AB231. SOH21AS233. Total oesophagectomy and gastric pull-up as definitive management for a tracheo-oesophageal fistula following secondary puncture in an irradiated laryngectomee: a case report

Abstract: The use of a tracheo-oesophageal puncture (TEP) following total laryngectomy allows for speech rehabilitation and a huge improvement in quality of life for laryngectomees. However in the literature, tracheo-oesophageal fistula enlargement occurs in over 15% of cases, more commonly following primary TEP, which can lead to leakage of saliva, food contents and subsequent aspiration. We present the case of a 65-year-old male referred to a tertiary care centre for repair of a large tracheo-oesophageal fistula, following total laryngectomy and bilateral neck dissections with adjuvant radiotherapy 4 years prior. A secondary TEP led to a 2 cm × 1.5 cm fistula in the tracheo-oesophageal wall, causing recurrent aspiration pneumoniae. Initial management was a myogenous pectoralis rotational flap with three-layer closure. Post-op wound swabs confirmed MRSA, leading to extensive wound and flap breakdown, and ultimately the fistula enlarged to greater than prior. Definitively, a modified pharyngectomy, oesophagectomy & gastric pull-up with a pectoralis major myocutaneous flap was carried out. There were no intraoperative complications. Following formal swallow assessment with speech and language therapy on post-operative day 15, the patient was established on level 0 fluids and level 4 solids by day 18 and subsequently discharged home on day 36. This case demonstrates total oesophagectomy and gastric pull-up as successful definitive management for repair of a complex tracheo-oesophageal fistula in an irradiated patient. Coordination with Upper GI surgeons effectively led to optimal single institution management in this unique case.

Keywords: Gastric-pull up; laryngectomy; oesophagectomy; tracheo-oesophageal fistula; tracheo-oesophageal puncture