OBJECTIVE: To explore the value of placing a drainage tube through the esophageal fistula for the treatment of esophageal mediastinal fistula. METHODS: A retrospective analysis of the clinical data of 43 cases of anastomotic fistulous pustules among 3308 cases of esophageal cardia cancer surgically resected between 2000 and 2004 was performed. Among them, 3 cases of esophageal mediastinal fistula were treated with a Fulcrum catheter placed into the mediastinal pus cavity via the nasal cavity through the esophageal fistula. The drainage tube was connected to negative pressure to drain the pus, and the position of the drainage tube was adjusted and removed in time according to the drainage flow. RESULTS: The mediastinal pus cavity disappeared about 23 d after placement, and the drainage tube was completely removed through the fistula, and the patient could eat smoothly. Conclusion: The placement of a drainage tube through the esophageal fistula for the treatment of esophageal mediastinal fistula can effectively treat anastomotic fistula with simple operation technique, low cost, little trauma and easy acceptance by patients, which is a new technique worth promoting. The placement of a tube through the fistula of the esophagogastric anastomosis and the negative pressure drainage of the pleural cavity and the infected foci in the mediastinum can cooperate with the placement of a tube through the chest wall to fully drain the contents of the pus cavity and accelerate the reduction of the pus cavity until it disappears. This will promote the early healing of fistula and sinus tract. This method is simple and easy to use, reduces the trauma of multiple chest drainage and dissection, and shortens the healing time of anastomotic fistula significantly. It is particularly effective for esophageal-mediastinal fistula. Clinical data 1. Clinical statistics: From 2000 to the end of 2004, 43 cases of postoperative anastomotic fistulas for esophageal and cardia cancers occurred in our department, accounting for 1.3% of the surgeries in the same period. Among them, there were 13 cases of cervical anastomotic fistula, accounting for 30.2% (13/43). There were 3 cases of esophage-mediastinal fistula, accounting for 7% (3/43). Intrathoracic anastomotic fistula was found in 23 cases (54.5%) (23/43). There were 4 cases of gastric fistula, accounting for 9.3% (4/43). In addition, 4 cases of esophageal mediastinal fistula occurred after esophageal cancer and cardia cancer postoperative anastomotic stenosis with esophageal dilatation. The treatment: cervical anastomotic fistula, intrathoracic anastomotic fistula, and mediastinal fistula were treated conservatively. 3 cases of mediastinal fistula were drained through the fistula, 2 cases of thoracic fistula were drained through the fistula, and 4 cases of gastric fistula were repaired by open-heart surgery. In the case of esophageal mediastinal fistula caused by dilatation of the esophagus: 3 cases were treated conservatively and 1 case was treated with open-chest drainage. The average healing time of trans-anastomotic fistula was 12 days; the average healing time of thoracic fistula was 42 days; the average healing time of mediastinal fistula was 23 days; the healing time of thoracic fistula with trans-fistula drainage was 36 and 34 days in two cases. Four cases of esophageal mediastinal fistula caused by dilatation of the esophagus died after conventional treatment, and two cases of thoracic fistula died of hemoptysis on the 10th and 13th day after placement of esophageal stents. The rest were discharged from the hospital cured. Discussion Anastomotic fistula after surgery for esophageal and cardia cancer is a common and serious complication after surgery for esophageal and cardia cancer. Over the years, with rich clinical experience and increasingly mature anastomosis techniques, clinical workers have tried various anastomosis methods, which have significantly reduced the incidence of anastomotic fistula. However, the healing of anastomosis after esophageal cardia cancer surgery is influenced by multiple factors. For example, the blood flow of the stomach and esophagus around the anastomosis, the tension of the anastomosis, the patient’s physical condition, preoperative radiotherapy and chemotherapy, etc., all of them have direct influence on the healing of the anastomosis. These have a direct impact on anastomotic healing and make anastomotic fistula not completely avoidable. Therefore, how to make the fistula heal early is also the most important concern and pursuit of clinicians. Postoperative anastomotic fistulas for esophageal and cardia cancers are generally divided into early fistulas and mid- to late-stage fistulas in terms of time. Early fistulas are often related to anastomotic technique, while mid- to late-stage fistulas are mostly related to the blood flow of the anastomosis. Early fistulas are often combined with acute toxic symptoms such as high fever, and the classical “triple tube therapy” (drainage tube, gastric tube, and nutrition tube) is usually used in clinical practice. In the later stage, with the change of encapsulated septic chest, it is often necessary to drain the chest wall several times, which not only increases the pain of patients, but also puts them in a passive position in terms of treatment. Esophageal perforation due to postoperative anastomotic stenosis after esophageal cancer and cardia cancer is acute esophageal mediastinal fistula with severe symptoms of acute toxicity. Early occurrence of fistula is easier to diagnose. Patients often have severe pain in the chest and back, fever, chest tightness and shortness of breath, dyspnea, mediastinal gas and liquid flat or neck emphysema, etc. occur. The usual clinical treatment is another open-chest surgical repair plus mediastinal drainage. However, patients at this time are often in poor physical condition, and often cannot tolerate the trauma of cesarean surgery. However, if clinical management is not in place, the condition may deteriorate rapidly and even die. In our group, 4 cases of postoperative perforation were complicated by esophageal dilatation, 3 cases were treated conservatively, 1 case was treated by dissection and drainage, and all 4 cases died. The postoperative complications of esophageal cancer and cardia cancer with mediastinal fistula are mostly delayed anastomotic fistula. At this time, dense adhesions have occurred around the anastomosis and a mediastinal encapsulated abscess has been formed, which makes drainage very difficult and is more difficult in treatment. With the enrichment of clinical experience and the progress of postoperative detection methods, the diagnosis and treatment level of postoperative anastomotic mediastinal fistula and postoperative esophageal perforation caused by esophageal dilatation due to anastomotic stenosis have been improved. In the treatment of anastomotic pleural fistula and anastomotic mediastinal fistula, the author uses iodine oil imaging to understand the fistula and pus cavity under interventional conditions, and then carefully adjusts the placement of a porous gastric tube (such as Fulcrum tube) of suitable thickness under x-ray to reach the base of encapsulated septic chest or mediastinal abscess through the fistula, and connects it to negative pressure drainage. Take care to adjust the size of the negative pressure. If the negative pressure is too large, it is easy to form gastric juice aspiration, and the author believes that it is appropriate to maintain the negative pressure at 6-8 cmH2O. The pus cavity should be flushed with low pressure every day for 2 weeks after the placement of the tube to remove the viscous pus in the cavity. Under continuous negative pressure suction, the contents of the pus cavity can be fully drained and the encapsulated pus cavity can be rapidly reduced. Together with the synergistic effect of chest wall drainage tube and nutrition tube, the anastomotic fistula can be healed gradually and early. Usually after 2 weeks, the pus cavity becomes a sinus tract tightly wrapped around the drainage tube. At this time, the method of gradual retraining can be chosen to narrow and eliminate the sinus tract. It is important to retract the tube slowly according to the clinical and radiographic situation. Usually each retreat does not exceed 3 cm. 1 – 2 weeks or so, most of the drainage tube is retreated into the esophageal lumen. Continue the negative pressure suction for 1 week, can be removed for observation for 1 week, no special circumstances can be considered oral gradually eat. For refractory anastomotic mediastinal fistula, surgical repair of the drainage is generally traumatic and difficult for the patient to accept, while general conservative treatment does not solve the problem of drainage of pus. Negative pressure drainage using a Fulcrum gastric tube through the fistula to the bottom of the pus cavity is simple to place. A guide wire is placed under intervention followed by a drainage tube, which is more precisely in place and does not adversely affect the fistula. As observed by iodine oil imaging, the pus cavity starts to shrink significantly after 3 days of placement, and after 2 weeks it becomes a sinus tract surrounding the drainage tube. With the gradual retreat of the tube, the sinus tract generally disappears in 2 weeks. After the drainage tube is retreated into the esophageal lumen, the negative pressure is maintained for 1 week, so that the anastomosis is basically healed and oral feeding can be done gradually, and the duodenal nutrient tube can be removed after 1 week. Switch to complete oral feeding.