A 74-year-old male has been intubated for respiratory failure developing two weeks after oesophagectomy for adenocarcinoma. He has no other significant past medical history.

After intubation, an audible air leak was apparent. Urgent bronchoscopy demonstrated a fistula between the proximal left main bronchus and the oesophago-gastric anastomosis.

Outline the principles and priorities in the management of this patient.
 

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College answer

Overall approach and perspective (2 marks) 2 = Clear understanding that:
This is a life-threatening complication requiring early expert assistance with surgical and anaesthetic support.
Priorities are stabilization and facilitation of urgent return to theatre for surgical repair +/- stenting. High mortality even with optimal treatment.

1= Mentions these elements but without clear understanding of urgency and/or need for definitive repair. i.e. unable to be confident that candidate would communicate and coordinate effectively.

Management of airway and ventilation

Airway (3 marks)
 
Articulates main principles to support oxygenation, minimise leak by minimising airway pressures and isolate lungs prior to surgical repair.

3= Outlines the need to isolate L and R lungs prior to surgical repair.
Demonstrates clear understanding of potential approaches and the need for expert skill and consideration of clinical stability e.g. size of leak/presence of complications etc.
e.g. Ultimately likely to need for R sided DLT to enable surgical repair if oxygenation stable and appropriate equipment available (bronchoscopy etc.), ideally in theatre with surgeon present to deal with potential complications.
May need to urgently selectively intubate RMB to manage massive leak in emergency setting especially if initial intubation was difficult.
High risk of pneumothorax and/or empyema requiring pleural drainage.

2= Principles and priorities safe but lacking finer detail or clinical perspective

1= Basic understanding or listing or options without guiding principles and clinical perspective. Not clear the candidate would safely manage themselves.

Ventilation (2 marks)

2= Ventilatory strategy should include aiming for spontaneous ventilation if possible and techniques for minimizing airway pressures (e.g. low/no PEEP).
Need to consider/monitoring for likely respiratory complications (pneumothorax, hydro-pneumothorax, empyema).
1= mentions only one of clear ventilatory strategy  or knowledge of complications.    Alternatively, superficial comment on both.

Sepsis (1 mark)

1= Mentions likely complications of pneumonia, empyema and subsequent systemic sepsis. Need for cultures (esp. blood, bronch specimens) and appropriate broad-spectrum antibiotics. (half mark if one element missing)

Supportive Care (2 marks)
2= sensible concise priorities for supportive care and clear mentions need to communicate with and offer support to family.
e.g.
Haemodynamics - large bore IV access, art-line, CVC if time allows. Planning for potential need for vasopressors.
Cease feeding, NG on free drainage if present to minimise gastric dilation and/or contamination of lung via fistula.
Elevate bed
Communication with family early to inform and prepare for potential poor outcome and provide support as required.

1= some sensible elements but lacking clinical perspective or failure to mention family communication.

Discussion

Management priorities:

  1. Stabilise the patient (control ABCD)
  2. Organise definitive management, which will be surgical, bronchoscopic or endoscopic
  3. Prepare the family for the worse

As usual, the management can be divided into "supportive" and "specific".

Supportive management:

  • Airway management:
    • Intubate the patient with a right-sided  double lumen tube
    • Ideally do this in theatre, with an upper GI and thoracic surgen present. The risk here is that potentially, you will place the tube in such a violently stupid way that the bronchio-oesophageal tear is extended. The  consequence may be massive pneumomediastinum and an unventilatable patient with rapidly falling blood pressure due to greater vessel compression. 
  • Ventilator management
    • With a single lumen tube:
      • Account for large leak: use a pressure-control mode
    • With a double lumen tube:
      • Use differential lung ventilation
      • Ventilate the "good" lung with normal one-lung ventilation
      • Ventilate the "bad" lung with some modest  PEEP (~ 5-8) and zero inspiratory pressure (i.e. CPAP)
  • Sedation and analgesia
    • ​​​​With a double lumen tube, ideally the patient should be paralysed and sedated to prevent tube dislodgement and to facilitate differential lung ventilation
    • With a single lumen tube, spontaneous respiratory activity should be encouraged and sedation should be minimised
  • Gastrointestinal/nutritional management:
    • If this is feasible,place an NGT endoscopically and allow it to vent freely or place it on low wall suction
    • Most likely, this is not feasible, and the whole anastomotic site should be left well alone  
    • Feed the patient parenterally 
    • Use liberal PPI  therapy (perhaps an infusion of pantoprazole)
  • Management of infection
    • One can almost guarrantee that some infectious process will take place, 
      • in the lung (aspirtation)
      • in the chest cavity (collection)
      • in the abdominal cavity
    • Thus, empiric antibiotics should probably be commenced, and these should ideally be broad enough to cover upper GI anaerobes. You can always stop them again in a couple of days, when the antimicrobial stewardship people start mocking you openly in the corridors.
  • Management of family expectations
    • The outcome for these scenarios is almost uniformly bad, particularrly wherre a malignancy is involved

Specific management resembles the oesophageal perforation options mentioned above, with the exception of all the bronchoscopic stuff:

  • Bronchoscopic repair
    • Bronchial stent
  • Gastroscopic repair options
    • self-expanding esophageal stainless steel-covered metal stents (SEM)
  • Surgical repair options
    • Resection and diversion (i.e. oesophagus is externalised in the neck; one essentially disconnects the upper GI tract from the lower)
    • Resection and re-anastomosis (the latter is risky)
    • Conservative management (i.e. after having a look and the placement of a NG tube, the patient returns to ICU for conservative and palliative management)


 

References

References

Hasan, Shafqat, Ali NA Jilaihawi, and Dhruva Prakash. "Conservative management of iatrogenic oesophageal perforations—a viable option." European journal of cardio-thoracic surgery 28.1 (2005): 7-10.

Biancari, F., et al. "Treatment of esophageal perforation in octogenarians: a multicenter study." Diseases of the Esophagus 27.8 (2014): 715-718.

Spalding, Alanson R., Donald P. Burney, and Robert E. Richie. "Acquired benign bronchoesophageal fistulas in the adult." The Annals of thoracic surgery 28.4 (1979): 378-383.

Kalmár, Katalin, et al. "Non-malignant tracheo-gastric fistula following esophagectomy for cancer." European journal of cardio-thoracic surgery 18.3 (2000): 363-365.

Lolley, David M., et al. "Management of malignant esophagorespiratory fistula.The Annals of thoracic surgery 25.6 (1978): 516-520.

Shamji, Farid M., and Richard Inculet. "Management of malignant tracheoesophageal fistula." Thoracic surgery clinics 28.3 (2018): 393-402.