Perioperative veno-venous extracorporeal membrane oxygenation for facilitation of bronchogastric fistula repair following Ivor-Lewis oesophagectomy—case report

Abstract

Background: Bronchogastric fistulae are a devastating complication following oesophagectomy and despite their rare prevalence of 0.4–3.9%, can present significant morbidity and mortality. This case report presents a contribution that is first in the southern hemisphere, and only third in the world, of peri-operative veno-venous extra-corporeal membrane oxygenation was utilised for respiratory support in the repair of a bronchogastric fistula (BGF) following an Ivor-Lewis Oesophagectomy. The significance of this successful and relatively novel management of such a morbid complication is that it displays a significant, lifesaving methodology which could be replicated and become the status quo as extracorporeal membrane oxygenation (ECMO) becomes more ubiquitously available globally. Case Presentation: A 47-year-old male presented to the emergency department with dyspnoea progressing into rapid type-1 respiratory failure 13 days following an Ivor Lewis Oesophagectomy for oesophageal adenocarcinoma. Diagnosis of a BGF with bronchoscopy and gastroscopy was made and he was transferred to a quaternary centre for deterioration with adult respiratory distress syndrome (ARDS). Further deterioration following dual-lumen ventilation prompted the initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) and surgical management. A primary repair of the airway defect and oesophagus was made followed by an intercostal muscle flap. The patient was decannulated post-operative day 10 and discharged to rehabilitation day 40. He is engaging back to his daily activities 6 months following procedure. Conclusions: It is evident from this case that prompt transfer of a patient with a morbid complication such as a BGF to a larger centre with more specialised surgical and intensive care can be lifesaving, despite the inherent challenges of a relatively novel combined surgical/ECMO management confounded by the complications associated with a long intensive care unit (ICU) and inpatient stay. While there may never be effective studies performed to assess their feasibility, we have learned throughout the course of managing this case that the power and utility of ECMO in the management of BGFs cannot be denied, especially in quaternary centres where ECMO has become an integral part of intensive care.