Repair Of Refractory Gastrotracheal Fistula With A Pedicled Intercostal Perforator Flap After Thoracoscopic Esophagectomy For Esophageal Squamous Carcinoma

Objective This is to introduce the experience in the treatment of gastrotracheal fistula with severe respiratory failure?severe bilateral pneumonia and severe mediastinal infection early after thoracoscopic esophagectomy for esophageal squamous carcinoma by a pedicled intercostal myocutaneous flap.Methods On the 9th postoperative day an exploratory thoracotomy was performed.All necrotic tissues of the stomach including the anastomosis site were excised completely and a two-staged repair was arranged to restore the esophagogastic continuity.The gastrotracheal fistula was 13 mm long on the left side of thec membranous portion and associated with severe inflammation.A pedicled intercostal myocutaneous flap was developed in the seventh intercostal space.The size of the flap is 10 mm × 20 mm and the length of the muscular pedicle containing the 7th intercostal artery is 180 mm.The cutaneous part of the flap was sutured over the fistula orifice in the trachea and was covered by the muscular pedicle with the application of biological glue.Results The patient had to stay in the intensive care unit for 80 days due to severe respiratory distress ? severe bilateral pneumonia ? severe mediastinal infection?liver disfunction and renal failure.Bronchoscopy showed a new tracheal defect 3 mm long about 10 mm above the gastrotracheal fistula on day 4 postoperatively and total closure of the repaired tracheal defect with good vitality of the myocutaneous flap on the 6th postoperative day.The patient turned to intermittent mechanical ventilation after 18 days of persistent mechanical ventilation with the control of severe bilateral pneumonia?severe mediastinal infection.Control bronchoscopy on day 80 postoperatively showed complete epithelialization of the both tracheal defects.The patient was discharged from the hospital 3 month after treatment of the tracheoesophagogastric anastomosis fistula waiting for a second stage repair of the esophagogastic continuity restoration.Conclusion A pedicled intercostal myocutaneous flap,because of its rich blood supply and the long muscular pedicle,could be a good choice for closure of the gastrotracheal fistula early after thoracoscopic esophagectomy and prevention of recurrence of the fistula.