Case Report: Prolonged extracorporeal membrane oxygenation as a deliberate operative adjunct for tracheobronchial reconstruction in a child with invasive aspergillosis.

We report the case of a 6-year-old boy with newly diagnosed type 1 diabetes mellitus presenting in diabetic ketoacidosis, who developed a massive acquired tracheo-esophageal fistula (TEF) with extensive destruction of the tracheobronchial anatomy, including near-complete loss of the left main bronchus, secondary to invasive mediastinal aspergillosis. The clinical course was complicated by refractory respiratory failure and subsequent right ventricular failure, necessitating prolonged extracorporeal membrane oxygenation (ECMO) support totaling 96 days. The patient required veno-venous ECMO, followed by temporary conversion to veno-arterial ECMO to stabilize hemodynamics during profound atelectasis and pulmonary hypertension, before returning to veno-venous support until decannulation. Definitive airway reconstruction was achieved using a vascularized autologous esophageal muscular flap in a severely inflamed and infected operative field where prosthetic materials were contraindicated, with planned sacrifice of esophageal continuity to prioritize airway restoration. Antifungal therapy was initiated following histopathological confirmation of Aspergillus hyphae and adjusted in response to hepatic dysfunction. Postoperatively, intentional lung rest for 14 days, with gas exchange maintained entirely by ECMO, protected the fragile membranous reconstruction. Despite multiple life-threatening complications, survival with satisfactory neurological outcome was achieved through close multidisciplinary cooperation. This case illustrates the role of ECMO as a bridge to complex airway reconstruction in pediatric patients with destructive invasive fungal disease, and describes the esophageal muscular wall flap as an autologous salvage option for posterior tracheobronchial defects in infected mediastinal fields.