Carinal tracheo-oesophageal fistula repair using adjacent gastric conduit wall after Ivor–Lewis oesophagectomy: a case report

Neo-oesophagus–airway fistula after transthoracic oesophagectomy is rare but life-threatening. Standard therapeutic options, including stenting, primary repair with muscle or omental interposition, and diversion with delayed reconstruction, can be contraindicated in the context of sepsis and significant mediastinal contamination. We describe an emergency, staged approach employing the adjacent viable gastric conduit wall as a local flap to achieve closure of a carinal fistula in a hemodynamically unstable patient. A 75-year-old man with distal oesophageal squamous cell carcinoma underwent robotic Ivor–Lewis oesophagectomy following neoadjuvant chemoimmunotherapy in an institutional trial. Fifteen days post-operatively, he was readmitted with aspiration pneumonia, respiratory failure, and septic shock due to an intrathoracic anastomotic leak complicated by empyema and a tracheo-oesophageal fistula. The oesophagogastric anastomotic leak was located at the right apical intrathoracic anastomosis. Bronchoscopy demonstrated an airway defect at the carina approximately 4–5 cm from the intrathoracic anastomosis. Owing to the patient’s critical condition, elective airway planning and airway or oesophageal stenting were not feasible. Emergency surgery was undertaken using a staged approach. The first stage comprised pleural debridement and irrigation for empyema, complete diversion achieved by transection and closure of the oesophagus and gastric conduit both proximal and distal to the leak, and repair of the carinal defect. Following excision of approximately 2–3 mm of infected fistula margins, the defect was closed by suturing adjacent, well-perfused gastric conduit wall to the refreshed edges using interrupted 4 − 0 sutures. The second stage, performed after adequate infection control and nutritional and physical rehabilitation, involved retrosternal isoperistaltic colon interposition for definitive alimentary reconstruction. The patient recovered from staged procedures, resumed oral intake, and had no recurrent airway fistula on follow-up. In selected critically ill patients with post-oesophagectomy airway fistula complicated by severe pleural or mediastinal contamination, and in whom conventional flap options are constrained, the adjacent viable gastric conduit wall may represent a pragmatic option for urgent airway closure as part of a staged salvage approach.