Large Tracheoesophageal Fistula Research Articles

A case of successful treatment of an isolated tracheoesopha- geal fistula in a 2-month-old child

Isolated tracheoesophageal fistula is a very rare malformation, which is a pathological communication between the walls of the esophagus and the trachea. The entry of food into the trachea causes severe obstructive and ventilatory disorders in infants. Surgical treatment of developmental anomalies includes open thoracic or transsternal access, which is traumatic, often complicated by pleurisy and mediastinitis in the postoperative period and long-term musculoskeletal deformities. Purpose. To demonstrate the effectiveness of minimally invasive surgery in the correction of this defect. Fibro-tracheo-bronchoscopy confirmed an isolated tracheoesophageal fistula in a 2-month-old child. Thoracoscopic intervention using 3 ports was chosen and performed as a surgical method of treatment. A large tracheoesophageal fistula, up to 10 mm, was found. The tracheal end of the fistula was sutured with 2 ligatures, tied and cut off. The defect in the wall of the esophagus was hermetically sutured. The postoperative period proceeded without complications. Enteral nutrition through the nipple started on the 10th day. Control examination after 1 and 6 months: the child has no anxiety; psychomotor development corresponds to age, on esophagoscopy the esophagus is freely passable, constrictions and defects were revealed . Conclusion. The high resolution and ergonomics of modern endoscopic equipment made it possible to visualize the malformation in an infant in detail, to separate pathological communication with minimal trauma and to avoid early and long-term complications.

Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis.

Management of large tracheoesophageal fistulas complicated by tracheal stenosis remains challenging as it requires an ideal replacement for the membranous defect as well as a permanent buttress to reconstruct the stenotic segment. We present the successful use of an autologous free dermal flap reinforced with a pedicled pectoralis major muscle to repair the tracheal membranous wall and a rib cartilage graft to enlarge the tracheal lumen.

Salivary bypass tube in managing persistent and large pharyngocutaneous and tracheoesophageal fistulas: a series of seven cases

BackgroundA salivary bypass tube (SBT) is a silicone tube that directs oral content from the mouth to the esophagus. We studied a series of seven cases of persistent and large neck fistulas of different aetiologies to assess the beneficial use of SBTs in each case.Case presentationA total of seven patients underwent SBT insertion, six cases were post-total laryngectomy with underlying laryngeal malignancy, and one case was poor wound healing of a neck abscess after extensive drainage. Five cases have pharyngocutaneous fistula (PCF) and two cases have tracheoesophageal fistula (TEF), and all of the cases have failed conservative and multiple surgical management for fistula closure, with some concurrently having neopharynx stenosis. Post-insertion, all patients were able to eat orally after day 2 to 1-week. The duration of tube usage was one month in the three cases of persistent PCF post-operatively, and in two cases, the fistula was healed and the tube was removed without fistula recurrence. The other four cases (three post-radiotherapy fistulas and one stoma recurrence) were planned for lifelong use, with the duration of usage ranging from 4 months to 3 years. The outcome is their fistula is dry, and they tolerate the tube well. There were no intraoperative or immediate postoperative complications, and no complications were observed in the temporary usage cases. Among the patients who had to use the tube for a longer term, one had localised pressure necrosis of regional soft tissue that resolved after tube adjustment, and another had a loose-fitting tube that displaced distally into the oesophagus and resolved with a larger tube.ConclusionsSBT is safe, easy-to-apply, reduces morbidity, improves mental health, reduces inpatient stay, and overall improves the patient's quality of life in the management of persistent and large TEF and PCF for temporary or long-term usage.

Surgical management of large tracheoesophageal fistula in infants after button battery ingestion.

In recent years, an increase in severe and even fatal outcomes related to oesophageal or airway button battery (BB) ingestion by infants and small children has been reported. Extensive tissue necrosis caused by lodged BB can lead to major complications, including tracheoesophageal fistula (TEF). In these instances, best treatment remains controversial. While small defects may warrant a conservative approach, surgery often remains inevitable in highly complex cases with large TEF. We present a series of small children that underwent successful surgical management by a multidisciplinary team in our institution. This is a retrospective analysis of n = 4 patients <18 months undergoing TEF repair from 2018 to 2021. Surgical repair under extracorporeal membrane oxygenation (ECMO) support was feasible in n = 4 patients by reconstructing the trachea with decellularized aortic homografts that were buttressed with pedicled latissimus dorsi muscle flaps. While direct oesophageal repair was feasible in 1 patient, 3 required esophagogastrostomy and secondary repair. The procedure was completed successfully in all 4 children with no mortality and acceptable morbidity. Tracheo-oesophageal repair after BB ingestion remains challenging and is associated with major morbidity. Bioprosthetic materials in conjunction with the interposition of vascularized tissue flaps between trachea and oesophagus appear to be a valid approach to manage severe cases.

Case report: Surgical repair of a large tracheo-esophageal fistula in a patient with post-transplant esophageal lymphoproliferative disorder

Introduction and importanceThe management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.Case presentationA 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.Clinical discussionThe treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.ConclusionSurgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.

Acquired Benign Tracheoesophageal Fistula: An Alternative Tracheoplastic Technique.

We present a case of surgical management of a tracheoesophageal fistula (TEF) following prolonged intubation. After transverse tracheal division and retraction of the distal stump, direct closure of the esophageal defect and repair of the membranous tracheal defect using a synthetic bioabsorbable patch were performed, followed by interposition of muscle flap between the suture lines and tracheal reconstruction. Large TEFs, without tracheal stenosis or circumferential airway defect, associated with marked peritracheal inflammation, may be treated with this alternative tracheoplastic technique in patients deemed not suitable for tracheal resection and anastomosis.

Placement of a metallic Y stent to address a large tracheoesophageal fistula on the carina

We report a case of a 43-year-old woman who presented with a large tracheoesophageal fistula involving the main carina after chemo-radiotherapy for lung adenocarcinoma. A self-expanding fully covered metallic Y stent was placed with the use of both rigid and flexible bronchospopy and fluoroscopic guidance. An esophageal stent was placed subsequently. The patient survived 8 months without relevant symptoms. Keywords: tracheoesophageal fistula; metallic stent; esophageal stent; lung cancer.

S2104 Acquired Tracheoesophageal Fistula in Diffuse B Cell Lymphoma Associated With Persistent COVID-19

Introduction: Acquired tracheoesophageal fistula (TEF) is rare and commonly occurs due to tracheal or esophageal trauma, malignancy, infection, and as sequelae of intubation. Symptoms typically involve aspiration. We present an elderly patient with relapsed Diffuse Large B-Cell Lymphoma (DLBCL) complicated by persistent COVID-19 infection who develops acute onset aspiration and productive cough. After workup, she is found to have an acquired TEF. Case Description/Methods:: Our patient is a 76-year-old woman who presents with acute onset cough and recurrent aspiration of solids and liquids. Past medical history includes COVID-19 infection diagnosed 2-3 months prior, and relapsed DLBCL undergoing chemotherapy with Monjuvi/Revlimid (held for 4 months due to COVID-19 infection). She denies prior dysphagia, odynophagia, intubation, or endoscopy. Physical exam is notable for expiratory wheeze. Chest XRay shows diffuse interstitial opacities bilaterally. Barium esophagram shows contrast extravasation into the left bronchus (Figures 1 & 2). Esophagogastroduodenoscopy (EGD) shows 30 mm fistula in the proximal esophagus (Figure 2A). A 20 mm x 100 mm through-the-scope esophageal stent was placed over the fistula site and anchored with endo sutures (Figure 2B). The patient had persistent aspiration and was found to have left vocal cord paralysis likely from recurrent laryngeal nerve damage. Her course was complicated by respiratory failure and she was transitioned to comfort measures. Discussion: Acquired TEF is a rare finding with several different etiologies. Diagnosis is made via esophagram and treatment is typically esophageal stenting. Large TEFs serve as incubators for recurrent respiratory infections. There are no known cases of persistent COVID pneumonia due to TEF. Therefore, TEF should be considered in any immunosuppressed patient with history of persistent pneumonia and aspiration of unexplained cause. (Figure Presented).

Double hitch stitch is a novel technique for fixation of tracheal stent in a case of tracheoesophageal fistula: a case report

BackgroundCaudal tracheal stent migration can be potentially life threatening by causing distal luminal obstruction. We present a rare double hitch stitch procedure (for prevention of migration of tracheal stent), which is an external fixation technique in a case of tracheoesophageal fistula with tracheal and esophageal self-expandable metallic stent (SEMS).Case presentationA 50-year-old male patient who presented with cough and dyspnea was a known case of carcinoma of the esophagus with esophageal stent in situ. Computed tomography (CT) scan showed tracheoesophageal fistula with esophageal stent (esophageal SEMS) migrating into the trachea. Tracheal stenting was done with SEMS. Patient was followed up after 1 month with recurrent complaints of cough on deglutition. On follow-up bronchoscopy, migration of stent was observed. A rare procedure of double hitch stitch was performed with fixation of the tracheal stent (tracheal SEMS) using a percutaneous anchoring stitch, embedded in the subcutaneous tissue. Follow-up bronchoscopy after 1 month of the procedure showed no migration of stent.ConclusionFor the treatment of large tracheoesophageal fistula, stenting of both the trachea and the esophagus along with the double hitch stitch proved to be lifesaving. Stent migration prevention using “double hitch-stitch” is simple, safe, and successful, without any complications.

Massive gastric distension following tracheobronchial Y-shaped self-expanding metallic stent placement for large tracheoesophageal fistula.

Massive gastric distension following tracheobronchial Y-shaped self-expanding metallic stent placement for large tracheoesophageal fistula.

A tracheoesophageal fistula closed after being patent for over half a century

A 54-year-old man presented with a chief complaint of “a hole in his esophagus.” According to the patient, this had been diagnosed at birth and had never been definitively treated, although he stated that his prior physicians were aware of it. He described a lifetime history of chronic aspiration, which he had learned how to minimize by eating certain foods and swallowing with his neck severely flexed. Still, he had had innumerable episodes of pneumonia requiring treatment. A contrast study showed a large tracheoesophageal (TE) fistula with free extravasation of contrast material into the airway (A).

Use of a Pedicled Sternocleidomastoid Musculocutaneous Flap in a Large Tracheoesophageal Fistula

Repairing a large tracheoesophageal fistula with extensive involvement of the membranous wall of the trachea is sometimes troublesome because of the lack ofan ideal replacement for the large defect. We report the successful use of a pedicled sternocleidomastoid musculocutaneous flap to repair a large tracheoesophageal fistula in which the cutaneous component was applied to the defect of the membranous trachea after tracheal resection and the muscular component was interposed between the tracheal and esophageal walls.

Prolonged esophageal foreign body: Management strategies in the setting of complicated tracheoesophageal fistula

Abstract Esophageal coins rarely migrate extraluminally or cause systemic illness and the development of tracheoesophageal fistulae (TEF) secondary to coin ingestion is rare. When they do occur, surgical repair may be complicated by a contaminated operative site and systemic instability. As a means to review treatment options in this setting, we present a rare case of a 16-year-old female with a history of longstanding esophageal foreign body complicated by a large tracheoesophageal fistula, mediastinitis, and sepsis. She was ultimately managed by means of endoscopic diversion and tracheal stenting to reduce wound contamination in preparation for definitive open repair. A comprehensive literature review is performed and our approach to this patient's management is discussed. In the setting of a mediastinal leak, infection and systemic instability, endoscopic techniques and novel clip applicators may be employed to control wound contamination prior to definitive repair.

Veno- venous extracorporeal membrane oxygenation during surgical repair of a large tracheoesophageal fistula

Veno- venous extracorporeal membrane oxygenation during surgical repair of a large tracheoesophageal fistula

Collaborating with interventional pulmonology in managing a massive tracheoesophageal fistula that extends from cricoid to carina: a case report

Tracheoesophageal fistulas (TEF) present a perioperative management challenge. A 62 year-old man with esophageal carcinoma presented with a large tracheoesophageal fistula extending most of the trachea. Previously, the patient had two overlapping esophageal and one tracheal stent placed, but he developed progressive tracheal disruption due to esophageal stent perforation near the level of the cricoid. This case describes the anesthetic management of tracheal stent placement for an expanding TEF. Management included a spontaneous breathing inhalation induction followed by ventilation through a supraglottic device—laryngeal mask airway (LMA). Finally, during rigid bronchoscopy, a combination of bag ventilation and jet ventilation was utilized.

Swimming Upriver: Retrograde Laparoscopic-Assisted Placement of an Esophageal Stent for Palliation of Advanced Esophageal Cancer

There are several options for palliative relief of dysphagia in patients with advanced esophageal cancer including endoscopic stenting, cryotherapy, argon plasma coagulation, and palliative endoscopic resection. Stent placement is preferred in patients with secondary tracheoesophageal fistula (TEF) formation and is associated with dysphagia alleviation as well as fistula closure. We describe a difficult case esophageal cancer with TEF treated with SEMS placement involving a multidisciplinary approach requiring laparoscopic assisted. A 63-year-old male with advanced squamous cell carcinoma of the proximal esophagus complicated by TEF formation was referred to our institution due to worsening inability to swallow secretions. In order to place a fully covered self expandable metal stent, attempts were made to pass a guidewire under endoscopic and fluoroscopic guidance from above the tumor into the distal esophagus. Due to the altered anatomy from the tumor, the large TEF and airway stents, the guidewire placement was not successful with wire preferentially going into the airway despite numerous attempts. The GI surgery team, Interventional pulmonary team was consulted and a combined laparoscopic and endoscopic approach was chosen. The patient already had a J tube but no G tube to access the stomach. As a result, laparoscopic access to the stomach was provided via a 14mm trocar. A gastroscope was then inserted through the trocar and then retrograde up the esophagus. From the retrograde approach the wire was now able to traverse tumor and enter into the proximal esophagus and mouth where it was retrieved. The gastroscope was then backloaded onto the guidewire and a 10 cm x 10 mm fully covered biliary stent was deployed in the esophagus in an anterograde fashion, bridging the tumor. Placement was confirmed with fluoroscopy and direct visualization. The interventional pulmonary team performed bronchoscopy and airway stents were not compromised by the placement of the esophageal stent. The patient reported market improvement in his ability to swallow secretions and has also been able to enjoy a liquid diet. Collaboration with the surgical and pulmonary teams was essential for successful esophageal stent placement in this case. This method of retrograde guidewire and endoscopic insertion can be considered as an option in patients with advanced esophageal cancer for whom conventional stent deployment is not possible.

Tracheoesophageal fistula managed with tracheal stent through flexible bronchoscopy without fluoroscopy

Inoperable malignant tracheoesophageal fistula (TEF) is characterised by an extremely poor prognosis. Tracheal or double (tracheal-esophageal) stenting through rigid bronchoscopy has been suggested as a valuable therapeutic option. We report on a patient with a large TEF successfully sealed by deployment of a self-expandable stent through flexible bronchoscopy (FB) without fluoroscopy. Dramatically improved health status permitted him to undergo radiation, attaining further clinical improvement. Four months after stent placement no sequelae were observed. During the fifth month a new fistula developed distally to the stent finally leading to death from septic complication. Palliative management of inoperable malignant TEF by tracheal stent placement through FB without fluoroscopy, is feasible, safe and rewarding leading to important clinical improvement.

Closure of a large postintubation tracheoesophageal fistula using a covered self-expandable stent

Closure of a large postintubation tracheoesophageal fistula using a covered self-expandable stent

Post-radiation tracheoesophageal fistula following salvage laryngectomy: microsurgical repair using a “bi-laminar” lateral arm flap

Post-radiotherapy tracheoesophageal fistula (TOF) is a serious complication following salvage laryngectomy, associated with severe morbidity and high mortality. In the absence of recurrent disease, they commonly follow creation of a tracheoesophageal puncture for speech rehabilitation after total laryngectomy. Frequently, direct closure, local and regional flaps repairs are unsuccessful, further making the bed hostile or challenging for definitive treatment. We report using a free fasciocutaneous lateral arm flap, folded to create a bi-laminar (epithelial) reconstruction for salvage repair of large, high output persistent TOF initiated by tracheoesophageal puncture following total laryngectomy, two previous courses of radiotherapy and two unsuccessful repairs using small local flap and a pedicled pectoralis major. The folded lateral arm free flap provided resolution of the fistula, interposition of well-vascularised soft tissue, in addition to oesophageal lining and external tension-free cutaneous coverage, while maintaining a patent endotracheostomy. Chronic high output fistulas present extremely high risk and post-operative complications and necessitate complex reconstruction. Careful surgical planning, multidisciplinary approach and conservative measures to optimise the patient are paramount to achieve success. Microsurgical reconstruction provides an alternate and important adjunct in salvage repair of persistent and large TOFs. Level of Evidence: Level V, therapeutic study.

Novel technique of repair of large tracheo-esophageal fistula following battery ingestion in children: review of two cases

Surgical repair of acquired tracheo-esophageal fistula may result in tracheal stenosis or esophageal stricture. We used fistula with esophageal cuff as flap to repair the tracheal defect. Esophageal repair was performed by rotating ends through 90° in opposite direction. This technique offers excellent repair in a single stage.