Technical Approach to Repair of Tracheogastric Conduit Fistula Following Minimally Invasive Esophagectomy: A Case Report

BACKGROUND Tracheogastric conduit fistula (TGCF) is a rare but life-threatening complication of esophagectomy, particularly in high-risk patients with comorbidities or prior chemoradiotherapy. It typically develops in the setting of anastomotic leakage, ischemia, or infection. There is no standardized treatment, and outcomes vary depending on timing and surgical approach. We report a delayed TGCF after thoracolaparoscopic esophagectomy and describe the operative technique and key perioperative considerations. CASE REPORT A 78-year-old man with diabetes, hypertension, and a heavy smoking history underwent thoracolaparoscopic esophagectomy for Siewert type I adenocarcinoma following neoadjuvant chemoradiotherapy. On postoperative day 54, persistent coughing prompted imaging and endoscopy, which revealed a tracheogastric fistula between the gastric conduit and posterior membranous trachea. Surgical repair was performed via right thoracotomy, involving debridement, closure of the gastric and tracheal defects, and interposition of a vascularized intercostal muscle flap. Reinforcement with fibrin sealant and a bovine pericardial patch was applied. Initial bronchoscopy confirmed airtight repair. However, the patient later developed recurrent pneumonia and septic shock, ultimately dying to multiorgan failure on postoperative day 108. CONCLUSIONS This case illustrates the complex management of TGCF and reinforces the value of early recognition and aggressive surgical intervention. Despite the fatal outcome, the absence of fistula recurrence confirmed the technical success and offers insight for managing similar high-risk cases. Intercostal muscle flap remains a reliable option for fistula closure in irradiated and infected fields. Meticulous surgical planning and perioperative management are essential for optimizing outcomes in this rare complication.