key: cord-0946889-xpxf31z2
authors: Granata, Antonino; Martucci, Gennaro; Rizzo, Giacomo Emanuele Maria; Arcadipane, Antonio; Traina, Mario
title: Combined endoscopical treatments for tracheo‐esophageal fistula developed during V‐V ECMO for severe COVID‐19: A case series
date: 2021-11-09
journal: Artif Organs
DOI: 10.1111/aor.14101
sha: a7411560a7a0063d980f083b5dfcb36fc443d6cc
doc_id: 946889
cord_uid: xpxf31z2

nan

Patients affected with acute respiratory distress syndrome due to Covid-19 may require veno-venous extracorporeal membrane oxygenation (V-V ECMO), often undergoing tracheostomy. 1, 2 Tracheo-esophageal fistula (TEF) can develop as an immediate or late complication of tracheostomy, and can be enhanced by several conditions coexisting in severe Covid-19, such as malnutrition, soft tissue hypo-perfusion, need for high-dose vasopressors, mechanical damage during prone position, long hospitalization and ventilation, and long presence of nasogastric tubes. 3 Furthermore, TEF can be dramatic in these patients since it may potentially progress to a mediastinitis, worsening the outcomes. The "watch and see" approach takes too long to allow tissue recovery, and it is also in contrast with the need for anticoagulation, 4 as well as infection control and adequate nutrition, so it would extremely delay the patient's recovery. At the same time, during ECMO, the surgical approach may also be dangerous in terms of bleeding complications and risk of infection. A pro-active approach with advanced endoscopic may contribute to reduce the overall mortality and improve the success rate. 5 ECMO has been used for respiratory support after esophageal or tracheal surgery to allow apneic procedures or for the healing of TEF, especially in coronavirus (COVID-19) patients. On the opposite, ECMO is a potential tool to support endoscopy or other surgical procedures in severely ill patients with very low respiratory reserve, in fact, ECMO might guarantee adequate oxygenation while the ventilation is stopped to proceed. © 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.

Age, years (mean ± SD) 74. 5 6 Our approach to TEF consisted of one-time esophageal endoluminal suture, tracheostomic cannula replacement downstream, and percutaneous endoscopic gastrojejunostomy (PEG-J). Procedures were performed at the bedside. Our clinical practice consists of interventional procedures and patient management in line with the guarantee to propose the best therapeutic option. The informed consent T A B L E 2 Individual data of the patients, including ECMO parameters and ICU stay before every procedure acts as a guarantee for it, and it was obtained from a guardian ad litem if assigned, otherwise, the attending physician acted as a guarantor. First, under direct endoscopic guidance, the tracheostomic cannula was replaced with an adjustable flange longer cannula, which was relocated downstream (the distal tip placed about 2 cm from the tracheal carina) to overcome the injured tracheal wall. We then inserted the gastrostomy tube (Cook) using the "pull" technique and advanced the coaxial jejunal tube through the wire blocked by a foreignbody forceps over the Treitz ligament. So, we guaranteed both enteral nutrition and gastric aspiration, with a reduction in chemical stress at the fistula site. Finally, the TEF was closed with 1 or 2 discontinued sutures using the endoluminal endoscopic suture system (E-Video). Our management allowed us to treat all four TEFs, with a technical success rate of 100%, and recurrence at 4 weeks of 25%.

In our COVID-19 series, despite tracheostomy was performed by experienced personnel and despite there were no immediate complications we experienced a higher rate of TEF. The cause of the TEF is multifactorial and it is not known if COVID-19 patients are at higher risk to develop it. Some of them might be by the reduced availability of devices to reduce the mechanical stress on the trachea maintaining the tubes, the frequent and long-prone position after tracheostomy with further stress of the posterior tracheal wall, and also some patients' characteristics like the need for vasopressor and, potentially, the gastrointestinal sufferance due to COVID-19. Moreover, complications in ECMO may worsen the outcomes of already fragile patients, and a surgical approach to TEF may prolong the ICU-stay and, even lead to death. A less invasive treatment seems to be feasible and might improve the survival of these patients in the coming years. In conclusion, preliminary data suggest endoluminal sutures as a feasible treatment for TEF developed during V-V ECMO and the extracorporeal support might allow a safe a smooth procedure since it allows complete gas exchanges support during the procedure also during apnea times.

Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry

ECMO for COVID-19 patients in Europe and Israel

Risk factors of ischemic and hemorrhagic strokes during venovenous extracorporeal membrane oxygenation: analysis of data from the Extracorporeal Life Support Organization registry

Epidemiology of gastrointestinal bleeding in adult patients on extracorporeal life support

Tracheobronchial stent insertion under veno-venous extracorporeal membrane oxygenation in a coronavirus disease 2019 patient

Apneic tracheostomy in COVID-19 patients on venovenous extracorporeal membrane oxygenation

None.

Dr. Antonino Granata: conceptualization, methodology, resources and comments; Dr. Gennaro Martucci: resources, comments and data analysis; Dr. Giacomo Emanuele Maria Rizzo: manuscript writing, design, methodology, video editing, and image providing; Dr. Mario Traina: supervision, comments, and data analysis; Prof. Antonio Arcadipane: supervision, comments and data analysis; All the authors revised the manuscript and agreed on its conclusions.

https://orcid. org/0000-0001-8443-2414 Giacomo Emanuele Maria Rizzo https://orcid. org/0000-0001-9335-6740