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• W2921898916 abstract "We appreciate the insightful comments and questions by Bergeat and colleagues [1Bergeat D. Bertheuil N. Meunier B. The link between minimally invasive esophagectomy and tracheobronchial fistula occurrence (letter).Ann Thorac Surg. 2019; 108: 311Google Scholar] regarding our article [2Balakrishnan A. Tapias L. Wright C.D. et al.Surgical management of post-esophagectomy tracheo-bronchial-esophageal fistula.Ann Thorac Surg. 2018; 106: 1640-1646Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar]. Dr Bergeat’s group described an innovative technique using a pedicled intercostal myocutaneous flap to close postesophagectomy airway fistulas [3Bertheuil N. Cusumano C. Meal C. et al.Skin perforator flap pedicled by intercostal muscle for repair of a tracheobronchoesophageal fistula.Ann Thorac Surg. 2017; 103: E571-E573Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. In our own experience, most airway defects could be dealt with with a primary closure, and patch closure with biologic material was infrequent. We agree that segmental airway resection should be avoided after esophagectomy. Airway reconstruction in an infected field and the presence of airway inflammation is fraught; furthermore, the airway is relatively devascularized after esophageal mobilization. An intriguing question is whether esophageal diversion could be avoided by flap closure of an anastomotic or conduit defect. Our concern in patients with conduit necrosis or larger defects, as we have often observed, is whether a flap is effective in a local environment with extensive sepsis and tissue loss. Although intercostal myocutaneous flap preparation seems straightforward, the technique requires careful identification (with Doppler) and preservation of at least 2 perforators to perfuse the skin paddle. An intercostal muscle flap may become compromised during harvest and the tip of the flap is often underperfused [4Piwkowski C. Gabryel P. Gasiorowski L. et al.Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study.Eur J Cardiothorac Surg. 2013; 44: e77-e81Crossref PubMed Scopus (17) Google Scholar]; both would put the repair at risk. Finally, a high tracheoesophageal fistula approached in the neck, seen in half of our patients, does not lend itself to this technique. Nonetheless, our sense is that the intercostal myocutaneous flap is a valuable option for closure of a tracheoesophageal fistula. In our series, there was 1 patient with a very late tracheal fistula after an Ivor-Lewis esophagectomy caused by gastric staple line erosion. There are other reports, such as by Chen and coworkers, in which the gastric conduit rotated and the staple line along the lesser curve attached itself to the membranous wall of the trachea [5Chen Y.Y. Chang J.M. Lai W.W. Tracheo-neo-esophageal fistula caused by exposed metallic staples erosion.Ann Thorac Surg. 2012; 94: 1375Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. This small risk of delayed airway fistula may be mitigated by oversewing the conduit staple line. We suspect that the incidence of airway fistula is related more to anastomotic leak rate than surgical approach. A more robust lymphadenectomy [6Maruyama K. Motoyama S. Sato Y. et al.Tracheobronchial lesions following esophagectomy: erosions, ulcers, and fistulae, and the predictive value of lymph node-related factors.World J Surg. 2009; 33: 778-786Crossref PubMed Scopus (34) Google Scholar], longer-learning curve, and increased energy dissection in minimally invasive surgery might contribute. We support minimally invasive esophagectomy if anastomotic complications and fistulas are curtailed. Finally, there may not be an opportunity to optimize or defer management of patients presenting with early airway fistula, as significant mediastinal sepsis or conduit necrosis mandates emergent surgical intervention. The Link Between Minimally Invasive Esophagectomy and Tracheobronchial Fistula OccurrenceThe Annals of Thoracic SurgeryVol. 108Issue 1PreviewWe read with great interest the article on treating postesophagectomy tracheobronchial esophageal fistula (PETEF) surgical management in 11 patients [1]. This article highlights the difficulties of such management, reporting a 25% death rate and a 50% recurrence rate after salvage surgery. The authors performed primary membrane closure in 72.7% of patients. Unlike them, we use a flap to close the airway defect directly. We performed mostly a skin perforator flap pedicle by intercostal muscle [2]. Full-Text PDF" @default.
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• W2921898916 doi "https://doi.org/10.1016/j.athoracsur.2019.02.025" @default.
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