Salvage repair with esophagus-conduit segment in situ as a neo-posterior tracheal wall for multiple tracheoesophageal and trachea-conduit fistulas: a case report

Salvage repair with esophagus-conduit segment in situ as a neo-posterior tracheal wall for multiple tracheoesophageal and trachea-conduit fistulas: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Salvage repair with esophagus-conduit segment in situ as a neo-posterior tracheal wall for multiple tracheoesophageal and trachea-conduit fistulas: a case report Ying Jie Cui, Hyunjin Cho This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7791241/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Tracheoesophageal fistula (TEF) and trachea–conduit fistula (TCF) after esophagectomy are rare, life-threatening complications that may follow repeated endoscopic interventions and stent placement. When fistulas are large or multiple, conventional resection and tracheal reconstruction can be prohibitive. We report a salvage repair using an esophagus–conduit segment left in situ as a neo-posterior tracheal wall. Case: A 70-year-old man developed an anastomotic stricture after Ivor–Lewis esophagectomy for squamous cell carcinoma, treated with serial balloon dilatations and covered stenting. Progressive tissue injury led to a TCF and subsequently two additional large TEFs above the stent flares. Operative strategy included stent removal, takedown of distal conduit, closure of proximal conduit, creation of a substernal colon conduit, cervical division of proximal esophagus, and esophagocolostomy; the esophagus–proximal gastric conduit segment containing the fistulas was preserved in situ against the membranous trachea to function as a neo-posterior wall. Oral intake resumed after an esophagogram on postoperative day (POD) 6; bronchoscopy on POD 7 confirmed a well-perfused blind esophageal pouch. The patient was discharged on POD 24. He later died five months postoperatively from oncologic progression unrelated to airway–alimentary separation. Conclusions In selected patients with extensive, multifocal TEF/TCF, preserving an esophagus conduit segment in situ can achieve durable separation of airway and alimentary tract while avoiding extensive resection through densely adherent, inflamed fields. This technically demanding approach is a feasible salvage option when standard reconstruction carries excessive risk. esophagus salvage repair tracheoesophageal fistula tracheo-conduit fistula Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Post-esophagectomy anastomotic stricture occurs in up to 30% of patients is a common complication, often managed with endoscopic balloon dilatation (EBD) or endoscopic stent placement. 1 However, repeated instrumentation, mechanical trauma from stent flares, ischemic injury, and radiotherapy predispose patients to the development of tracheoesophageal fistula (TEF) or tracheo-conduit fistula (TCF). 2 Large or multiple TEFs and TCFs are particularly challenging, often necessitating complex reconstructive strategies when the trachea defect is extensive. Herein, we present a unique case of large, multiple TEFs that developed after repeated balloon dilatations and esophageal stent placements for post-esophagectomy stricture, which were managed with salvage repair using the esophageal segment in situ technique and esophagocolojejunostomy. Written informed consent for publication was obtained from the patient; IRB approval was not required. Case Presentation A 70-year-old male with a history of Ivor–Lewis esophagectomy for esophageal squamous cell carcinoma (pT2N1M0) presented four months later with progressive dysphagia. Esophagogram and endoscopy demonstrated an anastomotic stricture (Fig. 1 A and B), managed with multiple EBD sessions at two-week intervals. One month later, the patient developed severe cough and dysphagia. Chest CT, esophagogram and bronchoscopy subsequently confirmed a TCF with aspiration pneumonia (Fig. 1 C-E). He initially refused surgery and underwent covered esophageal stent placement. The TCF did not improve following stent placement. The patient later received concurrent chemoradiation for nodal recurrence. Four months later, a new TEF developed above the upper flare of the stent(Fig. 2 A and B), necessitating the placement of additional stent. The additional stent was located inside the previous stent and proximal flare of the inner stent was covered a new TEF(Fig. 2 C). Four months later, the patient’s symptoms worsened, and chest CT with bronchoscopy revealed another large TEF above the upper flare of the inner stent(Fig. 3 ), ultimately necessitating surgical intervention. Salvage reconstruction was performed using the esophageal segment and proximal gastric conduit containing TEFs and TCF, in situ against the membranous portion of the trachea(Fig. 4 A). The surgical procedure was as follows. First, the previously placed stents were removed, followed by dissection to the level below the most distal fistula, after which the distal conduit was taken down. (Fig. 4 B and C). The proximal conduit was closed with a continuous suture using 3 − 0 Prolene approximately 2 cm above the carina. Next, the mid-to-transverse colon, based on the mid-colic artery as the feeding vessel, was prepared as a conduit. The esophagus was approached through a left cervical incision. Using a stapler, the proximal esophagus was divided above the most proximal fistula, thereby creating a blind pouch without disturbing the esophageal segment and the proximal gastric conduit that contained the TEFs and TCF. Reconstruction was performed with an esophagocolostomy using a 25-mm circular stapler, anastomosing the proximal esophagus to the colon conduit, which was brought up through the substernal route. The patient resumed oral intake with supplemental jejunostomy feeding after an esophagogram on POD 6. Bronchoscopy on POD 7 demonstrated that the esophageal segment was well maintained as a blind pouch with a fresh color appearance(Fig. 5 ). The patient was discharged on POD 24 but ultimately died five months later due to progression of esophageal cancer. Discussion TEF or TCF after esophagectomy is rare but potentially fatal. Esophageal stents may offer temporary relief, but risks such as migration, mechanical trauma, and secondary infection can exacerbate tissue injury. In this case, repeated metallic stent placement and local inflammation likely contributed to progressive tissue destruction and multiple fistula formation. Large or persistent fistulas usually require surgery, and recent studies suggest better survival with surgical repair of TEF or TCF compared with non-surgical management. 3 Definitive surgery for TEF or TCF usually requires resection of the esophagus and gastric conduit with tracheal repair, but these procedures are invasive, technically demanding, and carry high morbidity. When fistulas are extensive, tracheal reconstruction is particularly difficult. In our case, multiple TEFs involved nearly half of the trachea. We therefore performed a salvage repair using the esophagus in situ as the posterior tracheal wall, which avoided extensive resection and dissecting the fistulous area with dense adhesion, and achieved functional separation of the airway and alimentary tract. The gastric conduit in this case had already lost its distal portion, and major feeding vessel, the left gastroepiploic artery, had been sacrificed. This raised concern regarding the adequacy of perfusion to the remaining proximal gastric conduit. In our procedure, we first resected the distal conduit and the feeding artery, removed the esophageal stent, and then dissected the conduit up to the fistulous area to assess mucosal bleeding. After confirming that the mucosa was adequately perfused, we proceeded to repair the remaining proximal gastric conduit. Postoperative imaging showed the esophageal segment left in situ remained intact without ischemia, likely supported by inflammation-induced neoangiogenesis. Moreover, although it was not applied in this case, the use of indocyanine green to assess conduit perfusion may be a useful adjunct in similar situations. To the best of our knowledge, only four cases in two previous reports have described using an esophageal segment left in situ as a neo-posterior tracheal wall for large TEFs repair. One case involved a TEF caused by prolonged endotracheal intubation, 4 and the other three were trauma-related TEFs, such as those following traffic accidents all were successfully treated. 5 Compared with these cases, our case was more challenging because the fistulas developed in the setting of severe inflammation due to long-term instrumentation after esophageal surgery, and involved not only the esophagus but also the gastric conduit. Nevertheless, successful functional recovery was achieved after surgery. Conclusion This case demonstrates that salvage repair using the esophagus-conduit segment in situ can provide effective separation of the airway and alimentary tract in patients with extensive TEFs and TCF. Although technically challenging, this approach may serve as a viable alternative when conventional resection and reconstruction carry prohibitive risks. Abbreviations EBD: Endoscopic balloon dilatation TEF: Tracheoesophageal fistula TCF: Tracheo-conduit fistula POD: Postoperative day Declarations Ethics approval and consent to participate All procedures were conducted in compliance with institutional and national regulations and the principles of the Helsinki Declaration. Because this report describes a single, non-experimental clinical case, separate ethical committee approval was not required. The patient was thoroughly informed of the therapeutic options, surgical risks, and the rationale for the staged reconstructive approach. Written informed consent was obtained for the surgical procedures, follow-up, and publication of anonymized clinical details and images. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient consented to the publication of anonymized clinical data and operative photographs. All personal identifiers have been removed to maintain confidentiality. Clinical trial number Not applicable. Availability of data and materials All relevant data supporting the conclusions of this case report are included within the article. Additional clinical materials are available from the corresponding author on reasonable request. Competing interests The authors report no conflicts of interest. Funding This work supported by Chungnam National University Hospital Research Fund (2019-CF-006). Authors' contributions YJC contributed to the conception of the report, data collection and drafting of the manuscript. HJC performed the surgery, supervised the treatment, and critically revised the manuscript for important intellectual content. Both authors read and approved the final manuscript. Acknowledgements The authors would like to thank the patient for his cooperation and consent to publish this case. References Pierie JP, de Graaf PW, Poen H, van der Tweel I, Obertop H, van Lanschot JJ. Incidence and management of benign anastomotic stricture after cervical oesophagogastrostomy. Br J Surg. 1993;80(4):471-474. doi:10.1002/bjs.1800800424. Bi Y, Ren J, Han X. Long-term outcomes of large balloon dilatation for benign anastomotic stricture following surgical resection of esophageal cancer. Medicine (Baltimore). 2023;102(34):e34766. doi:10.1097/MD.0000000000034766 Balakrishnan A, Tapias L, Wright CD, et al. Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula. Ann Thorac Surg. 2018;106(6):1640-1646. doi:10.1016/j.athoracsur.2018.06.076 Landreneau RJ, Hazelrigg SR, Boley TM, et al. Management of an extensive tracheoesophageal fistula by cervical esophageal exclusion. Chest. 1991;99(3):777-780. doi:10.1378/chest.99.3.777 He J, Chen M, Shao W, et al. Surgical Management Of 3 Cases With Huge Tracheoesophageal Fistula With Esophagus Segment in situ As Replacement Of The Posterior Membranous Wall Of The Trachea. J Thorac Dis. 2009;1(1):39-45. Additional Declarations No competing interests reported. Supplementary Files CAREchecklistEnglish2013.pdf SupplementaryMaterialCaseinformedconsentforpublication.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 02 May, 2026 Reviews received at journal 24 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers invited by journal 29 Oct, 2025 Editor invited by journal 09 Oct, 2025 Editor assigned by journal 08 Oct, 2025 Submission checks completed at journal 08 Oct, 2025 First submitted to journal 06 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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the gastric conduit to the trachea (arrow).E: Bronchoscopic finding of tracheo-conduit fistula (arrow).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/edcfd1d727ec6c90200ca058.png"},{"id":95532045,"identity":"1ca95943-e48a-4bee-9bf1-b2d0bc3678cd","added_by":"auto","created_at":"2025-11-10 10:26:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":766081,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e2nd fistula after esophageal stent placement (tracheoesophageal fistula).\u003c/strong\u003e A: Chest CT (axial and sagittal view) demonstrates a tracheoesophageal fistula (arrow) above upper flare of esophageal stent (arrowhead).B: Bronchoscopic finding of a tracheoesophageal fistula (arrow).C: An inner stent (red arrow) was inserted within the existing stent to cover the second tracheoesophageal fistula, which developed above the upper flare of the initial esophageal stent (yellow arrow).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/30e8e57312a8a41e7896fe64.png"},{"id":95531959,"identity":"d039d921-018b-47b5-9eac-04f82d84f87d","added_by":"auto","created_at":"2025-11-10 10:26:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":751781,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e3rd fistula after inner esophageal stent placement (tracheoesophageal fistula).\u003c/strong\u003e A: Chest CT (axial and sagittal view) demonstrates newly developed large tracheoesophageal fistula (red arrow) above upper flare of inner esophageal stent (red arrowhead). Yellow arrow indicates 2nd fistula and yellow arrowhead indicates upper flare of previous esophageal stent.B: Bronchoscopic findings. Upper image demonstrates 2nd fistula and upper flare of previous esophageal stent (yellow arrowhead) and lower image demonstrates 3rd fistula and upper flare of inner esophageal stent (red arrowhead).C:3D volume rendering images of the trachea demonstrates large tracheal defects from posterior aspect of the trachea. Upper defect indicates 3rd fistula (red arrow) and lower defect indicates 2nd fistula (yellow arrow).D: 3D volume rendering images of the esophagus and gastric conduit demonstrates large defects by upper flares of esophageal stent. 1st fistula (arrowhead), 2nd fistula (yellow arrow), 3rd fistula (red arrow).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/8a3183d22ee7fd7621c374e8.png"},{"id":95653996,"identity":"ec8ea064-8556-450a-a0d3-1e15d8ec51b2","added_by":"auto","created_at":"2025-11-11 16:07:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":771105,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic illustration of the surgical planning.\u003c/strong\u003e A: Surgical planning. B: The distal gastric conduit was removed, and the esophageal stent (arrowhead) exposed from the proximal gastric conduit (arrow).C: The removed inner (red arrowhead) and outer (yellow arrowhead) esophageal stents.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/f5b63f16b24521aade185c1a.png"},{"id":95532067,"identity":"fc3a5aaa-6c40-4fc1-b746-c05f3b74c86d","added_by":"auto","created_at":"2025-11-10 10:26:23","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":586867,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative bronchoscopic findings and neck CT.\u003c/strong\u003e A: Bronchoscopy on postoperative day 6. The upper image shows the remnant third fistula (red arrowhead), and the lower image shows the remnant second fistula (yellow arrowhead) and an additional fistula (blue arrowhead) after stent removal and salvage repair with the esophageal segment in situ. B: Neck CT on postoperative day 7. In the sagittal view, residual fistulas connected to esophagus segment in situ are demonstrated. The esophageal segment in situ (yellow star) functioned effectively as the posterior wall of the trachea without ischemia or dehiscence at the suture or staple site.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/ce10798780db9c45e4708695.png"},{"id":95797803,"identity":"9ea0510c-f01f-4246-be97-01b50ea71ee8","added_by":"auto","created_at":"2025-11-13 08:11:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4222799,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/84e4b62f-9623-45d9-8cf1-0fc37355accc.pdf"},{"id":95654186,"identity":"cca0f2af-8552-462e-aab4-4fffb3c0aaba","added_by":"auto","created_at":"2025-11-11 16:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":741854,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/d8a4e2d52a4442f1238ba18f.pdf"},{"id":95532064,"identity":"96a21690-21dd-4f97-9776-d6163e20bf3d","added_by":"auto","created_at":"2025-11-10 10:26:22","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":747183,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialCaseinformedconsentforpublication.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7791241/v1/f0d090e1456f5d83fce86873.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Salvage repair with esophagus-conduit segment in situ as a neo-posterior tracheal wall for multiple tracheoesophageal and trachea-conduit fistulas: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003ePost-esophagectomy anastomotic stricture occurs in up to 30% of patients is a common complication, often managed with endoscopic balloon dilatation (EBD) or endoscopic stent placement.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e However, repeated instrumentation, mechanical trauma from stent flares, ischemic injury, and radiotherapy predispose patients to the development of tracheoesophageal fistula (TEF) or tracheo-conduit fistula (TCF).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Large or multiple TEFs and TCFs are particularly challenging, often necessitating complex reconstructive strategies when the trachea defect is extensive.\u003c/p\u003e\u003cp\u003eHerein, we present a unique case of large, multiple TEFs that developed after repeated balloon dilatations and esophageal stent placements for post-esophagectomy stricture, which were managed with salvage repair using the esophageal segment in situ technique and esophagocolojejunostomy. Written informed consent for publication was obtained from the patient; IRB approval was not required.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 70-year-old male with a history of Ivor\u0026ndash;Lewis esophagectomy for esophageal squamous cell carcinoma (pT2N1M0) presented four months later with progressive dysphagia. Esophagogram and endoscopy demonstrated an anastomotic stricture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and B), managed with multiple EBD sessions at two-week intervals. One month later, the patient developed severe cough and dysphagia. Chest CT, esophagogram and bronchoscopy subsequently confirmed a TCF with aspiration pneumonia (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC-E). He initially refused surgery and underwent covered esophageal stent placement.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe TCF did not improve following stent placement. The patient later received concurrent chemoradiation for nodal recurrence. Four months later, a new TEF developed above the upper flare of the stent(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA and B), necessitating the placement of additional stent. The additional stent was located inside the previous stent and proximal flare of the inner stent was covered a new TEF(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Four months later, the patient\u0026rsquo;s symptoms worsened, and chest CT with bronchoscopy revealed another large TEF above the upper flare of the inner stent(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), ultimately necessitating surgical intervention.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSalvage reconstruction was performed using the esophageal segment and proximal gastric conduit containing TEFs and TCF, in situ against the membranous portion of the trachea(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). The surgical procedure was as follows. First, the previously placed stents were removed, followed by dissection to the level below the most distal fistula, after which the distal conduit was taken down. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB and C). The proximal conduit was closed with a continuous suture using 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene approximately 2 cm above the carina. Next, the mid-to-transverse colon, based on the mid-colic artery as the feeding vessel, was prepared as a conduit. The esophagus was approached through a left cervical incision. Using a stapler, the proximal esophagus was divided above the most proximal fistula, thereby creating a blind pouch without disturbing the esophageal segment and the proximal gastric conduit that contained the TEFs and TCF. Reconstruction was performed with an esophagocolostomy using a 25-mm circular stapler, anastomosing the proximal esophagus to the colon conduit, which was brought up through the substernal route.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient resumed oral intake with supplemental jejunostomy feeding after an esophagogram on POD 6. Bronchoscopy on POD 7 demonstrated that the esophageal segment was well maintained as a blind pouch with a fresh color appearance(Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The patient was discharged on POD 24 but ultimately died five months later due to progression of esophageal cancer.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTEF or TCF after esophagectomy is rare but potentially fatal. Esophageal stents may offer temporary relief, but risks such as migration, mechanical trauma, and secondary infection can exacerbate tissue injury. In this case, repeated metallic stent placement and local inflammation likely contributed to progressive tissue destruction and multiple fistula formation. Large or persistent fistulas usually require surgery, and recent studies suggest better survival with surgical repair of TEF or TCF compared with non-surgical management.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDefinitive surgery for TEF or TCF usually requires resection of the esophagus and gastric conduit with tracheal repair, but these procedures are invasive, technically demanding, and carry high morbidity. When fistulas are extensive, tracheal reconstruction is particularly difficult. In our case, multiple TEFs involved nearly half of the trachea. We therefore performed a salvage repair using the esophagus in situ as the posterior tracheal wall, which avoided extensive resection and dissecting the fistulous area with dense adhesion, and achieved functional separation of the airway and alimentary tract.\u003c/p\u003e\u003cp\u003eThe gastric conduit in this case had already lost its distal portion, and major feeding vessel, the left gastroepiploic artery, had been sacrificed. This raised concern regarding the adequacy of perfusion to the remaining proximal gastric conduit. In our procedure, we first resected the distal conduit and the feeding artery, removed the esophageal stent, and then dissected the conduit up to the fistulous area to assess mucosal bleeding. After confirming that the mucosa was adequately perfused, we proceeded to repair the remaining proximal gastric conduit. Postoperative imaging showed the esophageal segment left in situ remained intact without ischemia, likely supported by inflammation-induced neoangiogenesis. Moreover, although it was not applied in this case, the use of indocyanine green to assess conduit perfusion may be a useful adjunct in similar situations.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, only four cases in two previous reports have described using an esophageal segment left in situ as a neo-posterior tracheal wall for large TEFs repair. One case involved a TEF caused by prolonged endotracheal intubation,\u003csup\u003e4\u003c/sup\u003e and the other three were trauma-related TEFs, such as those following traffic accidents all were successfully treated.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Compared with these cases, our case was more challenging because the fistulas developed in the setting of severe inflammation due to long-term instrumentation after esophageal surgery, and involved not only the esophagus but also the gastric conduit. Nevertheless, successful functional recovery was achieved after surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case demonstrates that salvage repair using the esophagus-conduit segment in situ can provide effective separation of the airway and alimentary tract in patients with extensive TEFs and TCF. Although technically challenging, this approach may serve as a viable alternative when conventional resection and reconstruction carry prohibitive risks.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEBD: Endoscopic balloon dilatation\u003c/p\u003e\n\u003cp\u003eTEF: Tracheoesophageal fistula\u003c/p\u003e\n\u003cp\u003eTCF: Tracheo-conduit fistula\u003c/p\u003e\n\u003cp\u003ePOD: Postoperative day\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were conducted in compliance with institutional and national regulations and the principles of the Helsinki Declaration. Because this report describes a single, non-experimental clinical case, separate ethical committee approval was not required. The patient was thoroughly informed of the therapeutic options, surgical risks, and the rationale for the staged reconstructive approach. Written informed consent was obtained for the surgical procedures, follow-up, and publication of anonymized clinical details and images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient consented to the publication of anonymized clinical data and operative photographs. All personal identifiers have been removed to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data supporting the conclusions of this case report are included within the article. Additional clinical materials are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work supported by Chungnam National University Hospital Research Fund (2019-CF-006).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYJC contributed to the conception of the report, data collection and drafting of the manuscript. HJC performed the surgery, supervised the treatment, and critically revised the manuscript for important intellectual content. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the patient for his cooperation and consent to publish this case.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePierie JP, de Graaf PW, Poen H, van der Tweel I, Obertop H, van Lanschot JJ. Incidence and management of benign anastomotic stricture after cervical oesophagogastrostomy. Br J Surg. 1993;80(4):471-474. doi:10.1002/bjs.1800800424.\u003c/li\u003e\n \u003cli\u003eBi Y, Ren J, Han X. Long-term outcomes of large balloon dilatation for benign anastomotic stricture following surgical resection of esophageal cancer. Medicine (Baltimore). 2023;102(34):e34766. doi:10.1097/MD.0000000000034766\u003c/li\u003e\n \u003cli\u003eBalakrishnan A, Tapias L, Wright CD, et al. Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula. Ann Thorac Surg. 2018;106(6):1640-1646. doi:10.1016/j.athoracsur.2018.06.076\u003c/li\u003e\n \u003cli\u003eLandreneau RJ, Hazelrigg SR, Boley TM, et al. Management of an extensive tracheoesophageal fistula by cervical esophageal exclusion. Chest. 1991;99(3):777-780. doi:10.1378/chest.99.3.777\u003c/li\u003e\n \u003cli\u003eHe J, Chen M, Shao W, et al. Surgical Management Of 3 Cases With Huge Tracheoesophageal Fistula With Esophagus Segment in situ As Replacement Of The Posterior Membranous Wall Of The Trachea. J Thorac Dis. 2009;1(1):39-45.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"esophagus, salvage repair, tracheoesophageal fistula, tracheo-conduit fistula","lastPublishedDoi":"10.21203/rs.3.rs-7791241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7791241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTracheoesophageal fistula (TEF) and trachea\u0026ndash;conduit fistula (TCF) after esophagectomy are rare, life-threatening complications that may follow repeated endoscopic interventions and stent placement. When fistulas are large or multiple, conventional resection and tracheal reconstruction can be prohibitive. We report a salvage repair using an esophagus\u0026ndash;conduit segment left in situ as a neo-posterior tracheal wall.\u003c/p\u003e\u003ch2\u003eCase:\u003c/h2\u003e\u003cp\u003eA 70-year-old man developed an anastomotic stricture after Ivor\u0026ndash;Lewis esophagectomy for squamous cell carcinoma, treated with serial balloon dilatations and covered stenting. Progressive tissue injury led to a TCF and subsequently two additional large TEFs above the stent flares. Operative strategy included stent removal, takedown of distal conduit, closure of proximal conduit, creation of a substernal colon conduit, cervical division of proximal esophagus, and esophagocolostomy; the esophagus\u0026ndash;proximal gastric conduit segment containing the fistulas was preserved in situ against the membranous trachea to function as a neo-posterior wall. Oral intake resumed after an esophagogram on postoperative day (POD) 6; bronchoscopy on POD 7 confirmed a well-perfused blind esophageal pouch. The patient was discharged on POD 24. He later died five months postoperatively from oncologic progression unrelated to airway\u0026ndash;alimentary separation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIn selected patients with extensive, multifocal TEF/TCF, preserving an esophagus conduit segment in situ can achieve durable separation of airway and alimentary tract while avoiding extensive resection through densely adherent, inflamed fields. This technically demanding approach is a feasible salvage option when standard reconstruction carries excessive risk.\u003c/p\u003e","manuscriptTitle":"Salvage repair with esophagus-conduit segment in situ as a neo-posterior tracheal wall for multiple tracheoesophageal and trachea-conduit fistulas: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 09:50:20","doi":"10.21203/rs.3.rs-7791241/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"254823745324422581085874165691943255778","date":"2026-05-02T22:00:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T16:22:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123068258192368313586922993788454608951","date":"2025-11-06T01:00:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-29T13:34:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-09T17:28:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-09T02:22:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-09T02:21:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-10-06T12:01:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f31d3793-5edb-4bec-b8c8-c5d8c7ac0b6e","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T09:50:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 09:50:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7791241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7791241","identity":"rs-7791241","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}