Gastrobronchial fistula following minimally invasive esophagectomy for esophageal cancer in a patient with myotonic dystrophy: Case report

Silje Hugin; Egil Johnson; Hans-Olaf Johannessen; Bjørn Hofstad; Kjell Olafsen; Harald Mellem

doi:10.1016/j.ijscr.2015.10.023

Gastrobronchial fistula following minimally invasive esophagectomy for esophageal cancer in a patient with myotonic dystrophy: Case report

Int J Surg Case Rep. 2015:17:31-5. doi: 10.1016/j.ijscr.2015.10.023. Epub 2015 Oct 21.

Authors

Silje Hugin¹, Egil Johnson², Hans-Olaf Johannessen³, Bjørn Hofstad⁴, Kjell Olafsen⁵, Harald Mellem⁶

Affiliations

¹ Departments of Gastrointestinal Surgery, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway. Electronic address: silje.hugin@gmail.com.
² Departments of Gastrointestinal Surgery, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway. Electronic address: egil.johnson@medisin.uio.no.
³ Departments of Gastrointestinal Surgery, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway. Electronic address: uxhojo@ous-hf.no.
⁴ Departments of Gastroenterology, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway. Electronic address: uxbjho@ous-hf.no.
⁵ Departments of Intensive Care, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway. Electronic address: uxkjol@ous-hf.no.
⁶ Departments of Lung Medicine, Oso University Hospital, Ullevål, P. O. Box 4950 Nydalen, Oslo, Norway. Electronic address: uxhame@ous-hf.no.

Abstract

Introduction: Myotonic dystrophies are inherited multisystemic diseases characterized by musculopathy, cardiac arrythmias and cognitive disorders. These patients are at increased risk for fatal post-surgical complications from pulmonary hypoventilation. We present a case with myotonic dystrophy and esophageal cancer who had a minimally invasive esophagectomy complicated with gastrobronchial fistulisation.

Presentation of case: A 44-year-old male with myotonic dystrophy type 1 and esophageal cancer had a minimally invasive esophagectomy performed instead of open surgery in order to reduce the risk for pulmonary complications. At day 15 respiratory failure occurred from a gastrobronchial fistula between the right intermediary bronchus (defect 7-8mm) and the esophagogastric anastomosis (defect 10mm). In order to minimize large leakage of air into the gastric conduit the anastomosis was stented and ventilation maintained at low airway pressures. His general condition improved and allowed extubation at day 29 and stent removal at day 35. Bronchoscopy confirmed that the fistula was healed. The patient was discharged from hospital at day 37 without further complications.

Discussion: The fistula was probably caused by bronchial necrosis from thermal injury during close dissection using the Ligasure instrument. Fistula treatment by non-surgical intervention was considered safer than surgery which could be followed by potentially life-threatening respiratory complications. Indications for stenting of gastrobronchial fistulas will be discussed.

Conclusions: Minimally invasive esophagectomy was performed instead of open surgery in a myotonic dystrophy patient as these patients are particularly vulnerable to respiratory complications. Gastrobronchial fistula, a major complication, was safely treated by stenting and low airway pressure ventilation.

Keywords: Cancer; Esophagectomy; Fistula; Myotonic dystrophy.