The Journal of ExtraCorporeal Technology No 58-1 | Page 98

92 J. L. Che Morales and G. K. Vargas Mendoza: J Extra Corpor Technol 2026, 58, 90--94

Table 1. Settings, vital signs and blood gases during VV-ECMO run.

Abrev. LPM: liters / min; RPM: revolutions / min; FiO2: inspired fraction of oxygen; ACT: activated time of coagulation.

patient to the ICU. A chest CT scan performed over one week after the surgery revealed no evidence of TEF. Finally, a month later, the patient returned to her referral hospital, breathing spontaneously through Montgomery’ s tube. Six months after the surgery, she was under comprehensive care, experiencing a slow neurological recovery, the family gave consent to communicate the clinical data anonymously for academic purposes.

Comments

The surgical team’ s conduct aligned with current evidence across the three challenges: 1) Access / minimally invasive strategy-- an extensive transcervical approach avoided thoracotomy while femoro-femoral VV-ECMO kept the neck free of cannulas, reflecting the principle of selecting the least invasive exposure that still provides secure control of the upper-mid trachea and is described in ECMO-assisted airway cases; 2) Airway manipulation-instituting VV-ECMO and repairing in total apnea eliminated positive-pressure ventilation through the fistula and removed the ETT from the field, matching ELSO-aligned practice and contemporary reviews favoring VV( over VA) for airway surgery; and 3) Postoperative ventilatory support-- in the setting of neurological impairment precluding early extubation, use of a Montgomery T-tube provided cuff-less airway splinting, allowed ventilation and secretion management, and protected the repair, consistent with published experience in ventilator-dependent and ECMOassisted airway scenarios.

In this scenario, the team decided to avoid thoracotomy by making an extensive cervical incision. Given the potential difficulties in managing the distal third of the trachea, the procedure in total apnea with bifemoral VV-ECMO was performed as previously described by other authors [ 4 ]. The bifemoral VV- ECMO approach allowed oxygenated blood return similar to the femoro-jugular configuration. This femoro-femoral strategy was specifically chosen for the patient because it kept the neck region completely free of cannulas [ 6, 7 ], thereby enabling unobstructed surgical access and optimal manipulation of cervical structures during the procedure, and can provide full pulmonary support without the potential complications of veno-arterial modality [ 3, 8 ]. Contemporary guidelines and expert literature recommend VV-ECMO as the preferred approach for airway surgeries, including tracheal and TEF repair procedures, whenever extracorporeal support is indicated [ 9 ]. VV-ECMO is favored because it adequately supports gas exchange without the additional risks associated with arterial cannulation, and it is aligned with the principle of using the least invasive ECMO mode required for the patient’ s needs [ 9, 10 ]. ELSO recommends VV-ECMO for isolated respiratory failure, and recent reviews and case series consistently report routine use of VV-ECMO( often over 80 % of cases) in airway operations [ 9 ]. VA-ECMO is reserved for the minority of situations where cardiac support or higher perfusion pressures are necessary( for example, coexisting cardiac compromise or certain extensive mediastinal tumors) [ 10 ].

As described by Jin et al., significant advantages of Montgomery T-tube usage during ECMO-supported complex airway surgery include stable airway splinting, preservation of airway patency, and facilitation of secretion clearance in patients dependent on prolonged mechanical ventilation [ 11 ]. These benefits are supported by previous reports demonstrating effective long-term airway support and secretion drainage capability provided by the Montgomery T-tube in ventilatordependent and airway stenosis patients [ 12, 13 ]. Our clinical experience aligns with these observations, reinforcing the T-tube’ s role as an effective airway management tool. The management of an acquired TEF in a patient who cannot be weaned from mechanical ventilation presents a unique challenge. In such cases, standard practice of early extubation or conventional ventilation is often not feasible, as positivepressure ventilation risks blowing air through the fistula and jeopardizing the surgical repair. This case highlights a novel, multidisciplinary strategy combining veno-venous extracorporeal membrane oxygenation( VV-ECMO) and a Montgomery T-tube to overcome these issues. VV-ECMO can temporarily take over gas exchange, allowing the lungs to be ventilated without positive pressure. This avoids ventilation through the injured airway and protects the fresh TEF repair from barotrauma. In a reported case of a large TEF, mechanical ventilation was deemed technically impossible, and VV-ECMO was used without any need for conventional ventilation [ 3 ]. Additionally, by using the T-tube, the team ensured the airway remained secure and the fistula repair was not disrupted by a traditional endotracheal or tracheostomy tube cuff. Notably, Caronia et al. have reported a similar approach where, following endoscopic TEF closure, a T-tube was inserted to protect the suture and maintain the airway patency, resulting in a successfully healed fistula at follow-up [ 14, 15 ]. Finally, the use of ECMO did not significantly prolong the surgery; the procedure duration( 10 hours) aligns well with previously reported ECMO-supported airway surgeries lasting up to 8 h [ 3, 16 ]. Additionally, VV-ECMO allowed oxygenation and ventilation control, ensuring cerebral protection through stable normoxia, normocapnia, and acid-base balance in this neurologically compromised patient as ELSO recommends( Table 1)[ 17 ].

To our knowledge, there are no published cases to date that have employed ECMO together with a T-tube for repairing TEF in an adult patient who could not be weaned from the ventilator in the short term due to neurologic sequelae.