Benign Intrathoracic Fistula

Thyroid Factor

The Natural Thyroid Diet

Get Instant Access

Benign acquired fistula is not often seen in the thorax, but inflammatory diseases, including tuberculosis, histoplasmosis, and silicosis, produce tracheoesophageal fistulae just above the carina or broncho-

Trachea Cutaneous Fistula Device

figure 26-5 Closure of tracheoesophageal fistula in the absence of a circumferential tracheal lesion. A, A small fistula may be approached initially laterally at esophageal depth with the trachea drawn anteriorly. The left recurrent nerve can remain with the trachea, depending on the size and location of the fistula. The thyroid lobe may have to be elevated to provide access. Alternatively, it may sometimes be preferable to identify the tracheal wall and follow this plane carefully to the esophagus, displacing the undissected nerve laterally. A clear plan of approach is essential. Although tapes are shown encircling the trachea, circumferential tracheal dissection is not always necessary. The fistula is isolated. In reoperation after prior exploration, a bilateral approach may be preferable. B, Division of the fistula is made close to the esophagus to preserve enough tissue for easy closure of the membranous wall of trachea, where there is no excess of tissue. Closure is most often, although not necessarily, vertical, using interrupted 4-0 Vicryl sutures. The esophagus is repaired longitudinally in two layers, as previously described. A large posterior fistula is in some instances best managed by short tracheal segmental resection and esophageal closure.

figure 26-5 Closure of tracheoesophageal fistula in the absence of a circumferential tracheal lesion. A, A small fistula may be approached initially laterally at esophageal depth with the trachea drawn anteriorly. The left recurrent nerve can remain with the trachea, depending on the size and location of the fistula. The thyroid lobe may have to be elevated to provide access. Alternatively, it may sometimes be preferable to identify the tracheal wall and follow this plane carefully to the esophagus, displacing the undissected nerve laterally. A clear plan of approach is essential. Although tapes are shown encircling the trachea, circumferential tracheal dissection is not always necessary. The fistula is isolated. In reoperation after prior exploration, a bilateral approach may be preferable. B, Division of the fistula is made close to the esophagus to preserve enough tissue for easy closure of the membranous wall of trachea, where there is no excess of tissue. Closure is most often, although not necessarily, vertical, using interrupted 4-0 Vicryl sutures. The esophagus is repaired longitudinally in two layers, as previously described. A large posterior fistula is in some instances best managed by short tracheal segmental resection and esophageal closure.

esophageal fistula (see Figures 12-12, 12-13 in Chapter 12, "Acquired Tracheoesophageal and Broncho-esophageal Fistula"). If a fistula has been previously approached transthoracically with failure, it is usually better to reoperate transthoracically. Furthermore, with the diseases listed above, the dense scar that is likely to be encountered is best dealt with by this route, at a distal level through the wide exposure it offers. Post-traumatic fistula is discussed in Chapter 31, "Repair of Tracheobronchial Trauma."

Exposure is usually through a right thoracotomy, at the fourth interspace or fifth rib bed. A long, flexible single-lumen tube is placed with endoscopic guidance into the left main bronchus, permitting easier retraction and manipulation of the trachea and carina than does a double-lumen tube. If left thoracotomy is performed to deal with a left main bronchial fistula, the tube is positioned in the right main bronchus. A bronchial blocker may also be useful. High-frequency ventilation is not appropriate for esophageal fistula repair. The azygos vein is divided and the trachea dissected and retracted above the fistula. The esophagus is dissected and retracted above and below the fistula and the fistula isolated. The extent of bronchial and carinal dissection depends upon the unique pathology. The principles of fistula closure were outlined above, including preservation of sufficient tissue for closure of the membranous tracheal wall and a two-layer esophageal repair. The trachea is closed with interrupted 4-0 Vicryl sutures. Tracheal resection is unlikely to be necessary.

In these cases, I prefer to elevate a long posteriorly-based intercostal muscle pedicled flap as the thoracotomy incision is made (see Figure 31-6 in Chapter 31, "Repair of Tracheobronchial Trauma"). The flap is sutured in linear fashion over the esophageal closure, using multiple 4-0 silk or Vicryl mattress sutures, placed closely enough so that a complete tissue layer seal is obtained. The muscle will also lie against the membranous tracheal wall. Additional sutures may be placed from the trachea to the muscle flap, if thought to be necessary to secure the tracheal closure. In this situation, where the intercostal flap is used as an onlay buttress, and not circumferentially, it is not necessary to remove the costal periosteum from the flap. A circumferential wrap of intercostal muscle is avoided, since it can result later in an obstructive "grommet" of new bone formation from the attached periosteum. If there is any question about the integrity of the esophageal closure, it is tested by injecting a large volume of methylene blue-colored saline into the esophagus at the level of repair via a nasogastric tube prior to applying the intercostal muscle flap. The tracheal closure is tested by applying 30 cm of water ventilatory pressure through the endotracheal tube, with the cuff transiently deflated, while the hemithorax is filled with saline.

If prior irradiation is a factor, the pedicled omentum is advanced and wrapped around the esophagus and trachea and interposed between them to facilitate healing. The omentum may be prepared through an upper midline incision. If an omentum is likely to be needed, the patient should be positioned for lateral thoracotomy with hips slightly angled, so that abdominal access is facilitated (see Chapter 42, "The Omentum in Airway Surgery and Tracheal Reconstruction after Irradiation").

Was this article helpful?

0 0
Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

This guide will help millions of people understand this condition so that they can take control of their lives and make informed decisions. The ebook covers information on a vast number of different types of neuropathy. In addition, it will be a useful resource for their families, caregivers, and health care providers.

Get My Free Ebook


Post a comment