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Tracheoplasty in a large tracheoesophageal fistula
Ann Thorac Surg 1999;68:1071–2
´ N ET AL CASE REPORT GALA TRACHEOPLASTY IN TRACHEOSOPHAGEAL FISTULA
1071
8. Hamaoka K, Onouchi Z, Ohmochi Y, Sakata K. Coronary arterial flow-velocity dynamics in children with angiographically normal coronary arteries. Circulation 1995;92:2457– 62.
Tracheoplasty in a Large Tracheoesophageal Fistula Genaro Gala´n, MD, Vicente Tarrazona, MD, Juan Soliveres, PhD, Victor Calvo, PhD, and Francisco Parı´s, MD Thoracic Surgery Unit and Anesthesiology Service, Clinic University Hospital, Valencia, Spain
Postintubation tracheoesophageal fistulas (TEFs) are severe lesions that can be associated with tracheal stenosis and therapeutic difficulties. A case is reported of a woman with TEF and postintubation tracheal stenosis with 6.5 cm of affected trachea, and total esophageal exclusion. A tracheoplasty method is described patching the loss of the tracheal membranous wall with the posterior esophageal wall. In a final step, a self-expanded tracheal stent and esophagocolic bypass were added. (Ann Thorac Surg 1999;68:1071–2) © 1999 by The Society of Thoracic Surgeons
T
racheoesophageal fistulas (TEFs) are mainly iatrogenic lesions produced by tracheal intubation. The lesion size determines the surgical technique and the final prognosis [1]. A single-stage repair is preferable in most situations, once the patient is weaned from mechanical ventilation (MV) [1– 4]. Most TEF may be resected through a low cervical incision, and a few by right lateral thorachotomy through the fourth interspace [1]. The simple division and direct closure of the fistula with a buttress of nearby healthy tissue is desirable in properly selected cases. When the fistula is associated with stenosis or if the defect of the membranous tracheal wall is excessive, a tracheal resection and reconstruction is needed with a simultaneous closure of the esophageal defect. Mathisen and associates [1] performed this technique in 76% of the patients, and Couraud and associates [4] in 30%. A 58-year-old woman needed MV during 25 days due to pneumonia after an aortocoronary bypass. She had problems swallowing after the extubation because of TEF. In the original hospital, a total esophageal exclusion was practiced with jejunostomy for feeding, and she was sent for final treatment. The bronchoscopy and computed tomography confirmed a TEF 4 cm in length, in the middle third of the trachea, with the disappearance of cartilage. In addition, there existed 2 cm of tracheal Accepted for publication Feb 5, 1999. Address reprint requests to Dr Gala´n, Unidad Cirugı´a Tora´cica, Hospital Clı´nico Universitario, Av Blasco Iban˜ez 17, 46010 Valencia, Spain.
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. A chest computed tomograph showed a very large tracheoesophageal fistula.
stenosis over and 0.5 cm under the fistula. In total, 6.5 cm was affected, with the remaining 5.5 cm of trachea healthy (Fig 1). In order not to remove so much trachea, we patched the loss of the tracheal membranous wall with the posterior esophageal wall. Through right thoracotomy, we performed resection of the lower esophagus up to the cardias. Simultaneously, by a low cervical incision, a resection of the upper esophagus was performed up to the cervical esophagostomy, and a resection of the upper tracheal stenosis with anastomosis at the second ring in a single layer of interrupted suture using polyglyconate. The tracheoplasty formed the lower posterior side of the anastomosis (Fig 2). The lower stenosis was respected, as it did not disturb the tracheal lumen. The tracheoplasty was protected with rib periosteum to give it consistence, as suggested by Padilla and associates [5]. We left a nasal intubation to shape the tracheoplasty. Ten days later, it had to be removed due to bad tolerance and an outbreak of malacia. After 30 days, a selfexpanded mesh tracheal stent, 14 mm in diameter and 6 cm long, was used (Vascular Wall-Stent; Schneider, Switzerland). The stent spread from 3 cm of the vocal cords to 2.5 cm of the carina, including the small lower stenosis. A latter presternal esophagocoloplasty restored digestive continuity, as there was a previous aortocoronary bypass. The final result was excellent after 2 years.
Comment The reconstruction of an extremely large TEF is problematic when the injured trachea exceeds the limits that can be safely resected. The resection of more than 60% of trachea must be avoided, because the tension of the suture does not allow a safe anastomosis [1, 2]. Some techniques limit the amount of trachea to be resected and allow reconstruction that otherwise might not be possible: (1) Fistulas that affect a large area in the tracheal 0003-4975/99/$20.00 PII S0003-4975(99)00660-8
1072
CASE REPORT MURRAY AND VLASNIK PROCAINAMIDE-INDUCED POSTOPERATIVE PYREXIA
Ann Thorac Surg 1999;68:1072– 4
An expandable tracheal stent was required to maintain a suitable tracheal lumen. Later on, there appeared some granulomas in the middle third, this leaving a 12-mm tracheal diameter. In summary, the tracheoplasty with posterior wall of the esophagus is a valid technique in very large fistulas, when there already exists a definitive esophageal exclusion. The self-expanding stent can be useful to treat an area of secondary tracheal malacia.
References
Fig 2. Diagram showing the patch of the fistula with the esophageal posterior wall. (A) Tracheal lesion consisting of a large fistula with two stenoses. (B) Esophagus section in the fistula: top and bottom sides. (C) Resection of the esophagus over and under the fistula, resection-reconstruction of upper tracheal stenosis, resecting the lower stenosis, and applying a tracheoplasty with the posterior esophageal wall.
membranous wall. Mathisen and associates [1] close the posterior defect tracheal longitudinally, borrowing some adjacent esophageal wall. Employed in 6 of 38 patients, they did well despite some narrowing of the trachea. Nevertheless, they presume that the cartilaginous trachea is healthy, and do not specify the size of the lesions nor long-term results. (2) Large fistulas with circumferential tracheal damage. Mathisen and associates [1] repair the fistula and buttress the closure with strap muscle. Employed in 1 of 38 patients, the airway needs to be maintained by a tracheal T tube, because of the extent of the injury in the patient’s airway. (3) Very wide TEF with complete destruction of the tracheal cartilages. Couraud performed a total esophageal exclusion in 2 patients, with jejunostomy feeding and posterior esophagocoloplasty [2, 4]. We carried out a posterolateral thoracotomy because the injury was 2.5 cm from the carina. This approach is seldom used by Mathisen and associates (in 4 of 38 patients) because of distal fistulas or previous failure in repairs done transthoracically [1]. The resection of the fistula and both stenoses would have forced us to remove at least 6.5 cm, that is, 57% of the trachea. Given that the amount of injured trachea was too big to allow reconstruction safely and that the esophagus exclusion was irreversible, we decided to perform a tracheoplasty with the posterior esophagus face at the level of the fistula. This tracheal patching is rarely employed, but has been described by Couraud and associates [4] in a patient with large TEF after chemotherapy for lymphoma, with good results after 3 years. Our patient developed a tracheoplasty malacia, as nasal intubation had to be interrupted. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759– 65. 2. Couraud L, Bercovici D, Zanotti L, Clerc P, Velly JF, Dubrez J. Traitment des fistules oesopago-tracheales de la reanimation. Experience de dis-sept cas. Ann Chir Thorac Cardio-Vasc 1989;43:677– 81. 3. Thomas AN. The diagnosis and treatment of tracheoesophageal fistula caused by cuffed tracheal tube. J Thorac Cardiovasc Surg 1973;65:612–9. 4. Couraud L, Ballester MJ, Delaic¸ment C. Acquired tracheoesophageal fistula and its management. Semin Thorac Cardiovasc Surg 1996;8:392–9. 5. Padilla J, Tarrazona V, Parı´s F. Comportement biologique et me´canique de greffons libre´s de perichondre et de perioste implante´s sur la paroi intestinal du chien. Ann Chir Thorac Cardiovasc 1981;35:643– 4.
Procainamide-Induced Postoperative Pyrexia Kevin D. Murray, MD, and Jon J. Vlasnik, PharmD Division of Cardiothoracic Surgery, Washington University School of Medicine, and Department of Pharmacology, Barnes-Jewish Hospital, St. Louis, Missouri
Procainamide is an effective antiarrhythmic that is often used to convert atrial fibrillation to normal sinus rhythm. A side effect of procainamide, rarely reported in the surgical literature, is pyrexia. The pyrexia is a manifestation of an allergic response to this medication. If unrecognized, procainamide-induced pyrexia can lead to unnecessary testing, hospitalization, and treatment. We present a case of a post-coronary artery bypass surgery patient who repeatedly displayed pyrexia when reexposed to procainamide indicating an allergic response to this drug. (Ann Thorac Surg 1999;68:1072– 4) © 1999 by The Society of Thoracic Surgeons
Accepted for publication Feb 13, 1999. Address reprint requests to Dr Murray, Division of Cardiothoracic Surgery, University of Nevada School of Medicine, 2040 W Charleston Blvd, Suite 601, Las Vegas, NV 89102; e-mail: [email protected].
0003-4975/99/$20.00 PII S0003-4975(99)00658-X
´ N ET AL CASE REPORT GALA TRACHEOPLASTY IN TRACHEOSOPHAGEAL FISTULA
1071
8. Hamaoka K, Onouchi Z, Ohmochi Y, Sakata K. Coronary arterial flow-velocity dynamics in children with angiographically normal coronary arteries. Circulation 1995;92:2457– 62.
Tracheoplasty in a Large Tracheoesophageal Fistula Genaro Gala´n, MD, Vicente Tarrazona, MD, Juan Soliveres, PhD, Victor Calvo, PhD, and Francisco Parı´s, MD Thoracic Surgery Unit and Anesthesiology Service, Clinic University Hospital, Valencia, Spain
Postintubation tracheoesophageal fistulas (TEFs) are severe lesions that can be associated with tracheal stenosis and therapeutic difficulties. A case is reported of a woman with TEF and postintubation tracheal stenosis with 6.5 cm of affected trachea, and total esophageal exclusion. A tracheoplasty method is described patching the loss of the tracheal membranous wall with the posterior esophageal wall. In a final step, a self-expanded tracheal stent and esophagocolic bypass were added. (Ann Thorac Surg 1999;68:1071–2) © 1999 by The Society of Thoracic Surgeons
T
racheoesophageal fistulas (TEFs) are mainly iatrogenic lesions produced by tracheal intubation. The lesion size determines the surgical technique and the final prognosis [1]. A single-stage repair is preferable in most situations, once the patient is weaned from mechanical ventilation (MV) [1– 4]. Most TEF may be resected through a low cervical incision, and a few by right lateral thorachotomy through the fourth interspace [1]. The simple division and direct closure of the fistula with a buttress of nearby healthy tissue is desirable in properly selected cases. When the fistula is associated with stenosis or if the defect of the membranous tracheal wall is excessive, a tracheal resection and reconstruction is needed with a simultaneous closure of the esophageal defect. Mathisen and associates [1] performed this technique in 76% of the patients, and Couraud and associates [4] in 30%. A 58-year-old woman needed MV during 25 days due to pneumonia after an aortocoronary bypass. She had problems swallowing after the extubation because of TEF. In the original hospital, a total esophageal exclusion was practiced with jejunostomy for feeding, and she was sent for final treatment. The bronchoscopy and computed tomography confirmed a TEF 4 cm in length, in the middle third of the trachea, with the disappearance of cartilage. In addition, there existed 2 cm of tracheal Accepted for publication Feb 5, 1999. Address reprint requests to Dr Gala´n, Unidad Cirugı´a Tora´cica, Hospital Clı´nico Universitario, Av Blasco Iban˜ez 17, 46010 Valencia, Spain.
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. A chest computed tomograph showed a very large tracheoesophageal fistula.
stenosis over and 0.5 cm under the fistula. In total, 6.5 cm was affected, with the remaining 5.5 cm of trachea healthy (Fig 1). In order not to remove so much trachea, we patched the loss of the tracheal membranous wall with the posterior esophageal wall. Through right thoracotomy, we performed resection of the lower esophagus up to the cardias. Simultaneously, by a low cervical incision, a resection of the upper esophagus was performed up to the cervical esophagostomy, and a resection of the upper tracheal stenosis with anastomosis at the second ring in a single layer of interrupted suture using polyglyconate. The tracheoplasty formed the lower posterior side of the anastomosis (Fig 2). The lower stenosis was respected, as it did not disturb the tracheal lumen. The tracheoplasty was protected with rib periosteum to give it consistence, as suggested by Padilla and associates [5]. We left a nasal intubation to shape the tracheoplasty. Ten days later, it had to be removed due to bad tolerance and an outbreak of malacia. After 30 days, a selfexpanded mesh tracheal stent, 14 mm in diameter and 6 cm long, was used (Vascular Wall-Stent; Schneider, Switzerland). The stent spread from 3 cm of the vocal cords to 2.5 cm of the carina, including the small lower stenosis. A latter presternal esophagocoloplasty restored digestive continuity, as there was a previous aortocoronary bypass. The final result was excellent after 2 years.
Comment The reconstruction of an extremely large TEF is problematic when the injured trachea exceeds the limits that can be safely resected. The resection of more than 60% of trachea must be avoided, because the tension of the suture does not allow a safe anastomosis [1, 2]. Some techniques limit the amount of trachea to be resected and allow reconstruction that otherwise might not be possible: (1) Fistulas that affect a large area in the tracheal 0003-4975/99/$20.00 PII S0003-4975(99)00660-8
1072
CASE REPORT MURRAY AND VLASNIK PROCAINAMIDE-INDUCED POSTOPERATIVE PYREXIA
Ann Thorac Surg 1999;68:1072– 4
An expandable tracheal stent was required to maintain a suitable tracheal lumen. Later on, there appeared some granulomas in the middle third, this leaving a 12-mm tracheal diameter. In summary, the tracheoplasty with posterior wall of the esophagus is a valid technique in very large fistulas, when there already exists a definitive esophageal exclusion. The self-expanding stent can be useful to treat an area of secondary tracheal malacia.
References
Fig 2. Diagram showing the patch of the fistula with the esophageal posterior wall. (A) Tracheal lesion consisting of a large fistula with two stenoses. (B) Esophagus section in the fistula: top and bottom sides. (C) Resection of the esophagus over and under the fistula, resection-reconstruction of upper tracheal stenosis, resecting the lower stenosis, and applying a tracheoplasty with the posterior esophageal wall.
membranous wall. Mathisen and associates [1] close the posterior defect tracheal longitudinally, borrowing some adjacent esophageal wall. Employed in 6 of 38 patients, they did well despite some narrowing of the trachea. Nevertheless, they presume that the cartilaginous trachea is healthy, and do not specify the size of the lesions nor long-term results. (2) Large fistulas with circumferential tracheal damage. Mathisen and associates [1] repair the fistula and buttress the closure with strap muscle. Employed in 1 of 38 patients, the airway needs to be maintained by a tracheal T tube, because of the extent of the injury in the patient’s airway. (3) Very wide TEF with complete destruction of the tracheal cartilages. Couraud performed a total esophageal exclusion in 2 patients, with jejunostomy feeding and posterior esophagocoloplasty [2, 4]. We carried out a posterolateral thoracotomy because the injury was 2.5 cm from the carina. This approach is seldom used by Mathisen and associates (in 4 of 38 patients) because of distal fistulas or previous failure in repairs done transthoracically [1]. The resection of the fistula and both stenoses would have forced us to remove at least 6.5 cm, that is, 57% of the trachea. Given that the amount of injured trachea was too big to allow reconstruction safely and that the esophagus exclusion was irreversible, we decided to perform a tracheoplasty with the posterior esophagus face at the level of the fistula. This tracheal patching is rarely employed, but has been described by Couraud and associates [4] in a patient with large TEF after chemotherapy for lymphoma, with good results after 3 years. Our patient developed a tracheoplasty malacia, as nasal intubation had to be interrupted. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759– 65. 2. Couraud L, Bercovici D, Zanotti L, Clerc P, Velly JF, Dubrez J. Traitment des fistules oesopago-tracheales de la reanimation. Experience de dis-sept cas. Ann Chir Thorac Cardio-Vasc 1989;43:677– 81. 3. Thomas AN. The diagnosis and treatment of tracheoesophageal fistula caused by cuffed tracheal tube. J Thorac Cardiovasc Surg 1973;65:612–9. 4. Couraud L, Ballester MJ, Delaic¸ment C. Acquired tracheoesophageal fistula and its management. Semin Thorac Cardiovasc Surg 1996;8:392–9. 5. Padilla J, Tarrazona V, Parı´s F. Comportement biologique et me´canique de greffons libre´s de perichondre et de perioste implante´s sur la paroi intestinal du chien. Ann Chir Thorac Cardiovasc 1981;35:643– 4.
Procainamide-Induced Postoperative Pyrexia Kevin D. Murray, MD, and Jon J. Vlasnik, PharmD Division of Cardiothoracic Surgery, Washington University School of Medicine, and Department of Pharmacology, Barnes-Jewish Hospital, St. Louis, Missouri
Procainamide is an effective antiarrhythmic that is often used to convert atrial fibrillation to normal sinus rhythm. A side effect of procainamide, rarely reported in the surgical literature, is pyrexia. The pyrexia is a manifestation of an allergic response to this medication. If unrecognized, procainamide-induced pyrexia can lead to unnecessary testing, hospitalization, and treatment. We present a case of a post-coronary artery bypass surgery patient who repeatedly displayed pyrexia when reexposed to procainamide indicating an allergic response to this drug. (Ann Thorac Surg 1999;68:1072– 4) © 1999 by The Society of Thoracic Surgeons
Accepted for publication Feb 13, 1999. Address reprint requests to Dr Murray, Division of Cardiothoracic Surgery, University of Nevada School of Medicine, 2040 W Charleston Blvd, Suite 601, Las Vegas, NV 89102; e-mail: [email protected].
0003-4975/99/$20.00 PII S0003-4975(99)00658-X