Repair of a Bronchoesophageal Fistula Using a Pericardial U-Flap

Bronchoesophageal fistula (BEF) is a severe complication of esophagectomy and is burdened by high mortality rates, which has scarce reporting in the literature. These fistulas are usually the result of a prior leak from esophagogastric anastomosis. The etiology of a BEF after esophagectomy can be multifactorial. BEF occurrence can be further complicated by a history of esophageal malignancy, predisposing the patient to fistula formation. We present a 71-year-old male with a history of esophageal cancer, treated initially with neoadjuvant chemoradiation and an Ivor-Lewis esophagectomy five months later, discharged on post-operative day six, who had subsequent clinical symptoms, primarily respiratory in nature, two weeks later. Imaging and workup revealed a BEF. After the patient was admitted, he was taken to the operating room (OR) for initial lysis of adhesions and clearance of necrotic tissue and aspiration of secretions. For approximately the next month, every four to five days, he was taken back to the OR for endoluminal sponge vacuum-assisted closure (VAC) placement and replacement as well as additional therapeutic aspiration of secretions, which were often purulent. As the patient was critically ill, this was determined to be the best course of action in the initial stabilization of the BEF as a bridging measure until definitive surgical management could be intervened. This was done in order to promote initial healing of the fistula to optimize tissue for surgical treatment (i.e., supported by presence of granulation tissue). The patient recuperated between procedures in the intensive care unit (ICU). Ultimately, the patient underwent surgical repair and esophageal exclusion. The patient was discharged on post-operative day 60 after recovery and continues seeing his primary care physician and the surgical groups who managed his care to assess for changes in symptoms and follow-up imaging. This case conveys the urgency of diagnosing and treating a BEF, demonstrating improved outcomes when surgically managed in a timely manner.