2020 FSA Posters

P058: DELAYED TRACHEOESOPHAGEAL FISTULA AFTER PENETRATING CHEST INJURY REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT
Jose Navas, MD; Philip Smith, MD; Alexander Fort, MD; University of Miami

Introduction: Penetrating thoracic injuries may lead to a constellation of injuries ranging from benign superficial wounds to aerodigestive injuries. Tracheoesophageal fistulae (TEF) may be attributed to iatrogenic, inflammatory, infectious and traumatic causes. The presentation is commonly delayed secondary to subacute necrosis of the devitalized tissue. Operative mortality of TEF is roughly 15% and the procedure is significantly more challenging when hypoxemia is present prior surgery as selective lung ventilation become crucial to facilitate surgical approach.

Case Report: 29-year-old patient presented to our facility after sustaining several gunshot wounds to his left back and neck. Imaging revealed multiple bullet fragments along the left 1st and 2nd thoracic vertebrae. The patient was endotracheally intubated on arrival due to confusion and agitation. Since scant bloody secretions were noticed from the endotracheal tube, the patient was taken to the operating room (OR). Esophagoscopy revealed a superficial lesion, 25 centimeters from the incisors, and bronchoscopy revealed a submucosal tracheal hematoma 2 centimeters from the carina. Computerized tomography of the chest did not to demonstrate any signs of mediastinitis and the patient was hemodynamically stable. On hospital day (HD) #4 the patient met extubation criteria and the endotracheal tube was subsequently removed. He initially tolerated extubation however three hours later developed increasing respiratory distress, persistent cough and hypoxemia requiring re-intubation. Bronchoscopy revealed a distal carinal mucosa injury with protrusion into the airway with positive pressure. Mucosal ulceration was noted in the region with presumed gastric secretions entering the airway through a small orifice. Gastric secretions were noted in the left middle and lower lobes. The patient had persistent hypoxemia with saturations in the low 90's on 100% fraction of inspired oxygen. The decision was made to return to the OR for exploration of the neck and chest with possible thoracotomy.

In the OR, a repeat esophagoscopy revealed a large lesion 25 centimeters from the incisors and bronchoscopy showed a moderate sized distal posterior tracheal defect. At this point, on anticipation of a right thoracotomy, both the trauma surgery and anesthesia teams decided that the patient would require right-sided lung isolation and given his level of hypoxemia would not likely tolerate selective lung ventilation; therefore, the decision was made to initiate bi-femoral VV-ECMO. Adequate flows were obtained and hypoxemia improved. A bronchial blocker was positioned for lung isolation and a right thoracotomy was performed. Both the tracheal and esophageal defects were primarily repaired and an intercostal flap was placed in between. The patient tolerated the procedure well and was admitted to the Intensive Care Unit. Daily bronchoscopy evaluations revealed an intact surgical repair. He was eventually decannulated from VV-ECMO on HD#13 and liberated from mechanical ventilation on HD#24. Follow up esophagograms were unremarkable and the patient was discharged home on HD#37.

Conclusion: The body of literature citing ECMO support as an adjunct for the management of a TEF is scarce. This case presents the successful management of a TEF with VV-ECMO support due to severe ARDS and assist with intraoperative one-lung ventilation.