respiratory insufficiency. Three weeks after the initial operation revision became necessary for anastomotic insufficiency. Furthermore, the anastomotic insufficiency of the esophago-gastrostomy had induced a recurrent left-sided fistula (1 cm length) to the trachea. The stomach was removed and the fistula was covered by a pedicled left sternocleidomastoideus muscle flap. In addition, a salivary fistula drainage was constructed to the left side at the neck. A feeding tube was inserted simultaneously into the jejunum and a tracheotomy was performed again. After the second operation the patient recovered gradually, was extubated after 18 days and dismissed from our clinic after 1 month. In 03/2001, 3 months after an uneventful clinical course and recovery at home, restoration of the upper gastro-intestinal tract with interposition of the right hemicolon was performed. The postoperative course was again complicated. Weaning from mechanical ventilation was delayed for 1 month, again due to respiratory insufficiency, symptoms of alcohol withdrawal, poor compliance of the patient and recurrent pleural effusions requiring drainage on both sides. Endoscopy displayed no anastomotic insufficiency, recurrent fistula, tracheal defect or stenosis. The patient recovered completely and was discharged from hospital after 6 weeks. She died 3 weeks later. The reasons for her death are unknown, because autopsy was not performed. However, continuation of severe alcohol abuse was reported by family doctor and may have contributed to the lethal outcome.
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Fig. 1. CT scan of the extended tracheal corrosive injury of the posterior wall of the patient after stenting of the trachea (Polyflex®) and the esophagus (Ultraflex®) 6 months after initial trauma.
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3. Discussion
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Reconstruction of tracheal defects can be performed with allotransplant grafts [3,5], prosthetic replacements or conduits [1,7,8]. However, most studies have evaluated circumferential tracheal lesions. We report here about a female undergoing successful reconstruction of an extended corrosive injury of the posterior tracheal wall. So far, surgical reconstruction of this type of tracheal lesion has been evaluated only in one animal study [9]. This is the first report of a patient who underwent reconstruction of a corrosive injury of the posterior tracheal wall with his own esophagus. The use of autologous tissue such as the esophagus has several advantages: even extended defects or lesions can be covered. The operation can be performed via a common surgical approach. Furthermore the defect is covered with mucosa. In contrast, the use of muscle flaps is limited due to their shortness. The disadvantage of using the esophagus is the interruption of the gastro-intestinal continuity, requiring interposition of the stomach or colon. This can be performed simultaneously or during a second operation. In addition, muscle flaps lack a mucosal layer. Since our patient presented with an extended tracheal lesion of the posterior wall, reconstruction with a muscle flap seemed not possible. Furthermore, advanced muscular atrophy voted against the use of a muscle flap. Therefore the patient underwent surgical reconstruction of the tracheal lesion with her own esophagus. In order to avoid an additional operation, reconstruction of the upper gastro-intestinal continuity with interposition of the stomach was performed simultaneously. However, our observation of anastomotic insufficiency and recurrence of the fistula indicates that reconstruction of the gastro-intestinal continuity in a second operation may be safer in these patients. It is however still unclear whether the tracheal corrosive injury was caused by severe inhalative trauma or was the consequence of long-term mechanical ventilation in this patient.
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References
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Abstract
1. Introduction
