title: Tracheobronchial fistula during the perioperative period of esophagectomy for esophageal cancer.
abstract: BACKGROUND
  Tracheobronchial (TB) injury and fistula formation during the perioperative period of esophagectomy is a rare but life-threatening complication.
  
  
  METHODS
  We examined the development of intraoperative TB injury and postoperative TB fistulas in consecutive 763 patients with esophageal cancer who underwent esophagectomy, including 494 patients who underwent transthoracic subtotal esophagectomy.
  
  
  RESULTS
  TB injury and fistulas developed in two (0.4 %) and four patients (0.8 %), respectively, who received transthoracic esophagectomy. TB injury developed during the dissection of a tumor invading a major airway. Direct suturing of the laceration and covering it using a muscle flap was effective for one patient, while additional repair with a major pectoral muscle flap was needed in another patient. Postoperative TB fistulas developed due to peri-tracheal infection in two patients, and conservative treatment with drainage was performed. In another two patients, gastro-tracheal fistulas developed due to mechanical compression of staplers on the gastric tube, which was elevated via the posterior mediastinal route. The direct repair of the gastric tube and covering it with a major pectoral muscle flap resulted in the resolution of these fistulas.
  
  
  CONCLUSIONS
  Careful dissection with direct vision of the esophagus, as well as oversewing of the staplers on the gastric tube, is mandatory for preventing TB injury and fistula formation. Appropriate drainage is effective in cases with peri-tracheal abscesses. If the TB fistula fails to heal within a 4- to 6-week period, conservative management should be abandoned. Direct surgical intervention with coverage by a muscle flap is important for TB fistulas.
authors.affiliation: Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan, masarum@surg2.med.kyushu-u.ac.jp.
authors.forename: Masaru
authors.initials: M
authors.lastname: Morita
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Saeki
authors.forename: Tatsuro
authors.initials: T
authors.lastname: Okamoto
authors.forename: Eiji
authors.initials: E
authors.lastname: Oki
authors.forename: Sei
authors.initials: S
authors.lastname: Yoshida
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Maehara
mesh_terms: D000038:Abscess / Q000209:etiology*; D000368:Aged; D001980:Bronchi / Q000293:injuries; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects*; D005260:Female; D005402:Fistula / Q000209:etiology*; D005747:Gastric Fistula / Q000209:etiology*; D006801:Humans; D007431:Intraoperative Complications; D022125:Lacerations / Q000209:etiology / Q000601:surgery; D008297:Male; D008477:Mediastinal Diseases / Q000209:etiology*; D008875:Middle Aged; D059035:Perioperative Period; D016156:Respiratory Tract Fistula / Q000209:etiology*; D014132:Trachea / Q000293:injuries; D014133:Tracheal Diseases / Q000209:etiology*