The classification and treatment strategies of post-esophagectomy airway-gastric fistula

BACKGROUND: Airway-gastric fistulas (AGFs) are rare but life-threatening complications after esophagectomy for esophageal cancer. Their effective and reasonable management is challenging and still controversial. This study reports the classification and management strategies of post-esophagectomy AGF based on a retrospective analysis of 26 cases in two large volume centers in China. METHODS: Between January 2000 and December 2017, 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy. AGF was verified in 26 patients. The patients with AGF were divided into two types based on the anatomic characteristics of the fistula. Type I was characterized by the presence of fistula orifices in digestive tract that were higher than those in the airway and were treated with conservative management. Type II had both fistula orifices located on the same horizontal plane and were treated with surgical management. Pearson Chi-Square (R software) was used to compare mortality rates. RESULTS: From January 2000 and December 2017, 26 cases occurred AGF in 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy and the incidence of AGF was 0.4%. Ten of 12 patients with type I AGF survived. Nine of 14 patients with type II AGF died. There was a significantly difference in the mortality rates between patients with AGF type I and II, which was 16.7% (2/12) and 64.3% (9/14) (χ(2)=6.003, P=0.014), respectively. CONCLUSIONS: AGF may be classified into two types according to the anatomic characteristics. Type I patients may be cured by conservative management and type II patients, require surgical intervention with pedicled tissues flap wrapping of the airway.