Tracheal and left bronchial-oesophageal fistula repair and salvage 3-phase oesophagectomy supported by extra-corporeal membrane oxygenation: a case report

We present the first report of salvage oesophagectomy for complicated airway-oesophageal fistula disease supported by perioperative veno-venous extracorporeal membrane oxygenation (ECMO). A 47-year-old female underwent definitive chemoradiotherapy for a locally advanced T4N0M0 oesophageal squamous cell carcinoma. During treatment, worsening dysphagia was treated with an oesophageal stent. She then presented with dysphagia and pneumonia, and was referred to our unit with two airway-oesophageal fistulae secondary to oesophageal stent insertion. After ruling out local or systemic recurrence, the patient underwent salvage 3-phase oesophagectomy. Treatment was planned and performed by a multi-disciplinary team (MDT) of anaesthetists, intensivists, thoracic and oesophago-gastric surgeons. Total gas exchange was maintained using ECMO, allowing discontinuation of mechanical ventilation for right thoracotomy and repair of the trachea and left main bronchus with intercostal muscle flaps. Intestinal continuity was restored with a retrosternal gastric conduit. The patient was extubated on the day of surgery and was weaned off ECMO by postoperative day 6. Slow postoperative recovery was complicated by re-intubation for 4 days for respiratory failure. Oral intake improved after pyloric dilation and the patient was discharged on postoperative day 40. Histological examination confirmed no residual malignancy. At 20 weeks post discharge, the patient is eating a normal diet, her weight is stable, and she has returned to full-time work. Elective ECMO support may facilitate safe oesophagectomy in the presence of airway-oesophageal fistula in carefully selected patients.