J Extra Corpor Technol 2026, 58, 90--94 Ó The Author( s), published by EDP Sciences, 2026 https:// doi. org / 10.1051 / ject / 2025055
Available online at: ject. edpsciences. org
CASE REPORT
Tracheoesophageal fistula repair with veno-venous extracorporeal support and Montgomery T-tube: a case report
José Luis Che Morales( MD, MSc) * and Gary Kosai Vargas Mendoza( MD)
Pulmonology and Thoracic Surgery Unit, Medical Center of the Americas, Mérida, Yucatán, México Received 16 January 2025, Accepted 19 September 2025
Abstract – Tracheoesophageal fistulas( TEFs) are a major surgical challenge requiring a meticulous approach. This case report describes the successful surgical treatment of a 50 mm TEF extending from the upper third of the trachea to 40 mm above the main carina in a young female patient. The chosen strategy involved an extensive transcervical approach, utilization of Veno-Venous Extracorporeal Membrane Oxygenation( VV-ECMO), and placement of a Montgomery T-tube. The use of ECMO allowed surgical manipulation of mediastinal structures in apnea, ensured adequate gas exchange in the absence of mechanical ventilation, and enhanced comfort during postoperative splinting of the involved structures. The integration of the Montgomery T-tube provided stable airway management postoperatively, particularly advantageous in the context of impaired neurological status precluding early extubation. This combined surgical approach, involving VV-ECMO and Montgomery T-tube, offers a novel, safe, and effective alternative for managing complex TEFs and is recommended for consideration in similar challenging clinical scenarios.
Key words: Tracheoesophageal fistula, ECMO, Montgomery tube, Airway surgery.
Overview
ECMO therapy has a wide range of indications, from cardiopulmonary resuscitation to the management of refractory cardiorespiratory failure to its use in elective surgical procedures. One of the earliest published reports on ECMO for airway diseases utilized this technology to treat tracheal stenosis in an infant, subsequently expanding its application to other intrathoracic pathologies [ 1 ]. Although ECMO is known to carry a higher risk of bleeding due to the need for anticoagulation [ 2 ], this risk can be mitigated by using short-term ECMO with minimal heparinization [ 3 ]. In fact, with careful management, we encountered no significant bleeding in this case, highlighting that the benefits of a clear surgical field can be realized without hemorrhagic complications. The surgical team’ s improved control over bleeding when using VV-ECMO arises indirectly from several physiological and practical mechanisms rather than from ECMO intrinsically reducing bleeding risks. VV-ECMO indirectly enhances bleeding control during TEF repair by providing a stable, motionless surgical field free from respiratory movements and obstruction by an orotracheal tube. Although ECMO inherently carries a bleeding risk due to anticoagulation, the primary benefit is superior surgical visualization, facilitating precise hemostasis [ 4 ].
* Corresponding author: neumo24che24 @ gmail. com
Description
In January 2022, a 25-year-old woman underwent a supratemporal and infratemporal craniectomy for a right petroclival meningioma. Three surgical stages led to a subtotal resection, during which there was significant bleeding. Prolonged mechanical ventilation necessitated a tracheostomy, and a few days later, the cannula yielded food remnants. The bronchoscopy revealed a 10 mm-long tracheoesophageal fistula in the middle third of the trachea, which was conservatively managed with gastrostomy. A week later, she experienced two cardiorespiratory arrests. The first occurred due to a complete obstruction of the cannula, and the second occurred during a new bronchoscopy, which revealed an extension of the fistula up to 50 mm( Figure 1).
The pulmonology-thoracic surgery service at our center thoroughly reviewed the patient’ s complex case. After careful consideration of her current condition-- including the absence of a diagnosis of brain death and the lack of an ominous prognosis-- the team determined that she was a suitable candidate for transfer and surgical intervention at our facility. This decision reflected a multidisciplinary approach focused on optimizing outcomes for patients with challenging airway pathology. The urgency of the surgery stemmed from the need to prevent further aspiration of food material and to ensure the airway’ s functionality.
All members of the surgical and critical care team involved in this procedure were certified by the Extracorporeal Life
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