Salvage sleeve-pneumonectomy for a malignant bronchomediastinal fistula and the feasibility of a modified tritube

backgroundBronchomediastinal fistula (BMF) is a rare and life-threatening complication following multimodality treatment for lung cancer. Surgical management is often the only definitive option but is technically challenging, especially in the context of radiation-induced fibrosis and the need for reliable intraoperative ventilation when the airway itself is the site of resection. We describe the surgical treatment of a large BMF in a patient with advanced non-small cell lung carcinoma (NSCLC), with an emphasis on the use of a modified narrow-bore Tritube® for airway management. CASE PRESENTATION: A 54-year-old woman with stage IIIc NSCLC of the right upper lobe underwent chemoradiotherapy followed by durvalumab. Four months later, a large BMF originating from the right tracheobronchial angle was detected. Conservative management failed, and progressive enlargement of the fistula prompted referral to our center. The patient underwent salvage right sleeve pneumonectomy with carinal resection and end-to-end anastomosis of the distal trachea to the left main bronchus. Intraoperative ventilation was secured with a Tritube® modified by shortening the cuff to allow selective occlusion of the left main bronchus, ensuring uninterrupted ventilation throughout the resection and reconstruction. Despite extensive fibrosis and intraoperative technical difficulties, the procedure was completed successfully. Postoperatively, the patient developed transient concerns for anastomotic necrosis and a minor partial dehiscence associated with Aspergillus infection. These were managed with antifungal therapy without the need for reoperation. At one-year follow-up, the patient remained in good condition, with stable airway healing and no recurrence of the fistula.

conclusionsThis case demonstrates that even in complex patients with complex treatment-related airway complications, salvage sleeve pneumonectomy with carinal resection can be performed successfully. Airway management with an off-label, modified Tritube® proved feasible and safe, providing stable ventilation and superior surgical exposure without the need for cross-field intubation or extracorporeal support. The modified Tritube® may represent a valuable adjunct in complex airway surgery where conventional ventilation techniques are limited.